Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery.

BACKGROUND: We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL). METHODS: Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months. RESULTS: From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes. CONCLUSION: It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.

Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial.

BACKGROUND: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. METHODS: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. RESULTS: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5-3.7) days for the experimental group and 4.9 (4.4-5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. CONCLUSIONS: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.

Critical Care Nurses' Physical and Mental Health, Worksite Wellness Support, and Medical Errors.

BACKGROUND: Critical care nurses experience higher rates of mental distress and poor health than other nurses, adversely affecting health care quality and safety. It is not known, however, how critical care nurses' overall health affects the occurrence of medical errors. OBJECTIVE: To examine the associations among critical care nurses' physical and mental health, perception of workplace wellness support, and self-reported medical errors. METHODS: This survey-based study used a cross-sectional, descriptive correlational design. A random sample of 2500 members of the American Association of Critical-Care Nurses was recruited to participate in the study. The outcomes of interest were level of overall health, symptoms of depression and anxiety, stress, burnout, perceived worksite wellness support, and medical errors. RESULTS: A total of 771 critical care nurses participated in the study. Nurses in poor physical and mental health reported significantly more medical errors than nurses in better health (odds ratio [95% CI]: 1.31 [0.96-1.78] for physical health, 1.62 [1.17-2.29] for depressive symptoms). Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health (odds ratio [95% CI], 2.16 [1.33-3.52]; 55.8%). CONCLUSION: Hospital leaders and health care systems need to prioritize the health of their nurses by resolving system issues, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce the incidence of preventable medical errors.

A National Study Links Nurses' Physical and Mental Health to Medical Errors and Perceived Worksite Wellness.

OBJECTIVE: The aim of this study was to describe (1) nurses' physical and mental health; (2) the relationship between health and medical errors; and (3) the association between nurses' perceptions of wellness support and their health. METHODS: A cross-sectional descriptive survey was conducted with 1790 nurses across the U.S. RESULTS: Over half of the nurses reported suboptimal physical and mental health. Approximately half of the nurses reported having medical errors in the past 5 years. Compared with nurses with better health, those with worse health were associated with 26% to 71% higher likelihood of having medical errors. There also was a significant relationship between greater perceived worksite wellness and better health. CONCLUSION: Wellness must be a high priority for health care systems to optimize health in clinicians to enhance high-quality care and decrease the odds of costly preventable medical errors.

Comparison of outcome of tibial plafond fractures managed by hybrid external fixation versus two-stage management with final plate fixation.

BACKGROUND: Tibial platfond fractures are usually associated with massive swelling of the foot and ankle, as well as with open wounds. This swelling may cause significant decrease of the blood flow, so the state of the soft tissue is determinant for the surgical indication and the type of implant. This retrospective study compares the union times in cases of tibial plafond fractures managed with a hybrid external fixation as a definitive procedure versus those managed with a two stage strategy with final plate fixation. MATERIALS AND METHODS: A retrospective study in a polytrauma referral hospital was performed between 2005 and 2011. Patients with a tibial plafond fracture, managed with a hybrid external fixation as a definitive procedure or managed with a two stage strategy with the final plate fixation were included in the study. Postoperative radiographs were evaluated by two senior surgeons. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and anteroposterior X-ray. The clinical outcome was evaluated by means of 11 points Numerical Rating Scale for pain and The American Orthopedic Foot and Ankle Society ankle score, assessed at the last followup visit. Thirteen patients had been managed with a hybrid external fixation and 18 with a two-stage strategy with the final plate fixation. There were 14 males and 17 females with a mean age of 48 years (range 19-82 years). The mean followup was 24 months (range 24-70 months). RESULTS: The mean time from surgery to weight bearing was 7 ± 6.36 days for the hybrid fixation group and 57.43 ± 15.46 days for the plate fixation group (P < 0.0001); and the mean time from fracture to radiological union was 133.82 ± 37.83) and 152.8 ± 72.33 days respectively (P = 0.560). CONCLUSION: Besides the differences between groups regarding the baseline characteristics of patients, the results of this study suggest that in cases of tibial plafond fractures, the management with a hybrid external fixation as a definitive procedure might involve a faster union than a two-stage management with final plate fixation.

