Nurses' Perception of Tension, Stress, and Pressure before and during the COVID-19 Pandemic: A Multicenter Serbian Study.

The mental health of healthcare workers, especially the nursing staff in intensive care units, is crucial for the optimal functioning of healthcare systems during medical emergencies. This study implements a cross-sectional design to investigate the associations between nurses' personal characteristics, workplace challenges, and job satisfaction with the increased perception of tension, stress, and pressure at the workplace (TSPW) before and during the COVID-19 pandemic. In 2021, we surveyed 4210 nurses from 19 intensive healthcare facilities in the capital of Serbia, Belgrade, and, at that time, collected data about their perceived TSPW before and during the COVID-19 pandemic. Our study identified six predictors of the increase in TSPW, as perceived by nurses: their work in COVID-19 infectious zones (OR = 1.446), exhaustion due to work under protective equipment (OR = 1.413), uncertainty and fear of infection (OR = 1.481), a high degree of superiors' appreciation and respect (OR = 1.147), a high degree of patients' attitudes (OR = 1.111), and a low degree of work autonomy (OR = 0.889). The study's findings suggest that a solution to this issue is necessary to ensure that nurses are safe and able to alleviate the physical and mental strain that comes with prolonged use of protective equipment. Nurses on the frontline of the pandemic require better health protection, better conditions, and respect for their role. Strategies to promote mental health would help reduce nurses' stress and increase job satisfaction.

Chronic post-surgical pain after knee arthroplasty: a role of peripheral nerve blocks.

Introduction: Peripheral nerve blocks are an efficient method of pain control after total knee arthroplasty (TKA), but there is no report of their impact on chronic post-surgical pain (CPSP). Methods: This prospective observational study aimed to assess adductor canal block (ACB) and IPACK block (blocks vs. no blocks) on opioid consumption, postoperative pain score, chronic post-surgical pain 2 years after TKA. Results: 166 patients (82 vs. 84) were analyzed. Opioid consumption was less in the group with blocks (9.74 ± 3.87 mg vs. 30.63 ± 11.52 mg) (p < 0.001). CPSP was present in 20.24% of patients in the group without blocks and 6.1% of patients with blocks (p = 0.011). Predictor variables of CPSP included pain before surgery (cut-off of 5.5), pain at rest (cut-off of 2.35), pain during active movement (cut-off: 2.5), and opioid consumption (cut-off: 8 mg). Conclusion: Peripheral nerve blocks provide adequate analgesia, significantly decrease opioid consumption, improve functional outcomes, and reduce CPSP 2 years after surgery.

Associations between early postoperative pain outcome measures and late functional outcomes in patients after knee arthroplasty.

INTRODUCTION/AIM: Early rehabilitation, return to daily life activities and function are the ultimate goals of perioperative care. It is unclear which pain-related patient-reported outcome measures (PROM) mirror treatment effects or are related with early and late functional outcomes. METHODS: We examined associations between two approaches of pain management (scheduled vs 'on demand') and PROMs on post-operative days one and five (POD1, 5) with function on POD5 and 3 months after surgery in patients undergoing Total Knee Arthroplasty (TKA) in a single centre. The scheduled pain management consisted of pain assessment and routine administration of non-opioid drugs, and a weak opioid based on severity of pain reported by patients. The 'on demand' group received non-opioids and/or a weak opioid only when asking 'on demand' for analgesics. RESULTS: On POD1, patients in the scheduled treatment group reported reduced severity of worst pain, less interference of pain with activities in-bed and sleep, and a higher proportion got out of bed. On POD5, these patients reported as well significantly less worst pain, spent significantly less time in severe pain, experienced less interference of pain with activities in bed, and felt less helpless. Furthermore, tests of function, extension and flexion ranges, Barthel index and 6 minutes walking test on POD5, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) 3 months later were significantly better in the scheduled treatment group compared to the 'on demand' treatment group. Pain related PROMs assessed at POD1 and especially at POD5 are associated with better knee range of motion, better performance in activities of daily living, and faster gait speed, as well as less pain, better performance in activities of daily living, as well as higher knee-related quality of life 3 months postoperatively. CONCLUSIONS: Our study demonstrates that severe postoperative pain after TKA might have long lasting consequences, and even small improvements in treatment, although being far from optimal, are accompanied by improved outcomes.

