Concurrent uper limb and hip fracture in the elderly: experience at our centre. / Fracturas concomitantes de miembro superior y cadera en pacientes mayores de 65 años: experiencia en nuestro centro.

INTRODUCTION: The incidence of hip fracture in the elderly is on the rise, occasionally accompanied by concurrent upper limb fractures. Our investigation aims to determine whether these patients experience poorer functional outcomes, prolonged hospitalization, or higher mortality rates when compared to those with isolated hip fracture. MATERIAL AND METHODS: We retrospectively reviewed 1,088 elderly patients admitted to our centre with hip fracture between January 2017 and March 2020. We recorded the presence of concomitant fractures and their treatment. We analyzed the duration of hospital stay, in-hospital mortality and function. RESULTS: We identified 63 patients with concomitant upper limb fracture (5.6%). Among them, 93.7% were women, and the average age was 86.4 years. 80.9% of the upper limb fractures were distal radius or proximal humerus. Patients with concomitant fracture had increased length of stay (mean, 19.6 vs, 12.8, p=0.002), decreased proportion of patients returning to their own home at discharge (23.6% vs, 26.3%, p=0.042) and increased in-hospital mortality rate (9.5% vs, 5.9%, p=0.003). CONCLUSIONS: Patients with concomitant upper limb fracture require a longer length of stay and exhibit an elevated in-hospital mortality rate. Furthermore, this condition is associated with a reduced short-term functional recovery, thereby decreasing the chances of the patient returning home upon hospital discharge.

Best Practice Framework of Fracture Liaison Services in Spain and their coordination with Primary Care.

The coordination of Fracture Liaison Services (FLS) with Primary Care (PC) is necessary for the continuity of care of patients with fragility fractures. This study proposes a Best Practice Framework (BPF) and performance indicators for the implementation and follow-up of FLS-PC coordination in clinical practice in Spain. PURPOSE: To develop a BPF for the coordination of FLS with PC in Spain and to improve the continuity of care for patients with fragility fractures. METHODS: A Steering Committee selected experts from seven Spanish FLS and related PC doctors and nurses to participate in a best practice workshop. Selection criteria were an active FLS with an identified champion and prior contact with PC centres linked to the hospital. The main aim of the workshop was to review current FLS practices in Spain and their integration with PC. A BPF document with processes, tools, roles, and metrics was then generated. RESULTS: Spanish FLS consists of a multidisciplinary team of physicians/nurses but with low participation of other professionals and PC staff. Evaluation and treatment strategies are widely variable. Four desired standards were agreed upon: (1) Effective channels for FLS-PC communication; (2) minimum contents of an FLS clinical report and its delivery to PC; (3) adherence monitoring 3 months after FLS baseline visit; and (4) follow-up by PC. Proposed key performance indicators are (a) number of FLS-PC communications, including consensus protocols; (b) confirmation FLS report received by PC; (c) medical/nursing PC appointment after FLS report received; and (d) number of training sessions in PC. CONCLUSIONS: The BPF provides a comprehensive approach for FLS-PC coordination in Spain, to promote the continuity of care in patients with fragility fractures and improve secondary prevention. The implementation of BPF recommendations and performance indicator tracking will benchmark best FLS practices in the future.

Spanish National Hip Fracture Registry (RNFC): analysis of its first annual report and international comparison with other established registries.

Hip fracture registries have helped improve quality of care and reduce variability, and several audits exist worldwide. The results of the Spanish National Hip Fracture Registry are presented and compared with 13 other national registries, highlighting similarities and differences to define areas of improvement, particularly surgical delay and early mobilization. INTRODUCTION: Hip fracture audits have been useful for monitoring current practice and defining areas in need of improvement. Most established registries are from Northern Europe. We present the results from the first annual report of the Spanish Hip Fracture Registry (RNFC) and compare them with other publically available audit reports. METHOD: Comparison of the results from Spain with the most recent reports from another ten established hip fracture registries highlights the differences in audit characteristics, casemix, management, and outcomes. RESULTS: Of the patients treated in 54 hospitals, 7.208 were included in the registry between January and October 2017. Compared with other registries, the RNFC included patients ≥ 75 years old; in general, they were older, more likely to be female, had a worse prefracture ambulation status, and were more likely to have extracapsular fractures. A larger proportion was treated with intramedullary nails than in other countries, and spinal anesthesia was most commonly used. With a mean of 75.7 h, Spain had by far the longest surgical delay, and the lowest proportion of patients mobilized on the first postoperative day (58.5%). Consequently, development of pressure ulcers was high, but length of stay, mortality, and discharge to home remained in the range of other audits. CONCLUSIONS: National hip fracture registries have proved effective in changing clinical practice and our understanding of patients with this condition. Such registries tend to be based on an internationally recognized common dataset which would make comparisons between national registries possible, but variations such as age inclusion criteria and follow-up are becoming evident across the world. This variation should be avoided if we are to maximize the comparability of registry results and help different countries learn from each other's practice. The results reported in the Spanish RNFC, compared with those of other countries, highlight the differences between countries and detect areas of improvement, particularly surgical delay and early mobilization.

