Emergency department crowding and older patients: a nationwide retrospective cohort study.

OBJECTIVE: Emergency department (ED) crowding is a worldwide problem and one of the main causes internationally is an increase in presentations by older patients with complex and chronic care needs. Although there has been a 4,3% reduction in total ED visits from 2016-2019 in the Netherlands, the EDs still experience crowding. National crowding research has not focused on the older group in detail, hence their possible role remains ill defined. The primary aim of this study was to map the trend in ED visits by older patients in the Netherlands. The secondary aim was to identify healthcare utilization 30 days before/after ED visit. METHODS: We conducted a nationwide retrospective cohort study, using longitudinal health insurance claims data (2016-2019). The data encompasses all Dutch patients of 70 years or older who visited the ED. RESULTS: The number of older patients who visited the ED followed by admission, increased from 231,223 patients (2016), to 234,817 (2019). The number without admission also increased from 244,814 patients, to 274,984. There were 696,005 total visits by older patients (2016) increasing to 730,358 visits (2019). CONCLUSION: The slight rise in older patients at the ED is consistent with overall population growth of older people in the Netherlands. These results indicate that Dutch ED crowding cannot be explained by mere numbers of older patients. More research is needed with data on patient level, to study other contributing factors, such as complexity of care needs within the ageing population.

How to improve inpatient sleep in regular care wards: a systematic review and meta-analysis of sleep disturbers and non-pharmacological interventions.

OBJECTIVE: To determine factors affecting inpatient sleep and assess the range and effectiveness of non-pharmacological interventions aimed at improving the sleep of patients admitted to regular care wards. METHODS: A systematic literature search was conducted in five scientific databases, including articles published from inception to June 23rd, 2023. Eligible studies evaluated sleep disturbing factors or the effect of non-pharmacological intervention(s). Meta-analyses on intervention studies were conducted using a random effects model. Certainty of evidence was assessed using the GRADE approach. RESULTS: Out of 591 potentially eligible studies, 229 were included in this review. Sleep disturbers were identified in 153 studies, and 102 studies were eligible for meta-analysis. Common factors contributing to poor sleep included noise, light, care-related interruptions, pain, and anxiety. The meta-analyses revealed large pooled effects in favor of sleep for the use of eye masks and earplugs, headphones and white noise, aromatherapy, massage, muscle relaxation and breathing exercises, and advanced nursing strategies. However, the certainty of the evidence ranged from moderate to very low. CONCLUSION: Inpatient sleep is often disturbed by patient-related, care-related, and environmental factors. While there are promising non-pharmacological interventions, the overall quality of studies, heterogeneity in study populations, and differences in outcome measures present challenges for drawing definitive conclusions.

Non-grafted versus grafted sinus lift procedures for implantation in the atrophic maxilla: a systematic review and meta-analysis of randomized controlled trials.

The aim of this systematic review and meta-analysis was to critically evaluate the currently existing clinical evidence on the efficacy of graftless maxillary sinus membrane elevation for implantation in the atrophic posterior maxilla. A search protocol without limitations to November 2020 was followed by two independent researchers. Randomized controlled trials using the lateral window approach for graftless sinus membrane elevation were included. Uncontrolled, retrospective, non-comparative studies, case reports, and experimental studies in animals or cadavers were excluded. The search identified 2777 studies. Critical selection by two independent researchers then led to the inclusion of a total of nine studies. A risk of bias assessment was applied using the revised Cochrane risk-of-bias tool for randomized trials. A meta-analysis was conducted for seven studies. Results showed a high overall implant survival rate in both the graftless and bone-grafted sinus lift groups (97.92% and 98.73%, respectively). The graftless sinus lift group showed a significantly lower vertical bone height gain, with a mean difference of -1.73mm (P=0.01), and a significantly lower bone density, with a mean difference of -94.7 HU (P<0.001). The implant stability quotient values did not differ significantly between the test and control groups (P=0.07).

Improving care for older patients in the acute setting: a qualitative study with healthcare providers.