Simultaneous Hip and Distal Radius Fractures-Does It Make a Difference with Respect to Rehabilitation?

INTRODUCTION: A minority of patients with hip fractures sustain concomitant wrist fractures. Little is known about the rehabilitation outcome in this group of patients. AIM OF STUDY: Prospective investigation of functional outcome and survival in patients with combined hip and wrist fractures compared with patients who sustain an isolated hip fracture. METHODS: 341 patients who presented with an acute hip fracture during a 12 month period were included in the study. Outcome at discharge and 4 months follow-up was compared between patients with isolated hip fractures and those patients who sustained simultaneous distal wrist fractures. RESULTS: The actual incidence of concurrent hip and wrist fractures in our cohort was 4.7%. Patients who sustained a concurrent hip and wrist fracture showed no differences regarding short- and long-term functional outcome and survival. CONCLUSION: Our results imply that patients with simultaneous hip and wrist fractures have no difference in rehabilitative outcome. Future studies should further investigate the distinctive characteristics of this patient subgroup.

Can early assessment of hand grip strength in older hip fracture patients predict functional outcome?

Decreased muscle strength is not only a risk factor for hip fracture in older patients, but plays a role in recovery of physical function. Our aim was to assess the role of grip strength measured early after hip fracture, and classified according to the EWGSOP2 criteria in predicting short- and long-term functional recovery. One hundred ninety-one patients with acute hip fracture consecutively admitted to an orthopaedic hospital have been selected. A multidimensional geriatric assessment evaluating sociodemographic variables, cognitive status, functional status and quality of life prior to fracture, as well as perioperative variables were performed. Follow-ups at 3 and 6 months after surgery were carried out to evaluate functional recovery. Multivariate regression models were used to assess the predictive role of handgrip strength. The mean age of the participants was 80.3 ±6.8 years. Thirty-five percent of our patients with clinically relevant hand grip strength weakness were significantly older, more often female, had a lower BMI, and were of worse physical health. They also had a lower cognitive level, lower Barthel index, and lower EQ5D scores before fracture. Multivariate regression analysis adjusted for age and gender revealed that hand grip weakness was an independent predictor of worse functional outcome at 3 and 6 months after hip fracture for both genders and in all age populations. Our study supports the prognostic role of hand grip strength assessed at hospital admission in patients with hip fracture. Thus, clinicians should be encouraged to include hand grip assessment in their evaluation of hip fracture patients in the acute setting in order to optimize treatment of high-risk individuals.

The efficacy and safety of autologous conditioned serum (ACS) injections compared with betamethasone and placebo injections in the treatment of chronic shoulder joint pain due to supraspinatus tendinopathy: a prospective, randomized, double-blind, controlled study.

AIMS: Autologous conditioned serum (ACS; marketed as Orthokine®) is an autologous blood product that has previously shown efficacy in treatment of joint osteoarthritis, spinal radiculopathy, tendon and muscle injuries in randomized controlled trials. In this 24-week, randomized, double-blind study, we compared the efficacy and safety of ACS with glucocorticoid (betamethasone) injections in chronic supraspinatus tendinopathy patients. MATERIAL AND METHODS: Thirty-two patients with chronic supraspinatus tendinopathy were enrolled in the study. The ACS group received four ACS injections once weekly over four weeks and the glucocorticoid group received three betamethasone injections once weekly over three weeks with a placebo (saline) injection at week 4 into the enthesis and paratenon of the supraspinatus tendon. Study endpoints were pain intensity (VAS) and Constant Shoulder Score (CSS) assessed at weeks 0, 4 and 24. RESULTS: Shoulder pain intensity improved after 4 weeks and significantly improved after 24 weeks in patients treated with ACS compared with those treated with glucocorticoids (pain intensity week 4: ACS=22.0, glucocorticoid=32.0; week 24: ACS=15.0, glucocorticoid=40.0). CSS improved to a similar extent in both groups after 4 weeks. After 24 weeks, ACS patients exhibited significantly greater CSS improvements than glucocorticoid patients. Adverse events (n=8) were reported in betamethasone patients. CONCLUSIONS: Compared with betamethasone, ACS therapy improved joint function and reduced shoulder pain more effectively after 4 weeks of treatment; these improvements were sustained to week 24. Combined with its favorable safety profile, ACS appears to be a more effective treatment than glucocorticoids and could enhance the quality of life in patients with chronic rotator cuff tendinopathy.

