Agreement between physicians' and nurses' clinical decisions for the management of the fracture liaison service (4iFLS): the Lucky Bone™ program.

UNLABELLED: We determined if nurses can manage osteoporotic fractures in a fracture liaison service by asking a rheumatologist and an internist to assess their clinical decisions. Experts agreed on more than 94 % of all nurses' actions for 525 fragility fracture patients, showing that their management is efficient and safe. INTRODUCTION: A major care gap exists in the investigation of bone fragility and initiation of treatment for individuals who have sustained a fragility fracture. The implementation of a fracture liaison service (FLS) managed by nurses could be the key in resolving this problem. The aim of this project was to obtain agreement between physicians' and nurses' clinical decisions and evaluate if the algorithm of care is efficient and reliable for the management of a FLS. METHODS: Clinical decisions of nurses for 525 subjects in a fracture liaison service between 2010 and 2013 were assessed by two independent physicians with expertise in osteoporosis treatment. RESULTS: Nurses succeeded in identifying all patients at risk and needed to refer 27 % of patients to an MD. Thereby, they managed autonomously 73 % of fragility fracture patients. No needless referrals were made according to assessing physicians. Agreement between each evaluator and nurses was of >97 %. Physicians' decisions were the same in >96 %, and Gwet AC11 coefficient was of >0.960 (almost perfect level of agreement). All major comorbidities were adequately managed. CONCLUSIONS: High agreement between nurses' and physicians' clinical decisions indicate that the independent management by nurses of a fracture liaison service is safe and should strongly be recommended in the care of patients with a fragility fracture. This kind of intervention could help resolve the existing care gap in bone fragility care as well as the societal economic burden associated with prevention and treatment of fragility fractures.

The impact of a standardized order set for the management of non-hip fragility fractures in a Fracture Liaison Service.

We analysed the impact of a standardized order set empowering staff nurses to independently manage a Fracture Liaison Service over a 9-month period. Nurses identified between 30 and 70 % of non-hip fragility fractures to the unit in charge of management over time. The latter managed 58 % of referred patients. INTRODUCTION: The main goal of this study was to evaluate the impact of a standardized order set empowering nurses to independently manage a fracture liaison service (FLS). METHODS: Since November 2014, an order set allowed nurses of a Montreal hospital, Quebec, Canada to entirely manage an FLS on their own. Nurses followed an 6-h training program on-site. Emergency department (ED) and orthopaedic outpatient clinic (OC) nurses identified non-hip fragility fractures. Medical day treatment unit (MDTU) nurses were in charge of the management (investigation and treatment initiation). The list of patients, 50 years and older, with a fracture were retrieved for the period of November 2014 to July 2015. Performance was assessed with the rate of identification over time and the rate of management of non-hip fragility fractures. RESULTS: Over the 9-month period, 346 patients of ≥50 years old were seen for a fracture, of which 190 met fragility criteria (excluding hip fractures). A sinusoid pattern of rates of identification between 30-70 % was observed over time. An average proportion of 58.1 % of fracture patients were managed by MDTU nurses. CONCLUSIONS: A standardized order set legally allowing nurses to manage an FLS led to identification rates varying from 30-70 % and a management rate close to 60 % for referred patients over a 9-month period, which largely exceeds that of standard care. Identification was mostly compromised by difficulty integrating the order set into routine practice. Enforcement of the hospital policy on fragility fractures could help yield efficiency of identification of osteoporosis-related fractures by the staff.

Orbital Solitary Fibrous Tumor in a Commercial Airline Pilot.

BACKGROUND: In the literature, central serous retinopathy (CSR) accompanying solitary fibrous tumors (SFT) in a pilot has not been reported. In airline pilots, mass effect-related symptoms such as diplopia, ptosis, etc., seen with orbital tumors may endanger flight safety.CASE REPORT: A 62-yr-old male commercial airline pilot presented with blurred vision in the right eye. He had been receiving treatment for 2 mo because of CSR. His visual acuity was 10/20 in the right eye and 20/20 in the left. During examination, ptosis and exophthalmos were noticed in the right eye. Ocular movements were free in all cardinal directions and there was downward displacement in the right eye. There was no diplopia. Magnetic resonance imaging revealed a 1.5- to 2-cm well-defined contrast-enhancing mass in the lateral extraconal orbit. His medical flight certificate was suspended for 3 mo due to decreased visual acuity and superior visual defect. Superior orbitotomy was performed without any complication. Ptosis and CSR had regressed 1 wk after surgery. All systemic and ophthalmological examinations met aviation medical certificate requirements. He returned to flight on the condition of being checked every 3 mo. At the 1-yr follow-up, there was no sign of recurrences of SFT or CSR.DISCUSSION: SFTs are slow-growing neoplasms that can manifest symptoms related to mass effect. In the current literature, there are no reported cases of the coexistence of orbital SFT and CSR or pilots able to resume flight duties only 1 wk after a successful orbitotomy and tumor resection surgery.Altinbas M, Ozpinar A, Akbaba M, Nacaroglu SA, Sargolzaeimoghaddam M, Sargolzaeimoghaddam M. Orbital solitary fibrous tumor in a commercial airline pilot. Aerosp Med Hum Perform. 2024; 95(6):333-336.