BACKGROUND: The proportion of older people needing acute care is rapidly growing, thereby posing an increased burden on the acute care chain. The aim of this study is to gain more insight into the obstacles and potential improvement opportunities of the acute care process for older patients arriving at the hospital. METHODS: Semi-structured interviews were conducted to determine the experiences of 18 different primary (i.e. general practitioner, community nurse) and secondary healthcare professionals (i.e. emergency department (ED) nurse, ED physician, geriatric physician, geriatric nurse, ambulance nurse, acute medical unit nurse), and three experts (2 researchers, 1 older adult advisor). RESULTS: Four core themes emerged from the interviews: 1) The concept of frailty, awareness concerning frail older patients, and identification of frailty, 2) Barriers in the care process of older patients within the acute care chain, 3) Optimising the discharge process of older patients, and 4) Improvement opportunities suggested by the respondents. Early identification of frailty, improving the continuity of care by means of structured information exchange between care providers in the acute care chain, and a more generalist approach were considered important by the respondents in order to deliver appropriate care to older patients. CONCLUSION: This explorative study identified several barriers and improvement opportunities which are important to improve the quality, efficacy and appropriateness of the acute care of older patients. More seems needed in the future in order to share experiences, expertise and develop potential improvement strategies for the acute care of older patients.

Physician consensus on preventability and predictability of readmissions based on standard case scenarios.

BACKGROUND: Policy makers struggle with unplanned readmissions as a quality indicator since integrating preventability in such indicators is difficult. Most studies on the preventability of readmissions questioned physicians whether they consider a given readmission to be preventable, from which conclusions on factors predicting preventable readmissions were derived. There is no literature on the interobserver agreement of physician judgement. AIM: To assess the degree of agreement among physicians regarding predictability and preventability of medical readmissions. DESIGN: An online survey based on eight real-life case scenarios was distributed to European physicians. METHODS: Physicians were requested to rate from the first four (index admission) scenarios whether they expected these patients to be readmitted within 30 days (the predictability). The remaining four cases, describing a readmission, were used to assess the preventability. The main outcome was the degree of agreement among physicians determined using the intra class correlation coefficient (ICC). RESULTS: 526 European medical physicians completed the survey. Most physicians had internal medicine as primary specialism. The median years of clinical experience was 11. ICC for predictability of readmission was 0.67 (moderate to good) and ICC for preventability of readmission was 0.13 (poor). CONCLUSION: There was moderate to good agreement among physicians on the predictability of readmissions while agreement on preventability was poor. This study indicates that assessing preventability of readmissions based solely on the judgement of physicians is far from perfect. Current literature on the preventability of readmissions and conclusions derived on the basis of physician opinion should be interpreted with caution.

Exploring the preventable causes of unplanned readmissions using root cause analysis: Coordination of care is the weakest link.

IMPORTANCE: Unplanned readmissions within 30days are a common phenomenon in everyday practice and lead to increasing costs. Although many studies aiming to analyze the probable causes leading to unplanned readmissions have been performed, an in depth-study analyzing the human (healthcare worker)-, organizational-, technical-, disease- and patient-related causes leading to readmission is still missing. OBJECTIVE: The primary objective of this study was to identify human-, organizational-, technical-, disease- and patient-related causes which contribute to acute readmission within 30days after discharge using a Root-Cause Analysis Tool called PRISMA-medical. The secondary objective was to evaluate how many of these readmissions were deemed potentially preventable, and to assess which factors contributed to these preventable readmissions in comparison to non-preventable readmissions. DESIGN: Cross-sectional retrospective record study. SETTING: An academic medical center in Amsterdam, The Netherlands. PARTICIPANTS: Fifty patients aged 18years and older discharged from an internal medicine department and acutely readmitted within 30days after discharge. MAIN OUTCOME MEASURES: Root causes of preventable and unpreventable readmissions. RESULTS: Most root causes for readmission were disease-related (46%), followed by human (healthcare worker)- (33%) and patient- (15%) related root causes. Half of the readmissions studied were considered to be potentially preventable. Preventable readmissions predominantly had human-related (coordination) failures. CONCLUSION AND RELEVANCE: Our study suggests that improving human-related (coordinating) factors contributing to a readmission can potentially decrease the number of preventable readmissions.

Readmissions of medical patients: an external validation of two existing prediction scores.

