Risk scoring models for patients with proximal femur fractures: Qualitative systematic review assessing 30-day mortality and ease of use.

BACKGROUND: Hip fractures are a common orthopaedic injury affecting a particularly frail and vulnerable patient cohort. They are at risk of many complications, including prolonged length of stay and mortality. Efforts to identify those at high risk may be beneficial. Over 25 risk prediction models are published for patients with hip fractures. AIM: The primary aim of this study was to assess the performance of predictor scores in predicting 30-day mortality. The secondary aim was to assess the ease of use of these systems. METHODS: A qualitative systematic review was performed. A search was conducted on online databases, including PubMed, CINAHL, Clinical Trials.gov, Cochrane, DARE, EMBASE, SCOPUS, and Web of Science.. The terms fragility hip fractures and risk prediction models were utilised while performing the search. These were then expanded using Boolean operators and similar terms. Search results were imported to Covidence. Primary observational studies using one or more hip fracture mortality prediction models and 30-day mortality as an outcome were included. Systematic reviews and studies on specific patient groups defined other medical conditions (e.g. COVID positive or dialysis patients) were excluded. RESULTS: 3,101 studies were screened following duplicate removal. 34 papers were included in the review, in which 23 scoring systems were reported. Six of these were pre-operative and reported in multiple studies. Most demonstrated appropriate fit and fair discrimination. Five of the six pre-operative scoring systems examined, displayed appropriate ease of use, allowing risk calculation at the time of admission. CONCLUSION: Nottingham Hip Fracture Score remains the most extensive reported scoring system and performs fair overall with AUROCs of 0.64-0.80 and good fit in calibration across all studies. However, new systems utilise many similar predictors. There is a need for the standardisation of publications on scoring systems to allow further systematic review and meta-analyses.

Losing your head? An evaluation of the readability and reliability of patient information available online for avascular necrosis of the head of the femur.

TITLE: Losing your head? An evaluation of the readability and reliability of patient information available online for Avascular Necrosis of the Head of Femur. BACKGROUND: Avascular necrosis of the head of femur commonly affects patients with an average age of 58.3 years, and is generally managed in the elective setting, allowing patients a timeframe to research their diagnosis and management options. The aim of this study is to evaluate the readability and reliability of the information available online to patients about this condition. METHODS: Google, Bing and Yahoo internet search engines were utilised, using the search terms "Avascular necrosis head of femur" and "hip avascular necrosis", with the first 30 URLs selected for analysis. Readability was assessed using an online readability calculator to produce 3 scores (Gunning FOG, Flesch Kincaid Grade and Flesch Reading Ease). Information quality was assessed using a HONcode detection web-extension and the JAMA benchmark criteria. RESULTS: 86 webpages were identified for inclusion for assessment. CONCLUSION: The majority of the information available online about avascular necrosis of the head of the femur is not at an appropriate reading level for the general population, and less than 20% of the most accessible information available online is accredited to be of sufficient quality to be providing advice to patients. Medical professionals must work together to improve health literacy among the patients encountered, and ensure recommendation of only reliable and accessible sources of information should patients ask for guidance on finding these resources.

The association between weather warnings and hip fractures in the Republic of Ireland.

This study examined the relationship between hip fractures and weather warnings with the hypothesis higher rates of fractures occur during warnings. National hip fracture database and weather warning records were utilised. Higher rates of hip fractures were found with severe warnings. This has implications for planning in future severe warnings. BACKGROUND: Hip fractures represent a significant burden on the Irish Health system with 3666 in 2020. The Irish National Meteorological Service operates a colour coded warning system. Yellow being least severe, while orange represents weather with capacity to impact individuals in affected areas and red represents advice to protect themselves and property. Previous studies investigated the seasonality of hip fractures, which remains but none have investigated the relationship between weather warnings and rates of hip fractures. The hypothesis was that increasing weather warnings would be associated with increased hip fractures. The aim was to investigate the relationship between weather warnings and hip fractures in the Republic of Ireland. METHODS: Comparison of national weather warning archives from 2013 to 2019 to Fracture Database records. Reviews assessed whether fractures occurred on days a weather warning was in place in the individual's local county. A statistical analysis of warning features and their relationship to hip fractures was then performed. Fractures and weather warnings were stratified by county with both a panel and case crossover analysis performed. RESULTS: There was a tendency towards increased incidence of hip fractures with weather warnings in adjusted analysis (IRR 1.02; 95%CI 0.99-1.06; p-value 0.123). Orange warnings were associated with a statistically higher incidence of fractures (IRR 1.06; 1.01-1.12; p-value 0.026). In both panel and case crossover analysis, both orange and yellow warnings were associated with fractures. Red warnings were associated with a lower incidence of fracture on day of warning (adjusted incidence rate ratio 0.92; 0.70-1.22; p-value 0.569) but a higher incidence on the following day (adjusted incidence rate ratio 1.14; 0.88-1.46; p-value 0.313). CONCLUSION: An increased incidence of hip fractures appears to occur during weather warnings. Consideration should be given when preparing for periods of extreme weather, ensuring sufficiently resources.

Internship commencement during COVID-19: the impact of an extended induction model.