Tourniquet and closed-suction drains in total knee arthroplasty. No beneficial effects on bleeding management and knee function at a higher cost.

BACKGROUND: Blood loss is a major concern in total knee arthroplasty (TKA) along with postoperative knee function. The present study explores the impact of tourniquet (T) and closed-suction drains (D) on these parameters in TKA. MATERIALS AND METHODS: A prospective study was conducted on 111 patients admitted for TKA. Subjects were divided into three groups: 36 in group T+D+, 42 in T-D+ and 33 in T-D- (where T+: prolonged tourniquet use, T-: cementation-only tourniquet, D+: closed-suction drain use, and D-: no drain). RESULTS: No statistically significant differences were observed among the three groups(T+D+, T-D+ and T-D-) for total blood loss, hemoglobin levels over the first six postoperative weeks and blood transfusion rate. Intraoperative bleeding was significantly reduced in T+ subjects compared to T- subjects (100±88mL vs. 279±235mL respectively, P<0.001), yet length of surgery was unaffected. Hidden blood loss was lower in D+ subjects compared to D- subjects (1161±554mL vs. 1667±554mL respectively, P<0.001), but was offset by the blood loss in the drains. Early postoperative range of motion (ROM) was superior in group T-D- compared to group T+D+. Nevertheless, postoperative week 6 ROM was similar between the 3 groups as was patient-reported postoperative pain. A patient with a drain represents 35min of extra nursing time and a total cost of $31.87 CAD. CONCLUSIONS: Whole-course tourniquet and closed-suction drain use in TKA do not yield beneficial results while increasing costs. Their use is therefore deemed unnecessary. LEVEL OF EVIDENCE: III (case control prospective study).

Mean platelet volume in euthyroid patients with Hashimoto's thyroiditis.

Mean platelet volume (MPV) is the measure of platelet size. MPV possibly is a simple way to estimate platelet activity. In this study, we aimed to investigate MPV levels in euthyroid Hashimoto's thyroiditis patients. Fifty-one euthyroid patients with Hashimoto's thyroiditis attending our outpatient clinic of the endocrinology department, and 51 age and BMI-matched healthy individuals were included in this study. All patients with euthyroid Hashimoto's thyroiditis were at euthyroid state. None of the study patients was subjected to levothyroxine replacement therapy. Anti-thyroid peroxidase (anti-TPO) antibody and anti-tiroglobulin antibody were positive. All the study participants were evaluated by biochemical and platelet parameters. There were no significant differences in age (33.88 ±â€Š12.87 and 30.18 ±â€Š12.43 years, respectively; P > 0.05) and BMI (23.55 ±â€Š3.34 and 22.25 ±â€Š3.65 kg/m, respectively, P > 0.05) between the study and the control groups. Anti-TPO and anti-tiroglobulin levels were significantly higher in the study group (anti-TPO 428.32 ±â€Š668.39 IU/ml in the euthyroid Hashimoto's thyroiditis group; 14.85 ±â€Š9.66 IU/ml in the control group, P = 0.001; anti-tiroglobulin 320.46 ±â€Š796.05 IU/ml in the euthyroid Hashimoto's thyroiditis group, 21.28 ±â€Š26.24 IU/ml in the control group, P = 0.09). There were no significant differences in terms of serum thyroid-stimulating hormone (TSH) (1.76 ±â€Š0.79 and 1.85 ±â€Š1.14 uIU/ml, respectively), FT3 (3.10 ±â€Š0.37 and 3.29 ±â€Š0.76 pg/ml, respectively) and FT4 (1.22 ±â€Š0.42 and 1.46 ±â€Š0.78 pg/ml, respectively) levels between the study and the control groups. Serum triglyceride levels were significantly higher in the study group than in the control group (133.81 ±â€Š91.50 and 90.18 ±â€Š41.15 mg/dl, respectively; P = 0.015). Mean MPV levels were significantly higher in the euthyroid Hashimoto's thyroiditis group than in the control patients (8.8 ±â€Š1.05 and 7.9 ±â€Š0.79 fl, respectively; P = 0.0001). To assess the correlation with MPV, a Pearson's correlation analysis was performed on each variable. There were positive correlations between anti-TPO and MPV levels (r = 0.246, P = 0.042), and between anti-tiroglobulin and MPV levels (r = 0.256, P = 0.033). The multiple regression analysis of MPV and other risk factors was performed. Age, BMI, C-reactive protein and waist circumference were independent predictive factors of MPV. Adjustment for other factors did not alter these relative risks. Our results suggest that even if in euthyroid state, patients with euthyroid Hashimoto's thyroiditis have higher MPV levels than the healthy controls. As higher MPV levels are closely related with cardiovascular diseases, euthyroid Hashimoto's thyroiditis patients have greater risk of atherothrombotic complications than controls.