BACKGROUND: Hospital readmissions are increasingly used as a quality indicator with a belief that they are a marker of poor care and have led to financial penalties in UK and USA. Risk scoring systems, such as LACE and HOSPITAL, have been proposed as tools for identifying patients at high risk of readmission but have not been validated in international populations. AIM: To perform an external independent validation of the HOSPITAL and LACE scores. DESIGN: An unplanned secondary cohort study. METHODS: Patients admitted to the medical admission unit at the Hospital of South West Jutland (10/2008-2/2009; 2/2010-5/2010) and the Odense University Hospital (6/2009-8/2011) were analysed. Validation of the scores using 30 day readmissions as the endpoint was performed. RESULTS: A total of 19 277 patients fulfilled the inclusion criteria. Median age was 67 (range 18-107) years and 8977 (46.6%) were female. The LACE score had a discriminatory power of 0.648 with poor calibration and the HOSPITAL score had a discriminatory power of 0.661 with poor calibration. The HOSPITAL score was significantly better than the LACE score for identifying patients at risk of 30 day readmission (P < 0.001). The discriminatory power of both scores decreased with increasing age. CONCLUSION: Readmissions are a complex phenomenon with not only medical conditions contributing but also system, cultural and environmental factors exerting a significant influence. It is possible that the heterogeneity of the population and health care systems may prohibit the creation of a simple prediction tool that can be used internationally.

Premature craniosynostosis--the role of skull base surgery in its correction. A surgical and radiological experience of 172 operated infants/children.

BACKGROUND: Most craniofacial abnormalities are non-syndromic craniosynostoses due to premature fusion of one or more craniofacial sutures. Functional impairment is caused either by a pathological growth pattern or increased intracranial pressure. The indications for surgery are to increase intracranial volume and to correct aesthetics. PATIENTS AND METHODS: We retrospectively reviewed 172 patients who had been operated on for premature craniosynostosis, including fronto-orbital advancement, from 1992 to 2002. Demographic data, clinical follow-up findings, and regular photo documentation were analyzed. RESULTS: After a mean follow-up of 6 years the overall outcome for those operated on within the first 6 months of life was satisfactory in 97%. The remaining 3% were reoperated at between 4 and 6 years of age. All cephalometric indices normalized postoperatively. Eight patients underwent SPECT studies which showed preoperative perfusion asymmetry corresponding to the fused sutures that were normalized following surgical decompression. No severe perioperative complications were seen. DISCUSSION: Cephalometric parameters represent an excellent method to compare the postoperative outcome. Standard skull base procedures need to be adapted carefully to the individual form of craniosynostosis to avoid an unfavourable result. Single Photon Emissin Computed Tomography (SPECT) studies give evidence that correction of single cranial suture synostosis allows for normalization of cerebral blood flow and should be performed within first 6-8 months of life.

Nature, causes and consequences of unintended events in surgical units.

BACKGROUND: Several studies have shown that the rate of unintended harm is higher in surgical than in non-surgical care. To improve patient safety in surgery, information about the underlying causes is needed. This observational study examined the nature, causes and consequences of unintended events in surgical units, and the completeness of event reporting. METHODS: Ten surgical units in the Netherlands participated. The study period per unit was 8-14 weeks, during which healthcare providers reported unintended events. Event reports were analysed with a root cause analysis tool (PRISMA). In addition, an independent surgeon reviewed about 40 patient records of patients in each surgical unit to examine whether an unintended event had occurred. RESULTS: A total of 881 unintended events were reported and analysed, of which 33.0 per cent were categorized as medication events. Most root causes were human (72.3 per cent), followed by organizational (16.1 per cent) and technical (5.7 per cent). More than half of the events had consequences for the patient. Sixty-four unintended events were identified in a review of 320 patient records. Only one of these events was also reported by a healthcare provider. CONCLUSION: Event reporting and patient record review provide insight into diverse types of unintended events and complement each other. The information on unintended events from both sources may help target research and interventions to increase patient safety.

[Evaluation of the postoperative clinical results of repositioning isolated zygomatic fractures]. / Beurteilung des postoperativen klinischen Repositionsergebnisses isolierter Jochbeinfrakturen.