Spanish National Hip Fracture Registry (SNHFR): a description of its objectives, methodology and implementation / Registro Nacional Español de Fracturas de Cadera (RNFC): descripción de sus objetivos, metodología e implementación

Objective: To ascertain the current situation and clinical variability of the provision of care for Hip Fracture (HF) in Spain and the factors related to it by using a National Registry (NHFR) with high patient numbers and territorial representation NHFR, and to compare results on a national and international level and propose standards and criteria to improve healthcare quality. Design: Continuous registry for at least three years of a representative sample of patients admitted to Spanish hospitals due to HF using the Minimum Common Dataset - international Fragility Fracture Network (FFN) MCD, adapted for Spanish. Study scope and subjects: all patients over the age of 74 years who are hospitalized with a diagnosis of a fragility HF at the participating hospitals distributed throughout the Spanish territory. Initially 48 hospitals are included, and we expect to incorporate the highest number of sites possible. Results: It is expected to ascertain the current situation of provision of care for HF in Spain. Each hospital will be offered information regarding their results and their situation compared to the rest. The results from national hospitals will be compared to others included in the registry and to hospitals abroad, which use the same database. Variability will be studied, care standards will be established, and objectives will be proposed for the continuous improvement of the care process of this condition

Objetivo: Conocer la situación actual y la variabilidad clínica del proceso asistencial a la Fractura de Cadera (FC) en España y los factores relacionados con la misma mediante la utilización de un Registro Nacional (RNFC) con elevada casuística y representación territorial RNFC, así como comparar resultados en el ámbito nacional e internacional y proponer estándares y criterios para mejorar la calidad asistencial. Diseño: Registro continuo durante al menos tres años de una muestra representativa de los pacientes ingresados por FC en los hospitales españoles mediante el Minimum Common Dataset - MCD internacional de la Fragility Fracture Network (FFN) adaptado al castellano. Ámbito y sujetos del estudio: se incluirán todos los pacientes mayores de 74 años hospitalizados con el diagnóstico de FC por fragilidad en los hospitales participantes repartidos por el territorio español. Inicialmente están incluidos 48 hospitales, a los que se espera que se vayan incorporando el mayor número posible de centros. Resultados: Se pretende conocer la situación actual de la atención a este proceso en España Se ofrecerá a cada hospital la información de sus resultados y su situación en relación al resto, se compararán los resultados de los hospitales nacionales entre sí y con los hospitales extranjeros incluidos en registros que usan la misma base de datos. Se estudiará la variabilidad, se establecerán estándares asistenciales y se plantearán objetivos para la mejora continua del proceso en la atención a esta patología

Spanish National Hip Fracture Registry (SNHFR): a description of its objectives, methodology and implementation.

OBJECTIVE: To ascertain the current situation and clinical variability of the provision of care for Hip Fracture (HF) in Spain and the factors related to it by using a National Registry (NHFR) with high patient numbers and territorial representation NHFR, and to compare results on a national and international level and propose standards and criteria to improve healthcare quality. DESIGN: Continuous registry for at least three years of a representative sample of patients admitted to Spanish hospitals due to HF using the Minimum Common Dataset - international Fragility Fracture Network (FFN) MCD, adapted for Spanish. STUDY SCOPE AND SUBJECTS: all patients over the age of 74 years who are hospitalized with a diagnosis of a fragility HF at the participating hospitals distributed throughout the Spanish territory. Initially 48 hospitals are included, and we expect to incorporate the highest number of sites possible. RESULTS: It is expected to ascertain the current situation of provision of care for HF in Spain. Each hospital will be offered information regarding their results and their situation compared to the rest. The results from national hospitals will be compared to others included in the registry and to hospitals abroad, which use the same database. Variability will be studied, care standards will be established, and objectives will be proposed for the continuous improvement of the care process of this condition.

Adecuación de las restricciones físicas y farmacológicas en los ancianos institucionalizados: estudio comparativo en Québec y la Suiza Romanda, con implicaciones en nuestro medio / Appropriateness of the use of physical restraints and psychotropic medication in institutionalised older people: comparative study in Quebec and French Switzerland. Applicability to Spain

