A survey on Koreans' preferred type of collaboration between conventional medical and traditional Korean medicine doctors.

ABSTRACT: Although collaborative treatment by traditional Korean medicine doctors (KMDs) and medical doctors occurs, it is mainly done by referral. As no survey of the general public's preference for the type of collaboration has ever been conducted, we aimed to investigate Koreans' preferences for a collaborative treatment type.The responders were extracted by random digit dialing and then reextracted using the proportional quota sampling method by sex and age. From July to October 2017, telephone interviews were conducted and the participant responses regarding treatment history for spinal or joint diseases, experiences with collaborative treatment, and preferred type of collaborative treatment were recorded.Of the 1008 respondents, 44.64% reported a history of treatment for spinal or joint diseases at a medical institution. The concurrent collaborative treatment system, in which both KMDs and medical doctors are present in one location participating in the treatment concurrently, was the most preferred system among the respondents. Respondents who reported experience with traditional Korean medicine hospitals were more likely to prefer a one-stop treatment approach than those who did not have experience with traditional Korean medicine hospitals (adjusted odds ratio: 1.73; 95% confidence interval: 1.12-2.68). Respondents who were familiar with collaborative treatment but did not report any personal experience with it were more likely to prefer a one-stop treatment approach than those who were not familiar with collaborative treatment (adjusted odds ratio: 1.82; 95% confidence interval: 1.37-2.44).Koreans prefer a concurrent type of collaborative treatment system by KMDs and medical doctors. Therefore, efforts and support are needed to increase the application of the concurrent type of collaborative system.

Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain.

OBJECTIVE: To determine whether the initial care provider for neck pain was associated with opioid use for individuals with neck pain. DESIGN: Retrospective cohort study. SETTING: Marketscan research databases. PARTICIPANTS: Patients (N=427,966) with new-onset neck pain from 2010-2014. MAIN OUTCOME MEASURES: Opioid use was defined using retail pharmacy fills. We performed logistic regression analysis to assess the association between initial provider and opioid use. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using bootstrapping logistic models. We performed propensity score matching as a robustness check on our findings. RESULTS: Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%-91% less likely to fill an opioid prescription in the first 30 days, and between 41%-87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47-3.69; P<.001). CONCLUSIONS: A patient's initial clinical contact for neck pain may be an important opportunity to influence subsequent opioid use. Understanding more about the roles that conservative therapists play in the treatment of neck pain may be key in unlocking new ways to lessen the burden of opioid use in the United States.

Pyoderma gangrenosum after orthopaedic or traumatologic surgery: a systematic revue of the literature.

INTRODUCTION: Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by a painful ulceration mimicking infection of the operative site. To this day, there is still no general agreement on the medical and surgical treatment of PG. This systematic review of the literature aims to summarise recent studies about post-operative PG in orthopaedic surgery to improve its medical and surgical management. METHOD: In April 2017, we carried out an exhaustive review of the literature in MEDLINE, PubMed and Cochrane databases. Key words were pyoderma gangrenosum, orthopaedic surgery, and surgical wound infection. We identified 183 articles. After excluding articles reporting idiopathic PG, cases secondary to non-orthopaedic surgery, and cases about other subtypes of dermatosis, 30 studies were identified. We only included articles reporting PG after orthopaedic or trauma surgery. RESULTS: Thirty-one cases of PG have been reported, 58% (18) of which were in women, whose mean age was 56.5 years. Clinical signs were constant, the most frequently affected site was lower limbs [77.4% (24)] and delay of symptom onset was two to 17 days. Systemic corticosteroid therapy was systematic, polyvalent immunoglobulins were used in two cases and immunosuppressive drugs in one. Negative pressure therapy was used in seven cases and hyperbaric oxygen in three. DISCUSSION: Delayed diagnosis leads to one or more surgical revisions, which could have been avoided by using early and adapted medical treatment. Early onset of a painful and infected ulcer at the operating site in a patient at risk of PG is an indicator that dermatologist advice is recommended before surgical debridement. Surgical revision, outside the inflammatory phase and/or covered by a systemic corticosteroid therapy, does not lead to PG relapse. LEVEL OF EVIDENCE: IV: Systematic revue of the literature.