Prolonged pre-operative hospital stay as a predictive factor for early outcomes and mortality after geriatric hip fracture surgery: a single institution open prospective cohort study.

INTRODUCTION: The aim of this open prospective cohort study was to determine if a prolonged pre-operative hospital stay is a true predictor of higher morbidity or mortality in geriatric patients with hip fractures. MATERIALS AND METHODS: We analysed early outcome parameters, such as functional independence measure (FIM), at discharge and four months post-operatively, peri-operative nonsurgical complications, intra-hospital and one year mortality compared with prolonged pre-operative hospital stay in 308 patients from a continuous cohort of 344. RESULTS: Average pre-operative stay was 8.39 ± 5.80 days. Delaying surgery for > 72 hours was independently predictive for general complications and lower motor FIM gain at four months. All findings worsen progressively after the fifth day of delay. Pre-operative period was not found to be an independent predictor of mortality. CONCLUSION: In all observed outcome parameters except mortality, pre-operative delay > 72 hours was shown to be a true predictive factor.

Evaluation of reversal osteofixation using K-wires in digital replantation.

INTRODUCTION: Modified, reversal technique of fixation in digital replantation using K-wires was analyzed. The results obtained from the standard technique and reversal technique of fixation using K-wires were compared. OBJECTIVE: The aim was to compare the results of osteofixation using K-wires in digital replantation when either standard or reversal, modified technique was used. METHODS: A retrospective study included 103 replanted fingers in 72 patients. The first group included standard fixation using K-wires and the second group included fixation using K-wires, but with a modified technique. Modification consisted of the opposite order of moves during the phalanges fixation compared to the standard technique: first, K-wire was introduced intramedullary in the proximal phalanx and the top of the wire was drawn out through the skin in proximal part of the finger or hand. Second, distal part of the wire was introduced in the phalanx of the amputated part of the finger intramedullary until the wire entered the cortex. RESULTS: Duration of bone healing after digital replantation was shorter in cases where reversal technique was used in comparison with standard technique (7.2 weeks compared to 7.5 weeks). CONCLUSION: The comparison of standard and reversal technique of phalangeal fixation with K-wires in digital replantation shows that both techniques are useful. Reversal technique expands the choice of operative techniques for bone fixation during the replantation. It shows some advantages and enables avoidance of vein injuries.

[Use of free vascularized fibular graft flap in the treatment of large bone defects after limb injury].

Free vascularized fibular graft is of the greatest importance in the orthopaedics and trauma. Bone, skeletal defects due to the trauma, infections and congenital anomalies could be successfully solved by the free vascularized fibular grafts. In this article the main anatomical data of fibular graft, surgical techniques, indications for the FVFG in the treatment of trauma caused bone defects or its complications -sequels are described.

Fractures of the scaphoid, diagnosis and management--a review.

The scaphoid is vitally important for the proper mechanics of wrist function. Fracture of the scaphoid bone is the most common carpal fracture. Among all wrist injuries the incidence of scaphoid fracture is second only to fractures of the distal radius. Scaphoid fractures are significant because a delay in diagnosis can lead to a variety of adverse outcomes that include nonunion, delayed union, decreased grips strength, range of motion and osteoarthritis of the radiocarpal joint. To avoid missing this diagnosis, a high index of suspicion and a through history and physical examination are necessary, because initial radiographs are often negative. Regardless of the technique of bone grafting, there will almost always be some loss of motion even if the fracture unites.

p14(ARF) methylation is a common event in the pathogenesis and progression of myxoid and pleomorphic liposarcoma.