BACKGROUND: The COVID-19 pandemic necessitated an enforced 8-week induction period (18 May to 12 July 2020) for all new interns in Ireland. These unprecedented circumstances presented a unique opportunity to assess this induction period. AIM: To assess the impact of a prolonged induction period on the technical abilities of interns embarking on their clinical careers. METHOD: We distributed a 12-item questionnaire to new interns at our institution during the COVID-19 pandemic. Section 1 of the questionnaire was designed to assess the rate of self-reported improvement in the successful and independent execution of practical 'intern' tasks. Section 2 of the questionnaire captured the subjective experience of interns during this time in relation to the effectiveness of an 8-week induction period with senior intern support available. Statistical analysis of categorical predictor and ordinal outcome variables was performed using the two-sample Wilcoxon rank-sum (Mann-Whitney) test. RESULTS: Our results demonstrated a statistically significant improvement in the proficiency at first attempt phlebotomy in week 8 compared with week 1 (p < 0.0001). There was a significant improvement in placing first-attempt peripheral IV lines in week 8 compared with week 1 (p < 0.001). Regarding the need for senior assistance, we demonstrated a statistically significant reduction in week 8 compared with week 1 (p = 0.046). There were 95.56% (n = 43) of interns that said they would recommend the induction period for future incoming interns. CONCLUSION: The COVID-19 pandemic has inadvertently identified a model of internship induction that benefits interns, their colleagues and their patients through the production of more technically capable interns.

Lessons from lockdown: Virtual Clinics and service reorganisation in fracture management during COVID 19 experience of an Irish Regional Trauma Unit.

BACKGROUND: Trauma places a burden on healthcare services accounting for a large proportion of Emergency Department presentations. COVID-19 spread rapidly affecting over 30 million worldwide. To manage trauma presentations the Department of Trauma & Orthopaedic Surgery reorganised service delivery. AIM: To assess the impact of service reorganisation and Virtual Clinics on patients in a Regional Unit in Ireland. METHODS: A retrospective review of trauma activity following introduction of Virtual Fracture Clinics and Theatre COVID Pathways for a 10 week period in comparison with the same 2019 period. All patients underwent both nasopharyngeal and oropharyngeal swabs PCR testing prior to operations. Theatre and outpatient activity were evaluated. Clinic data were accumulated using the Integrated Patient Management System. RESULTS: Theatre Activity: 242 patients underwent surgery in our trauma unit (mean 2.98 per list) during the COVID- 19 period. 29 cases were performed in repurposed elective hospital giving a total of 271 during the 2020 study period. 371 cases were performed in the same 2019 period (mean 4.58 per list). Outpatient Activity: We noted a 25.86% fracture clinic referral reduction during the COVID 19 period compared to 2019. There was a 150.77% increase in patients managed through Trauma Assessment Clinic. 639 patients were managed through the Virtual Fracture Clinic Pathway during COVID 19 period. CONCLUSIONS: Over one in four fracture clinic patients can be managed virtually. A new dedicated Acute Fracture Unit within our institution permitted streamlining of care and social distancing. The "Non-COVID" pathway for ambulatory trauma was essential in managing the growing presentations of these injuries.

Ankle conFUSION: The quality and readability of information on the internet relating to ankle arthrodesis.

BACKGROUND: The internet is an important source of information for patients undergoing surgery. Multiple studies have identified inappropriately high reading levels of patient information online. The average reading level in the United States is 7-8th grade. Multiple organisations have recommended that patient information not exceed 6th grade level. This study aims to evaluate the reading levels and quality of information regarding ankle fusion surgery online. METHODS: Google, Bing and Yahoo were searched (MeSH "ankle fusion", "ankle arthrodesis") and the top 30 URLs analysed. Readability was assessed using an online readability calculator to produce 3 scores (Gunning FOG, Flesch Kincaid Grade and Flesch Reading Ease). Quality was assessed using a HONcode detection web-extension and the JAMA benchmark criteria. RESULTS: Ninety-eight webpages were identified. The mean Flesch Kincaid Grade level was 9.24 ± 2.33 (95% CI 8.78-9.71). The mean Gunning FOG grade was 10.88 ± 3.1 (95% CI 10.26-11.5). The mean Flesch Reading Ease score was 49.88 ± 14.46 (95% CI 46.98-52.78). 7 webpages were at or below the 6th grade reading level. The mean JAMA score was 1.34 ± 1.32 out of 4 (95% CI 1.07-1.6). 14 websites were HONcode accredited. CONCLUSION: The overall readability of medical information online is too high for the average patient. Given the important role that health literacy provides in patient reported outcomes, improving the readability and quality of these materials is imperative. Awareness by the general public is essential for them to critically appraise the information they receive online.

Assessing the Diagnostic Accuracy of Multimedia Messaging for the Diagnosis of Scaphoid Fractures.

Introduction:Use of smartphone messaging applications, such as WhatsApp, for communication within clinical teams is widespread. Various studies have shown multiple uses for smartphones and multimedia messaging in orthopedic clinical practice for coordinating clinical duties and diagnosing various injuries but none have assessed scaphoid fractures. Our aims were to: (1) assess diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value) of viewing scaphoid X-rays on smartphones compared with desktop computers by using radiologist reports on the same X-rays as a reference test and (2) assess the intra-observer reliability of these studies.Methods:This was a prospective cross-sectional study of diagnostic accuracy using paired tests. The standard for reporting diagnostic accuracy (STARD) guidelines were used in its design. We asked orthopedic specialist registrars to interpret whether a scaphoid fracture was present on 20 scaphoid X-rays, obtained from the National Integrated Medical Imaging System (NIMIS). These were viewed on a desktop and on a smartphone. Data were then analyzed by using STATA 14 to run McNemar's test and to compare the sensitivity and specificity of the two index tests.Results:Phone and desktop interpretation had good sensitivity (72.7% and 78.2%) and specificity (75.2% and 77.9%) in assessing scaphoid fractures with no significant difference in sensitivity (p-value = 0.507) or specificity (p-value = 0.547). There was fair to moderate intra-observer reliability (kappa score 0.436; 95% confidence interval 0.295-0.577).Discussion:The fair to moderate scores of intra-observer agreement reflect the difficulty of diagnosing scaphoid fractures on X-rays. This study supports the use of smartphones for the diagnosis of scaphoid fractures.