Variation in Diagnoses for Hip Arthroplasty Among New York State Hospitals: Implications for the Comprehensive Care for Joint Replacement Model.

BACKGROUND: The Comprehensive Care for Joint Replacement model is designed to minimize costs and improve quality for Medicare patients undergoing joint arthroplasty. The cost of hip arthroplasty (HA) episode varies depending on the preoperative diagnosis and is greater for fracture than for osteoarthritis. Hospitals that perform a higher percentage of HA for OA may therefore have an advantage in the Comprehensive Care for Joint Replacement model. The purposes of this study are to (1) determine the variability in underlying diagnosis for HA in New York State hospitals, and (2) determine hospital characteristics, such as volume, associated with this. METHODS: The New York Statewide Planning and Research Cooperative System database was used to identify 127,206 primary HA procedures from 2010 to 2014. The data included underlying diagnoses, age, length of stay, and total charges. Hospitals were categorized by volume and descriptive statistics were used. RESULTS: OA was the underlying diagnosis for HA for 74.2% of all patients; this was significantly higher for high-volume (89.30%) and medium-volume (74.9%) hospitals than for low-volume hospitals (58.4%, P < .05). HA for fracture was significantly more common at low-volume hospitals (32.4%) compared to medium-volume (18.0%) and high-volume (4.7%) hospitals (P < .05). Length of stay was significantly greater at low-volume hospitals for all diagnoses. CONCLUSION: High-volume hospitals perform a higher ratio of HA cases for OA compared to fracture, which may lead to advantages in patient outcomes and cost. The variation in underlying diagnosis between hospitals has financial implications and underscores the need for HAs to be risk stratified by preoperative diagnosis.

Frequency of medical malpractice claims: The effects of volumes and specialties.

A medical malpractice occurs when a physician or healthcare personnel, because of lack of skill or negligence, causes injury to a patient, who can decide to claim for the damages suffered by suing the facility and/or healthcare personnel. In this paper we analyze the frequency of medical malpractice insurance claims in an Italian region, in order to estimate the presence of significant trends and to identify volume effects at both department and healthcare organization levels. We rely on a unique dataset reporting the universe of 2144 injuries caused by medical or surgical errors that resulted in a request to the insurer for coverage over the years 2004-2010 in ten public healthcare organizations. Results show the presence of positive volume effects, as the number of malpractice claims grows less than proportionally with respect to department volumes. Volume effects are particularly relevant for orthopedics and general surgery. We also find the presence of significant positive volume effects at the level of healthcare organizations. Finally, the joint observation of the results on the frequency of malpractice claims and on the time lag between the occurrence of the malpractice event and the filing of the related claim, suggests that the number of malpractice claims has increased over time. Results indicate that organizational and managerial actions concerning the increase in volumes of specific departments or health organizations are context specific and must be specifically tailored.

Cost-effectiveness analysis of the diagnosis of meniscus tears.

BACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.

Survey of inspection and palpation rates among spine providers: evaluation of physician performance of the physical examination for patients with low back pain.