Liposarcoma represents the most frequent group of soft tissue sarcomas. The group can be divided into three different classes: (1) differentiated/undifferentiated (WDLPS/DDLPS), (2) myxoid/round cell (MLPS/RCLPS) and (3) pleomorphic liposarcoma (PLS). It has become apparent that p53-p14 and Rb-p16 pathways play important roles in the pathogenesis of various sarcoma types. Molecular studies of the genes involved in these two pathways showed wide variations between the liposarcoma subtypes or even within the same subtype. We sought to examine mutational status of p53 and methylation status of p16 (INK4a) /p14 (ARF) genes in primary and recurrent liposarcoma tumors. There were twelve myxoid (12/18, 66.7 %) and six pleomorphic liposarcoma (6/18, 33.3 %) samples. Immunohistochemical analysis revealed that p53 protein was overexpressed in 3/12 MLPS (25 %) and 6/6 PLS (100 %). Mutational analysis showed that 2/11 MLPS (18.2 %) and 2/6 PLS (33.3 %) contained mutated p53 gene. On the other hand, 3/18 samples (16.7 %) had methylated p16 promoter. However, the frequencies of the p14 (ARF) gene methylation were 83.3 % (10/12) and 50 % (3/6) in myxoid and pleomorphic group, respectively. Overall, 15 out of 18 (83.3 %) samples had either p53 gene mutation or methylated p14 (ARF) promoter. The results from the current study suggest significant impact of the p14 (ARF) gene methylation on the pathogenesis and progression of myxoid and to a lesser extent pleomorphic liposarcoma. Despite the limited number of samples, our study points to necessity of further investigation of p53-p14 and Rb-p16 pathways in liposarcoma.

Forearm reconstruction after loss of radius: case report.

INTRODUCTION: Osteomyelitis of the radius resulting in the radial clubhand is a very rare condition and few studies have been published about its prognosis and treatment. CASE OUTLINE: This is a case report of hematogenous osteomyelitis of the radius with a complete loss of the radius leaving only the distal radial metaphysis to carry the carpus. In order to achieve best functional results, four-step operative protocol was performed for reconstruction; lengthening of the forearm by external fixator, radioulnar transposition to create a one-bone forearm, plate removal and transposition of brachioradialis to the extensor pollicis longus as well as proximal row carpectomy. After nine years of the last operation, the function of the elbow and hands is good with acceptable cosmetic result. The forearm is 5 cm shorter and there has been a persistent mild limitation of palmar flexion. CONCLUSION: Creation of the one-bone forearm normalizes the elbow and wrist function, corrects forearm malalignment, and improves forearm growth potential.

[Missed opportunities for prevention of hip fracture in older patients].

BACKGROUND/AIM: Osteoporotic fractures are a major cause of morbidity in the population. Therefore, fracture prevention strategies should be a major concern, and one of the priorities in the primary health care system. The aim of the study was to assess fracture and fall risk factors, and fracture risk level in patients with acute hip fracture, and to evaluate if there had been adequate osteoporosis treatment prior to fracture in this group of patients. METHODS: Fracture and fall risk factors were assessed in 342 patients, > or = 65 years old, hospitalized due to acute hip fracture at the Clinic for Orthopedic Surgery and Traumatology, Clinical Centre of Serbia in a 12-month period. Fall risk factors were assessed with the Fracture Risk Assessment (FRAX) algorithm, and patients were classified in respect to fracture risk level. RESULTS: Hip fracture occurred in the majority of the patients in the high risk group (74.2%), where no additional bone mineral density testing was needed. Less than 10% of the patients had a diagnosis of osteoporosis before injury, while less than 2% were treated. Cognitive impairment (95.3%), visual impairment (58.2%), lower index of daily activities (51.8%), and depression (47.1%) were the most frequently observed fall risk factors. CONCLUSION: The results of our investigation reveal insufficient identification of clinical fracture risk factors in the primary care setting, inadequate treatment of osteoporosis and, consequently, ineffective prevention of hip fractures in the geriatric population. The introduction of FRAX into clinical practice enables more effective acknowledgment of patients with elevated fracture risk, even if bone density measurement is not available. The results of this study have a special significance for everyday clinical practice, because they impose a need for reviewing the existing approaches to osteoporosis prevention, and precise definiment of hip prevention strategies.

Application of multifractal analysis on microscopic images in the classification of metastatic bone disease.

The paper considers the method, based on multifractal (MF) analysis, for classifying the shape of tissue cells from microscopis images, identifying the primary cancer in cases of metastasis bone disease. Diagnosis of primary cancer is of great importance, because further treatment depends on how successful and accurate that diagnosis is. This method can be applied as an additional and objective tool in primary cancer diagnosis, as well as in decreasing of the subjective factor and error probability. The method is tested over a large number (1050) of clinical cases from the Institute of Pathology, University of Belgrade. The results of computer-aided analysis of images have been presented and discussed.

[The treatment of subtrochanteric fractures].