Influence of Hindfoot Malalignment on Hallux Valgus Operative Outcomes.

BACKGROUND: Hindfoot deformity has been described as a risk factor for poor hallux valgus (HV) surgery outcomes. However, there has been no study that demonstrates it. The purpose of this investigation was to evaluate the influence of hindfoot misalignment in HV surgery results. METHODS: All patients operated on for HV during 2010 and 2011 at 3 university hospitals were included. The preoperative and 2-year postoperative radiologic data included the HV and the intermetatarsal (IM) angles, the naviculocuboid overlap (NC), the talonavicular coverage (TN) angle, the talus-first metatarsal (T-1MT) angle, as well as the calcaneal pitch (CP) angle. Additionally, the Short Form-36 questionnaire version 2.0 (SF-36) and the American Orthopaedic Foot & Ankle Society (AOFAS) score, satisfaction and recurrence were also analyzed. A total of 207 met the inclusion criteria. There were 26 patients (12.6%) who could not be assessed at the 2-year follow-up. Patients were allocated to a varus, normal, or a valgus hindfoot tertile using the values for the CP, NC, TN, and T-1MT angles. RESULTS: No significant differences (P > .05) were found between the groups when the HV or IM angles, AOFAS, SF-36 Mental Composite Scale, SF-36 Physical Composite Scale, or satisfaction were compared. Similarly, no significant and strong correlations were observed (P > .05, ρ < 0.3) between any of the mentioned hindfoot measures and the outcomes scales. CONCLUSION: No influence of hindfoot misalignment on HV surgery outcomes was found in the present study in terms of correction, pain, function, satisfaction, or quality of life. Patients with hindfoot misalignment did not obtain worse outcomes in HV surgery. LEVEL OF EVIDENCE: Level II, prognostic, comparative study.

The Million Hearts initiative: Guidelines and best practices.

Million Hearts is a national initiative to improve the nation's cardiovascular health through evidence-based practices and prevention. This article reviews the ABCS of Million Hearts with an emphasis on NP-led care models. Recommendations for clinical practice, education, research, and health policy are highlighted.

Silicone proximal interphalangeal joint arthroplasty for primary osteoarthritis using a volar approach.

PURPOSE: To evaluate the short-term clinical and radiographic outcome of a silicone proximal interphalangeal (PIP) joint implant using a volar approach in patients with primary osteoarthritis. METHODS: We retrospectively reviewed 36 proximal PIP joints that were replaced with Avanta silicone implants in 26 patients. Inclusion criteria were diagnosis of primary osteoarthrtitis of the PIP joint and failure to respond to conservative treatment. Clinical asessment included range of motion, patient satisfaction, and pain scores. The Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire was administered at final follow-up. Radiographs were reviewed for alignment and implant fracture. Complications were also recorded. RESULTS: After an average follow-up of 18 months (range, 12-60 mo), pain relief was markedly reduced in all patients, decreasing from a mean score of 7.2 preoperatively to 0.4 postoperatively. The arc of active motion of the PIP joint improved from 33° to 72°. Satisfaction averaged 4.8 on a 5-point Likert scale, and all patients stated they would repeat the surgery. The median final average Quick-Disabilities of the Arm, Shoulder, and Hand score was 7 (range, 4-12). Radiograph review showed 2 implant fractures at 1 and 2 years after surgery, respectively, but without clinical changes. The average deformity in the coronal plane changed from 12° (range, 8° to 18°) preoperatively to 4° (range, 3° to 8°) postoperatively, whereas the average flexion contracture changed from 18° (range, 10° to 30°) to 0° (all patients achieved full active extension). No other complications were observed. No revision surgery has been needed to date. CONCLUSIONS: The volar approach to PIP joint silicone arthroplasty offers the advantages of maintaining the integrity of the extensor mechanism, providing pain relief, and improving postoperative range of motion with minimal complications. However, further research is needed to determine the long-term efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.