STUDY DESIGN: Survey from July 2011 to April 2012 of adult patients with primary complaint of low back pain (LBP). OBJECTIVE: To determine the frequency of physical examination being performed by various providers, as measured by frequency of inspection and palpation, of patients with LBP and to describe patient ratings of these examinations. SUMMARY OF BACKGROUND DATA: The physical examination is a cornerstone of any evaluation of patients with LBP. With increasing reliance on diagnostic imaging, there is concern that patients are not being examined comprehensively, but to our knowledge, no studies have ever investigated how often the physical examination is performed in patients with LBP. METHODS: Survey participants were asked to list the types of physicians that they had seen for LBP within the past 1 year and for each physician encounter to answer 2 "yes/no" questions: (1) whether they had removed their clothes or put on a gown or shorts during the examination (our proxy for inspection) and (2) whether the provider had placed his or her hands on the patient (our proxy for palpation). Subjects also provided quality ratings for each provider's physical examination. Main outcome measures included frequency of inspection and palpation and subjects' ratings of each physical examination. RESULTS: A total of 295 surveys were collected reflecting 696 prior physician encounters. Inspection was done in 57% of physician encounters. Across specialties, orthopedic surgeons had the highest reported rate of inspection at 72%. The worst was among chiropractors at 40%. Palpation occurred in 80% of physician encounters. Chiropractors had the highest rate of palpation at 94%. The lowest rate was among neurosurgeons at 58%. CONCLUSION: Our data suggest that approximately 43% of patient visits for LBP involved no inspection and nearly 20% without palpation. These numbers reflect a need for improvement among providers who treat patients with LBP. LEVEL OF EVIDENCE: N/A.

[The role of psycho-oncology in orthopedic tumor centers]. / Stellenwert der Psychoonkologie und ihre Versorgungslage an Zentren für Tumororthopädie.

INTRODUCTION: Psychosocial screening has not been implemented into diagnosis-related guidelines for the treatment of orthopedic tumor patients. The aim of the study was to evaluate the significance of psycho-oncology in orthopedic institutions specialized in musculoskeletal tumors as well as the opinion and clinical experience of the treating physicians. METHODS: In total 60 orthopedic institutions were recruited. Data were assessed and analyzed by a newly developed, standardized questionnaire. To detect specific, demographic differences results were additionally analyzed according to gender, age and professional experience. RESULTS: A total of 118 physicians from 47 institutions participated. Significant differences between professional experience groups were obtained regarding the wish for psychosocial treatment in cases of own illness (p=0.032) and the difficulty of addressing patient feelings (p=0.05). CONCLUSIONS: The majority of orthopedic physicians deemed psycho-oncology important. To ensure a holistic approach to the treatment of orthopedic tumor patients, psycho-oncological aspects should be implemented in diagnosis-related guidelines.

Diffusion of innovation: enhancing the dissemination of the Ponseti method in Latin America through virtual forums.

This ethnographic study evaluated the use of low-bandwidth web-conferencing to enhance diffusion of a specific best practice, the Ponseti method to treat clubfoot, in three economically diverse countries in Latin America. A "Ponseti Virtual Forum" (PVF) was organized in Guatemala, Peru and Chile to examine the influences of economic level and telecommunication infrastructure on the effectiveness of tins approach. Across the three countries, a total of 14 different sites participated in the PVFs. Thirty-three Ponseti-trained practitioners were interviewed before and after each PVF, which included interactions with a Spanish-speaking Ponseti method expert. Semi-structured interviews, observations, and IP address data were triangulated and analyzed. The results demonstrated that 100% of the practitioners rated the sessions as very useful and that they would use this approach again. The largest obstacles to using PVFs were financial (7 out of 9 practitioners) in Guatemala; a lack of equipment and network access (6 out of 11) in Peru; and the organization and implementation of the conferences themselves (7 out of 9) in Chile. This study illustrates the usefulness of Ponseti Virtual Forums in Latin America. Health officials in Peru are currently developing a large-scale information session for traumatologists about the Ponseti method, while practitioners in Guatemala and Chile are organizing monthly scholarly meetings for physicians in remote areas. This initial feedback suggests that low-bandwidth web-conferencing can be an important vehicle for the dissemination of best practices, such as the Ponseti method, in developing countries.

Ponseti Brasil: a national program to eradicate neglected clubfoot - preliminary results.