Subtrochanteric fractures of the femur have a special place because of a significant number of complications following treatment. Powerful loading forces asymmetrically acting to this bone segment, as well as poor vascularization interfere with bone union. There are basically two current approaches in the fixation of subtrochanteric fractures; the first involves a plate with a compression screw and another one is intramedullary (IM) nail, with two options: centromedullary (standard interlocking femoral nail) and cephalomedullary femoral nail with two modifications, reconstructive and trochanteric. All IM nails may be used by open technique or closed minimal invasive method. IM nailing is favoured in view of a shorter operative time, shorter hospitalisation and complications. Indirect fracture reduction and knowledge of biology of bone fracture may result in full success without any bone graft.

[Legal aspects of medical errors].

Healing people and medical care are together highly organized technological system with significant expert, ethical and legal regulative. Taking medical care is very sensitive area and it interfears deep into one's integrity, so the law is necessary in this area as a regulator. The aim of work is to show medical errors from legal aspects and clinical practice. Errors, negligent conduct during the medical treatment and bad results of medical treatment are categories that can easily be switched or can sublime themselves into the same thing. That is why correct differentiation of medical errors and viewing every way of medical errors appearance is necessary.

Cemento-ossifying fibroma of jaws-correlation of clinical and pathological findings.

Cemento-ossifying fibroma (COF) belongs to the group of bone-related lesions of the oral cavity. The aim of this study was refine its histologic features and to correlate histopathological picture and clinical behavior of the tumor. The quantity of bone spherules, their cellularity, the existence of hemorrhage, inflammation, and endochondral ossification in the stroma of the tumor were analyzed and correlated with patients main symptoms of ten patients with COF. All patients had swelling that lasted between 3 and 20 months (mean 10.4 months). Other clinical symptoms were facial asymmetry, eye bulb protrusion, and teeth displacement. The evolution of the tumor was longer in the mandible (12.3 months) than in maxilla (9.5 months). The main histomorphological diagnostic criterion for COF was psammoma-like structures. In lesions with longer case history, the number of "psammomatoid" bodies was greater. In lesions with shorter course of the disease, their number was lower and stromal hemorrhage and inflammation were presented. One patient had secondary superposition of aneurysmal bone cyst in the prime COF of mandible. Histological appearance of COF may be influenced by the tumor evolution. A siginificant correlation between the clinical course of the disease and histological parameters has been certified.

[Medial subtalar dislocation--case report].

INTRODUCTION: Subtalar dislocation (SI) is a term that refers to an injury in which there is dislocation of the talonavicular and talocalcanear joint, although the tibiotalar joint is intact. CASE OUTLINE: A case of medial subtalar dislocation as a result of basketball injury, so-called "basketball foot", is presented. Closed reposition in i.v. anaesthesia was performed with the patient in supine position and a knee flexed at 90 degrees. Longitudinal manual traction in line of deformity was carried out in plantar flexion. The reposition continued with abduction and eversion simultaneously increasing dorsiflexion. It was made in the first attempt and completed instantly. Rehabilitation was initiated after 5 weeks of immobilization. One year after the injury, the functional outcome was excellent with full range of motion and the patient was symptom-free. For better interpretation of roentgenogram, bone model of subtalar dislocation was made using the cadaver bone. CONCLUSION: Although the treatment of such injury is usually successful, diagnosis can be difficult because it is a rare injury, and moreover, X-ray of the injury can be confusing due to superposition of bones. Radiograms revealed superposition of the calcaneus, tarsal and metatarsal bones which was radiographically visualized in the anterior-posterior projection as one osseous block inward from the talus, and on the lateral view as in an osteal block below the tibial bone. Prompt recognition of these injuries followed by proper, delicately closed reduction under anaesthesia is crucial for achieving a good functional result in case of medial subtalar dislocation.

Simultaneous bilateral avulsion fracture of the tibial tubercle in adolescent: a case report.

Acute avulsion of the tibial tubercle is an uncommon injury, accounting for less than 1% of all physeal injuries. Simultaneous bilateral avulsion fractures of the tibial tubercle are extremely rare. Only 10 cases have been reported in the literature to date. We report a case of a 15-year-old boy who suffered from the bilateral avulsion fractures of the tibial tubercle during basketball in take-off phase of the high jump. He went through surgery and 4 years after index procedures he has no deformities, the knee is painless and he participates in sport activities on daily basis.