This retrospective study included 148 patients who were evaluated for postoperative long-term results after osteosynthesis of isolated zygoma fractures. The influence of open reposition of the zygomaticoalveolar crest to middle face symmetry was evaluated quantitatively with a zygometer. In dependence on operative management patients were divided into two groups: In group I zygomaticofrontal suture (1-point-fixation) and infra-orbital rim were exposed (2-point-fixation), followed by osteosynthesis. In group II additional exposure of zygomaticoalveolar crest was performed and if required osteosynthesis was performed (3-point-fixation). For osteosynthetic reconstruction of isolated zygoma fractures the only 2-point-fixation is usually enough to achieve lateral middle face symmetry. In all cases zygomaticofrontal suture and alternatively infra-orbital rim or respectively zygomaticoalveolar crest should be supplied osteosynthetically. A further 3-point-fixation is indicated only in exceptional cases--for example comminuted fractures of lateral middle face columns. For an exact anatomical reposition of zygoma fractures the exposition and possible osteosynthesis of zygomaticoalveolar crest is recommended.

Piezoelectric bone surgery: a revolutionary technique for minimally invasive surgery in cranial base and spinal surgery? Technical note.

OBJECTIVE: Piezoelectric surgery represents an innovative, ultrasonic surgery technique for performing a safe and effective osteotomy or osteoplasty that contrasts with the traditional hard and soft tissue management methods with rotating instruments. METHODS: Because of its physical and mechanical properties, the definitive clinical advantage of piezoelectric bone surgery with regard to precision cutting lies in the sparing of vital neurovascular bundles or general soft tissue and better visualization of the surgical field, thus suggesting its great safety. Piezoelectric bone surgery has been previously described only in oral and maxillofacial operative procedures in adults. RESULTS: Five children between the age of 6 and 84 months were operated on for craniosynostosis, tethered cord, and an extraconal intraorbital tumor. The usefulness of piezoelectric bone surgery during neurosurgical procedures is presented for these cases. This technique is especially recommended when there are anatomic difficulties because of poor intraoperative visibility or the presence of delicate anatomic structures. CONCLUSION: The present preliminary report (comprising illustrative case reports) demonstrates and introduces for the first time the utility of piezoelectric bone surgery in cranial base and spinal surgery in children. Until now, there has been no documented neurosurgical experience of this technique even in adults.

Ultrasonic surgery--an alternative way in orthognathic surgery of the mandible. A pilot study.

The aim of this report is to present preliminary results and experiences using an ultrasonic bone-cutting device in bilateral sagittal split osteotomies of the mandible (BSSRO) with particular attention to possible damages to the inferior alveolar nerve (IAN). Seven patients with class II or class III malocclusion were treated by BSSRO with a conventional combined orthognathic and surgical approach. The osteotomy was carried out using an ultrasonic bone-cutting device. Subjective neurosensory deficits of the inferior alveolar nerve were assessed on 14 sides. Compared to the conventional techniques using saws, chisels and burs, the use of the ultrasonic device was more time-consuming, but the osteotomies were carried out at a high level of precision. In addition, this procedure offered the advantage of a blood-free surgical field and thus provided good control of the surgical procedure. Subjective neurosensory disturbances of the IAN showed a continuous decrease from 57.1% (eight sides) 2 months after the surgical procedure to 14.3% (2 sides) after 5 months and to 7.1% 7 months after BSSRO. Within the seven patients of this pilot study associated neurosensory disturbances were low. A possible advantage in terms of nerve protection is subject to a prospective study.

[Influence of different mixing fluids on mechanical and micromorphological in vitro qualities of hydroxyapatite cement]. / Einfluss unterschiedlicher Anrührflüssigkeiten auf die mechanischen und mikromorphologischen In-vitro-Eigenschaften von Hydroxylapatitzement.