BACKGROUND: After hearing about the reproducible and excellent results of the Ponseti method for clubfoot treatment, a group of Brazilian orthopaedic surgeons organized and participated in a standardized national program to teach the Ponseti technique in 21 different cities across Brazil. METHODS: A total of 21 Ponseti symposiums were organized in a standard fashion from January, 2007 to December, 2008. They consisted of a two-day program with lectures, hands-on cast application, and discussion of local clinical cases presented by orthopaedic surgeons. Thirteen Brazilian orthopaedic surgeons, who had been trained by the University of Iowa or centers recognized by them, taught the method. Financial support for travel was provided by an English charity: La Vida (Vital Investment for Developing Aid in Latin America). The physicians who attended the symposiums answered questionnaires before and after the training. RESULTS: About 7% of the 8000 orthopaedic surgeons in Brazil (556 orthopaedic surgeons) were trained. These orthopaedic surgeons stated that they had treated about 4905 babies in the previous year via other methods, including extensive surgery. Seventeen percent of the surgeons did not know about the Ponseti technique at the start of the symposium. Eighty-eight percent reported they felt able to treat children with the Ponseti technique after the symposium. Ninety-four percent of respondents reported that the symposium changed their way of treating clubfoot CONCLUSIONS: These Ponseti symposiums brought about an exchange of medical information and empowered the participants. This program is a good educational tool which can be used in eradicating neglected clubfoot in Brazil.

Lesiones tumorales y pseudotumorales de la mano de niños: estudio retrospectivo de casos / Tumor and pseudotumoral lesions of the hand in children: a retrospective review

Tumor lesions of the hand in children have different features than those found in adults. Objective: To identify the type and behavior of tumors and pseudotumors in hands of patients younger de 16 years of age. Material and Method: A retrospective and descriptive study of patients younger 16 years of age, operated (in a period of 10 years), with the diagnosis of tumor in any segment of the hand, through clinical records revision, images and anatomopathologic study was done. Patients operated because of an acute infection, or foreign body reaction were not included. Results: The 77 children studied had 82 lesions located in fingers, metacarpal zone and wrist: 50 percent of them were synovial cyst, 26 percent were of soft tissue origin (mostly of vascular origin). Three tumors affected the axis or growth of a finger and two condromas presented as a fracture in a pathologic bone. One myofibroma, one osteobastoma and 6 synovial cyst relapsed and were reoperated. No malignant lesions were found. Conclusion: Tumoral and pseudotumoral lesions of the hand in children are less frequent than in adults. Usually they are benign, although some of them have a tendency to relapse or may affect the physis to the phalanx or metacarpals.

Las características de las tumoraciones de las manos en niños son diferentes a las de los adultos. Objetivo: Identificar el tipo de comportamiento de los tumores y seudotumores en manos de menores de 16 años. Material y Método: Estudio retrospectivo y descriptivo de pacientes menores de 16 años, operados (en un período de 10 años), con el diagnóstico de tumoración en algún segmento de de la mano, mediante la revisión de fichas, imagenología y estudio anatomopatológico. No se incluyó a los pacientes que fueron operados por infección aguda o reacción evidente a cuerpo extraño en la mano. Resultados: Los 77 niños estudiados tenían 82 lesiones, ubicadas en dedos, metacarpo y muñeca; de las cuales el 50 por ciento fueron quistes sinoviales, 26 por ciento tumoración de origen óseo (principalmente osteocondromas y condromas) y 24 por ciento tumoración de partes blandas (generalmente de origen vascular). Tres tumores afectaron el eje o el crecimiento del dedo y dos condromas debutaron con fractura en hueso patológico. Un miofibroma, un osteoblastoma y 6 quistes sinoviales recidivaron y necesitaron nuevas cirugías. No hubo lesiones malignas. Conclusiones: Las lesiones tumorales y seudotumorales de la mano en niños son menos frecuente que en adultos. Habitualmente son benignas aunque, algunas dan problemas por su tendencia a recidivar o porque pueden afectar la fisis de las falanges o metacarpianos.

Access to spine care: a tale of two cities.

