Improving prescribing of antiosteoporosis discharge medication in fractured neck of femur patients: a completed audit cycle.

Fracture liaison specialist nurses at our institute, perceived deficiency in the level of prescription of osteoporosis secondary prevention medication on discharge of fractured neck of femur (NOF) patients. This aspect of management was therefore audited over two cycles with the aim of evaluating and improving current practice. A prospectively maintained database was utilized to establish identity, demographic data and specialist nurse treatment recommendation for all fractured NOF patients over an initial 12-month period. Computerized immediate discharge letters were reviewed to identify whether the recommended medication had been prescribed. Following the initial audit, fluorescent drug kardex stickers detailing simple treatment recommendations were introduced, and a second audit cycle was carried out using identical methods over the subsequent 12-month period. Primary audit demonstrated that discharge prescriptions included the recommended secondary prevention medications in 50.9%. Following the introduction of fluorescent drug chart stickers detailing the recommendations, re-audit demonstrated improvement to 84.6%. In conclusion, an improvement in the practice of prescription of osteoporosis medications on discharge was demonstrated following the introduction of fluorescent drug kardex stickers.

Repetitive TMS of the somatosensory cortex improves writer's cramp and enhances cortical activity.

Since the somatosensory system is believed to be affected in focal dystonia, we focused on the modulation of the primary somatosensory cortex (SI) induced by repetitive transcranial magnetic stimulation (rTMS) in order to improve symptoms of writer's cramp. Patients with writer's cramp (N=9 in the pilot study and N=11 in the advanced study) were treated with 30-minute 1 Hz real- or sham-rTMS of the SI cortex every day for 5 days. Before and after rTMS, 1.5 T fMRI was examined during simple hand movements. While in the pilot study the rTMS coil was navigated over the SI cortex with a maximum of blood oxygenation-level dependent (BOLD) signal induced by passive movement, patients in the advanced study had the coil above the postcentral sulcus. After real-rTMS, 4 pilot study patients and 10 advanced study patients experienced subjective and objective improvement in writing, while only minimal changes were observed after sham-rTMS. Patients involved in the active movement task exhibited a rTMS-induced BOLD signal increase bilaterally in the SI cortex, posterior parietal cortex and in the supplementary motor area (P<0.001 corrected). After sham-rTMS, no BOLD signal changes were observed. In conclusion, 1 Hz rTMS of the SI cortex can improve writer's cramp while increasing the cortical activity in both hemispheres. Handwriting improved in most patients, as well as the subjective benefit, and lasted for 2-3 weeks. The beneficial effects of rTMS paralleled the functional reorganization in the SI cortex and connected areas, reflecting the impact of somatosensory system on active motion control.

Cortical pattern of complex but not simple movements is affected in writer's cramp: a parametric event-related fMRI study.

OBJECTIVE: Patients with writer's cramp (WC) were studied for differences in cortical activation during movements likely to induce WC (complex movements) and movements which rarely lead to dystonia (simple movements). METHODS: Eleven WC patients (10F, 1M, mean age 41.5 ± (SD)7.2 years) and eleven age matched controls were examined for Blood oxygenation-level dependent (BOLD) 1.5 T fMRI. The complex task consisted of writing a single letter or random drawing using an especially adapted joystick with the line of trajectory visualized or hidden. The simple task consisted of self-initiated fingers flexion/extension using the affected hand. RESULTS: Unlike the controls, WC patients performing complex movements exhibited a lower BOLD signal in the primary sensorimotor cortex and in the posterior parietal cortex bilaterally. A hypoactivation was also observed in the right secondary somatosensory area, in the right anterior insula and in the left premotor cortex (p < 0.05 corrected). No significant inter-group differences were found for simple movements. CONCLUSIONS: Although WC patients' complex movements during fMRI were never associated with dystonic cramp, they exhibited an abnormally low cortical activity. This phenomenon was not observed in simple movements and was unrelated to the character of handwriting or to visual feedback. SIGNIFICANCE: Our results support the dualistic behavior in the sensorimotor system in WC.