AIM: In reconstructive craniofacial surgery a new synthetic hydroxyapatite cement has been used in the last few years. Tetra- and dicalcium phosphates react with either slow setting aqua bidest. or with faster setting sodium monophosphate solution to hydroxyapatite. The aim of this study was to investigate the two mixing fluids of hydroxyapatite for resulting micromorphology, pressure strength, and interactions with fibroblasts. MATERIAL AND METHODS: Pressure strength tests of hydroxyapatite cement test samples (n=80) were performed after a setting time of 3 and 24 h. The micromorphology of surfaces of the resulting particles was assessed under an electron microscope. In cell cultures L-929 and HEp2 cells were incubated with test samples and cell growth was assessed by light and electron microscopy. RESULTS: The test samples mixed with sodium monophosphate solution showed statistically significantly higher values of pressure strength. The resulting pressure strength depended on respective mixing fluids, setting time, and pressure of application. In general, test samples mixed with sodium monophosphate solution showed a more load-stable, homogeneous anorganic matrix whereas test samples mixed with aqua bidest. had a porous microarchitecture which was more fragile. In cell culture the porous structure showed disintegration in cell culture medium. CONCLUSION: To what extent the two mixing liquids of hydroxyapatite cement influence the resorption and bony substitution has to be shown in further studies.

Bioartificial bone grafting: Tarsal joint fusion in a dog using a bioartificial composite bone graft consisting of beta-tricalciumphosphate and platelet rich plasma--a case report.

Grafting of large bone defects caused by trauma or tumor resection still remains a problem to solve. In experimental studies as well as in human dentistry, osteoconduction and biodegradation of the beta-tricalciumphosphate Cerasorb as well as osteoinductive capabilities of platelet rich plasma have been proven. In case of luxation of the right tarsal joint, including a compressive fracture of the forth tarsal bone, the recommended use of autologous cancellous bone to support osseous fusion was replaced by the use of a bioartificial bone graft. Biodegradation of the bone graft was proven clinically and radiographically. Complete osseous fusion of the intertarsal joint occurred. The use of the beta-tricalciumphosphate Cerasorb in combination with platelet rich plasma to support a partial arthrodesis of the tarsal joint in a dog did not impede the healing process but led to full recovery of the patient, indicating that this concept of bioartificial bone grafting could support bone healing.

[Memory effect of resorbable polymers]. / Memory-Effekt resorbierbarer Polymere.

BACKGROUND: The present study analyzed the memory effect of resorbable polymers. Depending on temperature, this effect describes the ability of different materials to "remember" their original form after mechanical deformation. Resorbable polymers serve as materials to stabilize and fix bone fractures. Compared to metal transplants, resorbable polymers are able to undergo thermoplastic deformation. The precise adaptation of the transplant to the surrounding bone guarantees an exact anatomical reconstruction. However, during normal applications, it was observed that these biodegradable plastic materials tend to revert to their original form at body temperature. This "memory effect" could result in negative consequences for the medical treatment. METHODS: By the process of compression molding, geometrically formed specimens (lattice, rod, plate) consisting of different polyglycolides and polylactides were prepared. After warming up the specimens to 50 degrees C (water bath) they were deformed into definite angles. Following this procedure, the specimens were put in a water bath at 37 degrees C to mimic the adaptation of the transplant at body temperature. The retroflexion of the material (memory effect) was measured using an XY-measuring desk. RESULTS: The present study clearly reveals that highly deformed specimens react with stronger retroflexions. In addition, the results indicate that the memory effect depends on geometrical design as well as on chemical composition. All tested polymers showed a strong initial memory effect that decreased with time.

[Evaluation of B-scan ultrasound, 3-D ultrasound, roentgen diagnosis and sinus endoscopy in follow-up assessment of the maxillary sinus after sinus floor elevation]. / Evaluation der B-Scan-Sonographie, 3D-Sonographie, Röntgendiagnostik und Sinuskopie zur Kontrolle der Kieferhöhle nach Sinusbodenelevation.