INTRODUCTION: As governments struggle with increasing demand for accountability within the Canadian Health Care System and set wait-time standards, it is important to objectify data to allow a true understanding of present limitations and to facilitate comparisons to other systems. The purpose of this study was to compare wait list times for a cohort of patients requiring spinal surgery in Calgary, Alberta to a similar cohort in Sydney, Australia. METHODS: From January 1 until June 30, 2006 all outpatients admitted for spinal surgery to the Foothills Hospital were identified by the surgeons' office. Two time periods were quantified from their charts: (1) time from referral to surgical consultation; and (2) time from surgical consultation to operative intervention. From July 1 until December 31,2006 patients were similarly identified through Neurosurgical offices at the Prince of Wales Public and Private Hospitals in Sydney, Australia. RESULTS: Four hundred ninety-one surgical patients were captured during the six month period in Calgary and 155 patients during the subsequent six months in Sydney. The majority of patients in Sydney were treated in the Private Health Care system. Public patients in Sydney have access to a surgical consultant twice as fast as public patients in Calgary while private patients have access ten times faster. Access to operating room time within the public system is a rate limiting step in both countries. However, Sydney private patients receive their surgery four times faster than Calgary patients. CONCLUSIONS: Compared to Calgary, access to specialized spine care in Sydney appears more efficient not only in the Private but also the Public Health Care System. Part of this efficiency may arise from offloading from the public into the private system. Solutions proposed to reduce wait list times should consider benefits of a Private Health Care System.

Health service utilization patterns of primary care patients with osteoarthritis.

BACKGROUND: To assess factors associated with visits to GPs, orthopaedists, and non-physician practitioners of complementary medicine (alternative practitioners) by primary care patients with osteoarthritis (OA). METHODS: Cross-sectional survey among 1250 consecutively addressed patients from 75 primary care practices in Germany. All patients suffered from OA of the knee or hip according to ACR criteria. They received questionnaires collecting sociodemographic data, data about health service utilisation, prescriptions, comorbidities. They also included established instruments as the Arthritis Impact Measurement Scale (AIMS2-SF) to assess disease-specific quality of life and the Patient Health Questionnaire (PHQ-9) to assess depression. Hierarchical stepwise multiple linear regression models were used to reveal significant factors influencing health service utilization. RESULTS: 1021 of 1250 (81.6%) questionnaires were returned. Nonrespondents did not differ from participants. Factors associated with health service use (HSU) varied between providers of care. Not being in a partnership, achieving a high score on the PHQ-9, increased pain severity reflected in the "symptom" scale of the AIMS2-SF, and an increased number of drug prescriptions predicted a high frequency of GP visits. The PHQ-9 score was also a predictor for visits to orthopaedists, as were previous GP contacts, a high score in the "symptom" scale as well as a high score in the "lower limb scale" of the AIMS2-SF. Regarding visits to alternative practitioners, a high score in the AIMS -"social" scale was a positive predictor as older people were less likely to visit them. CONCLUSION: Our results emphasize the need for awareness of psychological factors contributing to the use of health care providers. Addressing the revealed factors associated with HSU appropriately may lead to decreased health care utilization. But further research is needed to assess how this can be done successfully.

A survey of sports medicine physicians regarding psychological issues in patient-athletes.

PURPOSE: To determine the extent to which sports medicine physicians encounter and discuss psychological issues among athletes they treat and to evaluate physicians' perceptions of the availability and efficacy of sport psychologists and other mental health resources. STUDY DESIGN: Cross-sectional study. METHODS: A survey was sent via e-mail to all physician members of 4 prominent sports medicine professional associations: the American Orthopaedic Society for Sports Medicine, American College of Sports Medicine, American Medical Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. RESULTS: The extent to which respondents discuss psychological issues with athletes varied by subspecialty and by specific issues assessed. Fears about reinjury, fears related to surgery, and lack of patience with recovery/rehabilitation were the 3 most common injury-related topics discussed with patient-athletes. The 3 most common non-injury-related topics discussed were stress/pressure, anxiety, and burnout. Family practitioners were more likely to discuss injury-related psychological issues than were orthopaedic surgeons. Orthopaedic surgeons reported the lowest frequencies of discussing non-injury-related psychological issues. Only 19% of all respondents indicated there were adequate numbers of sport psychologists and other mental health professionals in their geographical area to treat the needs of athletes. Three quarters of respondents reported they rarely or never referred athletes to sport psychologists for injury-related issues, and two thirds indicated they rarely or never referred athletes to sport psychologists for non-injury-related problems. Respondents rated sport psychologists and athletic trainers/physical therapists to be moderately effective in working with athletes regarding psychological problems. CONCLUSION: Sports medicine physicians frequently encounter psychological issues with patient-athletes. There is a need for tools to facilitate assessment of these problems as well as greater communication between the mental health community and sports medicine physicians. In addition, knowledge of and access to professionals who are specifically trained to deal with the sometimes unique psychological needs of athletes should be improved.