Objetivo: analizar la variabilidad dentro y entre diferentes países en el empleo de restricciones físicas y fármacos psicotropos en mayores de 65 años institucionalizados en centros de Québec y la Suiza Romanda, y estudiar la aplicabilidad de estos resultados a futuros estudios en nuestro medio. Material y método: se analizan los datos de los individuos institucionalizados en Québec y la zona francófona de Suiza mediante el sistema de información denominado PLAISIR, utilizado en dichos centros para la gestión y el análisis de los recursos financieros. Se obtienen datos de todos los ingresos habidos en 1998 en 179 instituciones de Québec (n = 8.183) y en 250 residencias de Suiza (n = 7.592). Las restricciones físicas se clasifican en fijas y móviles. A través de las Defined Daily Doses se codifica la prescripción diaria y semanal de psicotropos. Se determina la prevalencia de cada uno de los medios físicos y farmacológicos y, posteriormente, se calcula un índice de pertinencia de empleo de cada una de ellas por un método de ajuste indirecto. Mediante el análisis de regresión logística se estiman los valores esperados de uso de las diferentes restricciones en función del estado de salud y la situación funcional de los residentes. Resultados: la proporción de residentes con dependencia de otras personas es elevada en ambas regiones, y alcanza un 80% en las instituciones suizas y un 90% en las canadienses. Se observa una alta variabilidad en el empleo de los diferentes métodos restrictivos, tanto entre países como entre instituciones: los psicotropos se prescriben más en Suiza (78%) que en Québec (67%), mientras que las restricciones físicas se usan más en Québec (76%) que en Suiza (40%). La adecuación de su uso varía de forma importante y no puede atribuirse únicamente a las características de los residentes Conclusiones: la alta variabilidad observada en la adecuación del empleo de diferentes medios restrictivos, físicos y farmacológicos refleja probablemente la ausencia de aplicación de estándares de calidad y/o una legislación insuficiente, tanto en Québec como en Suiza. Estos resultados ilustran un método útil para iniciar la investigación sobre la prevalencia y la adecuación del uso de estos métodos en España

Objective: a) to examine intra- and inter-country variability in the use of physical restraints and psychotropic medication in institutionalised people older than 65 in Quebec and in Romande, Switzerland, and b) to study the applicability of the results to future studies in Spain. Material and method: data were collected through PLAISIR, an information system on persons institutionalised in Quebec and French-speaking Switzerland used for financing and planning, resource allocation and management, utilisation control and quality assurance. Data were obtained from all new admissions to 179 institutions in Quebec (n = 8183) and to 250 institutions in Switzerland (n = 7592) in 1998. Physical restraints were classified into fixed and mobile. Daily and weekly uses of psychotropic medication were coded by defined daily doses. The prevalence of the use of physical restraints and psychotropic medication were estimated and an index of the appropriateness of the use of each was calculated by an indirect adjustment method. A logistic regression model on the use of both types of restriction based on residents’ health and functional status was calculated to estimate expected values of use. Results: the rate of dependency was high in residents of both regions. Approximately 80% of residents in French Switzerland and 90% of those in Quebec were dependent for activities of daily living. Intra- and inter-country variability in the use of restrictions is high: psychotropic medication was more often used in French Switzerland (78%) than in Quebec (67%), while physical restraints were more often used in Quebec (76%) than in French Switzerland (40%). The appropriateness of use varied widely within both regions and cannot be fully explained by the characteristics of the residents. Conclusions: the high variability in the use of physical restraints and psychotropic medication may be a result of the absence of standards of quality and/or legislation both in Quebec and in French Switzerland. This research illustrates a method that could be useful to investigate the prevalence and appropriateness of the use of these restriction methods in Spain

Crisis comiciales en el anciano / Seizures in the elderly

Las crisis comiciales se encuentran entre los trastornos neurológicos más frecuentes de anciano, manifestando unas características propias tanto en su etiología como en su presentación clínica o en su proceso diagnóstico y tratamiento. Entre las causas que más frecuentemente producen crisis sintomáticas en el anciano se encuentra en primer lugar la enfermedad cerebrovascular, seguida de los trastornos tóxico-metabólicos, los traumatismos, la deprivación alcohólica y las infecciones del sistema nervioso central. En el manejo de un paciente con sospecha de crisis comicial se debe realizar una completa historia clínica, recogiendo los antecedentes personales y familiares e información del propio paciente y de los testigos que hayan presenciado el episodio; se debe poner en marcha un estudio diagnóstico en el que se incluya un estudio analítico completo, una prueba de imagen y un estudio neurofisiológico; se debe realizar el diagnóstico diferencial con diversas entidades, especialmente con accidentes isquémicos transitorios, síncopes vasovagales y episodios de amnesia global transitoria. A la hora de iniciar tratamiento se debe tener en cuenta el balance entre el riesgo de recurrencia, los beneficios de evitar las consecuencias de una segunda crisis, las profundas implicaciones psicosociales que la epilepsia produce sobre la calidad de vida de los ancianos y el riesgo de efectos secundarios de los fármacos anticomiciales (AU)

[Preoperative geriatric assessment in major surgery in the aged]. / Valoración preoperatoria geriátrica en la cirugía mayor del anciano.

The objective of this study is to investigate if a comprehensive geriatric assessment is useful for predicting morbimortality, functional impairment and the risk for institutionalization for elderly patients after major surgery. A prospective study was carried out at a tertiary hospital, between April and June 1993, including those elderly surgical inpatients for whom a preoperative assessment of the Geriatric Department was demanded. Beside traditional parameters of surgical risk (ASA clas, Goldman index, respiratory and nutritional risk), other medical, functional and social parameters were evaluated. A perioperative follow-up was made and a new functional evaluation one month after discharge. 49.5% of the patients presented perioperative complications and the mortality rate was 10%. 11% needed residential accommodation after discharge. Traditional surgical risks as well as previous functional capacity were predictors of perioperative morbimortality. But only previous functional capacity and nutritional status predict institutionalization. No predictors of functional impairment were found, with the exception of perioperative complications.