PROBLEM: The aim of this study was to determine which technique--B-scan sonography, 3D sonography, X-ray, or endoscopy--is the most effective for diagnosis in changes of the maxillary sinus after sinus lift and simultaneous augmentation. MATERIAL AND METHODS: In 33 patients the maxillary sinus was examined before sinus lift, 1 week and 6 months postoperatively with a 7.5-MHz linear scanner and 3D sonography. At the same time, the sonographic results were compared with the X-ray as well as the endoscopic results. Endoscopy of the maxillary sinus was only applied during the sinus lift operation and the abutment operation after 6 months. RESULTS: A total of 56 operations of sinus lift and simultaneous augmentation with autogenous bone were carried out. Preoperatively, there where no pathological findings detectable in the maxillary sinus. One week postoperatively, the X-rays as well as the sonographic images revealed thickening of the mucosa in 40 maxillary sinuses. After the healing period of 6 months, polyposa was still detected in three cases sonographically, in the radiographic follow-up as well as endoscopically. The sonographic 3D imaging of the maxillary sinus improved the spatial visualization of postoperative changes in the maxillary sinus and the reliability of the diagnosis. CONCLUSION: Due to the lack of radiation, the cost effectiveness, and its reproducibility, sonography is suitable as a primary screening technique in recall. In cases of normal sonographic findings but clinical symptoms, CT, MRT, and endoscopy should be performed to exclude pathological processes of the posterior maxillary sinus.

[Multislice helical CT (MSCT) for mid-facial trauma: Optimization of parameters for scanning and reconstruction]. / Mehrschicht-Spiral-CT (MSCT) beim Mittelgesichtstrauma: Optimierung der Aufnahme- und Rekonstruktionsparameter.

PURPOSE: To determine the optimal scan parameters in multislice helical CT (MSCT) of the facial bone complex for both axial scanning and multiplanar reconstructions. MATERIAL AND METHODS: An anthropomorphic skull phantom was examined with a MSCT. Axial scans were performed with continuously increasing collimations (4 x 1.25 - 4 x 2.5 mm), tube current (20 - 200 mA) and table speeds (3.75 mm/rot. and 7.5 mm/rot.). Multiplanar reconstructions in coronal and parasagittal planes with different reconstruction increment and slice thickness were evaluated in terms of image noise, contour artifacts and visualisation of anatomical structures. RESULTS: The best image quality was obtained with a collimation of 4 x 1.25 mm and a table speed of 3.75 mm/rot. A reconstruction increment of 0.6 mm achieved the best time to image quality relation. With these parameters the bone structures were depicted in an optimal way without artifacts. The tube current could be reduced to 50 mA without significant loss of image quality. The optimized protocol was used for regular routine examinations in patients with facial trauma (n = 66). CONCLUSIONS: Low-dose MSCT using thin collimation, low table speed and small reconstruction increments provides excellent data for both axial images and multiplanar reconstructions in patients with facial trauma. An additional examination in coronal orientation is therefore no longer necessary.

Degradation characteristics of alpha and beta tri-calcium-phosphate (TCP) in minipigs.

In seven Goettingen minipigs 3.5--4.7-ml cancellous bone defects were created in the area of the tibial head on both sides. The defects were filled with alpha-TCP or beta-TCP (tricalciumphosphate). ITI implants (Straumann, Freiburg, Germany) of 3.2 x 12-mm length were inserted into the underlying ceramic substitutes. Two additional pigs were used as control. Within the periods of observation (4, 16, 20, 28, 46, 68, and 86 weeks) fluorescent dyes were applied. Nondecalcified thin-sliced sections were examined by means of light and fluorescence microscopy. In addition microangiography and microradiography were performed. Bony regeneration occurred basally and on the sides of the defect according the angiogenetic reossification pattern. Resorption was due to a hydrolytic and cellular degradation process. After 46 weeks histomorphological evaluation showed an incomplete osseointegration of the simultaneously implanted dental implants. The bone contact surface ratio was lower than 25%. After 86 weeks 95--97% of both alpha- and beta-TCP were resorbed. Ceramic residuals stayed within the newly formed trabeculae thus resisting further degradation until remodeling occurred. Both alpha- and beta-TCP show a comparable degradation process. At the 86-week postoperative point only small residuals of the ceramic can be found. These residuals stay within the newly formed trabeculae, which show a functional orientation. In comparison control defects showed only sparse reossification. The beta-TCP material shows an accelerated degradation mode and has an optimal reactivity with the surrounding tissues. According to the results of this animal experiment both materials can be classified as bone-rebuilding materials.