Results of chiropractic treatment of lumbopelvic fixation in 44 patients admitted to an orthopedic department.

OBJECTIVES: The objectives of this study were to report on and evaluate the results of chiropractic care for patients with low back pain in an orthopedic department. METHODS: The target group consisted of 44 consecutive patients who experienced sudden and painful low back pain caused by lumbar flexion and rotation without axial loading. Clinical and neurologic examinations by orthopedic surgeons revealed no pathology; in addition, skeletal radiography, computerized tomography, and magnetic resonance imaging findings were all normal. Diagnosis before hospitalization was acute sciatica in all cases. Examination by the doctor of chiropractic indicated that the patients had lumbopelvic fixation. According to preestablished inclusion and exclusion criteria, 33 patients were treated in the chiropractor's clinic, whereas 11 who could not be transported were initially treated by the chiropractor in the hospital. The mean follow-up was 2 years. RESULTS: All but two patients returned to work. The period of sick leave among the patients was reduced by two thirds as compared with that associated with conventional medical treatment. CONCLUSIONS: To our knowledge, this is the first report on the work of a chiropractor participating within an orthopedic department of a Norwegian hospital as initiated by the hospital and with full support of the staff. The results support the initiative of the Norwegian government to increase reference to chiropractors in treating patients with neuromusculoskeletal dysfunctions. Based on our experience, we believe that the inclusion of chiropractors within hospital orthopedic departments is feasible and provides a patient care resource that may benefit not only the patients but also the department as a whole.

The impact of concomitant depression on quality of life and health service utilisation in patients with osteoarthritis.

To assess the impact of concomitant depression on quality of life (QoL) and health service utilisation of patients with osteoarthritis (OA). Data were collected from 75 primary care practices in Germany. Totally, 1,250 patients were consecutively approached; 1,021 (81.7%) questionnaires were returned and analysed. Measures included sociodemographic data, the Arthritis Impact Measurement Scale (AIMS2-SF) and the Patient Health Questionnaire (PHQ-9) to assess depression. A PHQ-9 score > or = 15 was defined as reflecting depression. Patients with a depressive disorder achieved significantly (all P < 0.001) higher scores in all AIMS2-SF dimensions. They had more contacts to general practitioners (P < 0.01), orthopaedics (P < 0.01) and to providers of Complementary Alternative Medicine offered e.g. by healers. Concomitant depression aggravates the burden of OA significantly. This results in increased health service utilisation. Appropriate treatment of depression would appear not only to increase QoL but also to lower costs by decreasing health service utilisation.

Medical management of patients over 50 years admitted to orthopedic surgery for low-energy fracture.

OBJECTIVE: To develop a cost-effective strategy for improving osteoporosis management in patients admitted to an orthopedic surgery department for low-energy fractures. METHODS: From November 2003 to July 2004, all patients over 50 years admitted to the orthopedics department of the Caen Teaching Hospital (France) for low-energy fractures were identified and evaluated by rheumatology department physicians in the same hospital. RESULTS: During the study period, 313 patients were identified, 257 women (mean age, 79.5+/-10.2 years) and 56 men (mean age, 74.6+/-10.8 years), each with one fracture (proximal femur, 58.9%; wrist, 13%). Among them, 91 (29%) had a previous history of osteoporotic fractures. Mean bone mineral density (BMD) values were lower at the femoral neck than at the total hip or lumbar spine (e.g. in women, -2.3+/-0.9 versus -1.8+/-1.0 and -1.4+/-1.7, respectively). Osteoporosis treatment was given to 88 (28%) patients and consisted of calcium and vitamin D supplements, combined with alendronate in 32 patients. Complete loss of self-sufficiency occurred in 73 patients. Thus, 161 patients (88 with osteoporosis treatment and 73 with loss of self-sufficiency) received optimal treatment. CONCLUSION: Cooperation between the orthopedics and rheumatology departments improved the management of osteoporosis in patients with low-energy fractures. However, appropriate investigation and treatment of osteoporosis proved difficult in the oldest old and in patients with cognitive impairments.

The pattern of orthopedic admissions in Tikur Anbessa University Hospital, Addis Ababa.

A one-year (April 1st 2003-March 31st 2004) prospective descriptive study of orthopedic admissions to Tikur Anbessa University Hospital (TAUH) was made in order to determine the burden of musculoskeletal conditions together with the present provision of care. A total of 824 patients were admitted of whom 576 were males and 248 females (M:F 2.3:1). The median age was 15 years (range 3 months to 80 years). Trauma was the cause for admission in 507 (61.5%), with road traffic accidents accounting for 211 (41.6%) and a fall for 195 (38.5%). 'Elective' patients waited for an average of 33.5 days for their admission. The mean duration of stay in hospital between admission and elective operation was 11.7 days. The post-operative stay was 20.6 days and the average length of hospital stay of all patients admitted was 35.4 days. The bed occupancy rate was 97.4% with an average time between the discharge of one patient and the admission of another (turnover interval) of 24 hours. Eighty-seven percent of the patients (97/112) who had previously visited a traditional healer presented with a chronic infection, a neglected or a complicated fracture or an advanced tumor. Eleven patients died (1.4%). Health education in the community and of traditional healers, together with a reduction of road traffic accidents would significantly reduce morbidity and mortality in Ethiopia. Major attempts must be made to reduce both the length of time patients wait for elective surgery after being admitted and their post-operative stay in order to serve more people. But it is vital to continue to teach conservative management of fractures as these will be the only methods available for the foreseeable future in hospital outside the centers of excellence. A series of specific recommendation are made to improve our care of orthopedic and trauma patients. We also suggest a broad based community study with an orthopedic input, which would help to produce a better profile and sound decisions to enable this to be achieved.

Geographical distribution of judo therapists and orthopedists in Japan.

BACKGROUND: Judo therapy is a unique and long-established Japanese comedical profession, specialized in manually treating fractures and sprains in practitioners' offices. Having the overlapped scopes of services between judo therapists and orthopedists, disputes between the 2 have gradually emerged recently. OBJECTIVE: To examine the relationship between judo therapists and orthopedists by comparing their geographic distributions at the whole country level and at prefecture level. STUDY DESIGN: Cross-sectional study. METHODS: The numbers of judo therapist facilities and orthopedists per 100,000 population in each municipality were obtained through web yellow pages and from the Japanese census data. Lorenz curves and Gini indices were calculated to show the distributions and to compare the numbers of judo therapist facilities and orthopedists per 100,000 population. RESULTS: The median number of judo therapist facilities per 100,000 population in all municipalities was 12.0 (range 0-135) and that for orthopedists was 4.3 (0-186). The Gini indices of the nationwide judo therapist facilities and those for orthopedists were 0.29 and 0.36, respectively. CONCLUSION: These data show the relatively homogeneous distribution of judo therapist facilities compared with orthopedists. In smaller municipalities, judo therapist facilities may fill in the absence of orthopedists. As for lager municipalities, further study is needed to examine whether the relationships between them are competitive or complementary.