Efficiency of the lausanne clinical pathway for proximal femoral fractures.

Purpose/Introduction: The number of hip fractures is rising, due to increases in life expectancy. In such cases, patients are at risk from post-operative complications and subsequently the average length of hospitalization may be extended. In 2011, we established a clinical pathway (CP), a specific model of care for patient-care management, to improve the clinical and economic outcomes of proximal femoral fracture management in elderly patients. The goal was to evaluate the CP using clinical, process, and financial indicators. METHODS: We included all surgical patients aged 65 and over, admitted to the emergency department with a fracture of the proximal femur following a fall. Assessment parameters included three performance indicators: clinical, process, and financial. The clinical indicators were the presence or absence of acute delirium on the third post-operative day, diagnosis of nosocomial pneumonia, and the number of patients fulfilling at least 75% of their nutritional requirements at the end of the hospitalization period. The process indicator was the time interval between arrival at the emergency department and surgery. The financial indicator was based on the number of days spent in hospital. RESULTS: From 2011 to 2013, 669 patients were included in the CP. We observed that the average length of stay in hospital decreased as soon as the CP was implemented and stabilized afterwards. The goal of 90% of patients undergoing surgery within 48 h of arrival in the emergency department was surpassed in 2013 (93.1%). Furthermore, we observed an improvement in the clinical indicators. CONCLUSION: The application of a CP allowed an improvement in the qualitative and quantitative efficiency of proximal femoral fracture management in elderly patients, in terms of clinical, process, and financial factors

Socioeconomic and living conditions are determinants of hip fracture incidence and age occurrence among community-dwelling elderly

Summary: In this prospective, 10-year study in community-dwelling elderly aged 50years and over, hip fracture incidence and accordingly age at hip fracture were inversely associated with the area-level income, independently of the geographical area. Age at hip fracture also depended of marital status but in a gender-specific way. Purpose: The purpose of this study is to investigate the impact of socioeconomic and living conditions on hip fracture incidence and age occurrence among community-dwelling elderly. Method: Between January 1991 and December 2000, 2,454 hip fractures were recorded in community-dwelling adults aged 50years and over in the Geneva University Hospital, State of Geneva, Switzerland. Median annual household income by postal code of residence (referred to as area-level income) based on the 1990 Census was used as a measure of socioeconomic condition and was stratified into tertiles (<53,170; 53,170-58,678; and ≥58,678 CHF). Hip fracture incidence and age occurrence were calculated according to area-level income categories and adjusted for confounding factors among community-dwelling elderly. Results: Independently of the geographical area (urban versus rural), community-dwelling persons residing in areas with the medium income category presented a lower hip fracture incidence [OR 0.91 (0.82-0.99), p = 0.049] compared to those from the lowest income category. Those in the highest income category had a hip fracture at a significant older age [+1.58 (0.55-2.61) year, p = 0.003] as compared to those in the lowest income category. Age at hip fracture also depended on marital status but in a gender-specific way, with married women fracturing earlier. Conclusions: These results indicate that incidence and age occurrence of hip fracture are influenced by area-level income and living conditions among community-dwelling elderly. Prevention programs may be encouraged in priority in communities with low incom

Late recognized vascular injury after high-energy fracture of the proximal tibia: a pitfall to know in current practice

Failure to recognize associated soft-tissue injuries after high-energy proximal tibia fractures is not uncommon. Despite the progress in managing these complex injuries, a prompt diagnosis of associated arterial injuries still remains difficult. A high index of suspicion for arterial damages is nevertheless mandatory in these severe fractures. Treatment protocols have been developed to reduce the previously reported high rates of amputation and permit an optimal management of soft-tissue and an acceptable functional outcome. We report here a well-documented case of a severely displaced proximal tibia fracture that illustrates the problem of diagnosing and managing the associated vascular injuries

Medial femoral condyle fracture as a complication of antegrade intramedullary nailing

A 49-year-old man suffered a closed oblique fracture of the middle third of his left femur. Closed reduction and internal fixation by intramedullary (IM) nailing were performed. Per-operative fluoroscopic imaging and initial postoperative X-rays were judged normal and the patient followed the usual rehabilitation protocol. At 3-month follow-up the patient still demonstrated poor knee function and pain. A plain X-ray and a CT scan of the left knee revealed a displaced fracture of the medial femoral condyle. Analysis of the postoperative imaging suggests that the fracture occurred during the insertion of the IM nail. The nail possibly hit the Steinmann traction pin in the distal femur causing the medial condyle fracture. The patient was reoperated; open reduction and internal plate and screw fixation were performed with satisfactory clinical progress postoperatively. The description and illustration of this case is intended to make trauma surgeons aware of this rare but serious complication of IM femoral nailin

Reversal of the hip fracture secular trend is related to a decrease in the incidence in institution-dwelling elderly women

Summary: In this prospective 10-year study in elderly aged 60years and over, there was a 1.3% per year reduction in the standardized incidence of hip fracture in women but not in men. This decrease was mainly due to changes in the standardized incidence of hip fracture in institution-dwelling women. Introduction: A decrease in age-adjusted hip fracture incidence has been recently demonstrated in some countries. Since a large proportion of hip fractures occur in nursing homes, we analyzed whether this decreasing trend would be more detectable in institution-dwelling elderly compared with community-dwelling elderly. Methods: All hip fracture patients aged 60years and over were identified in a well-defined area. Incidence of hip fracture, age- and sex-adjusted to the 2000 Geneva population, was computed in community- and institution-dwelling elderly. Results: From 1991 to 2000, 1,624 (41%) hip fractures were recorded in institutionalized-dwelling elderly and 2,327 (59%) in community-dwelling elderly. The standardized fracture incidence decreased by 1.3% per year in women (p = 0.039), but remained unchanged in men (+0.5%; p = 0.686). Among institution-dwelling women, hip fracture incidence fell by 1.9% per year (p = 0.044), whereas it remained stable among community-dwelling women (+0.0%, p = 0.978). In men, no significant change in hip fracture incidence occurred among institution- or community-dwelling elderly. Conclusions: The decrease in the standardized hip fracture incidence in institution-dwelling women is responsible for the reversal in secular trend. Future research should include stratification according to the residential status to better identify the causes responsible for the trend in hip fracture incidenc

Alterations of bone microstructure and strength in end-stage renal failure

Summary: End-stage renal disease (ESRD) patients have a high risk of fractures. We evaluated bone microstructure and finite-element analysis-estimated strength and stiffness in patients with ESRD by high-resolution peripheral computed tomography. We observed an alteration of cortical and trabecular bone microstructure and of bone strength and stiffness in ESRD patients. Introduction: Fragility fractures are common in ESRD patients on dialysis. Alterations of bone microstructure contribute to skeletal fragility, independently of areal bone mineral density. Methods: We compared microstructure and finite-element analysis estimates of strength and stiffness by high-resolution peripheral quantitative computed tomography (HR-pQCT) in 33 ESRD patients on dialysis (17 females and 16 males; mean age, 47.0 ± 12.6years) and 33 age-matched healthy controls. Results: Dialyzed women had lower radius and tibia cortical density with higher radius cortical porosity and lower tibia cortical thickness, compared to controls. Radius trabecular number was lower with higher heterogeneity of the trabecular network. Male patients displayed only a lower radius cortical density. Radius and tibia cortical thickness correlated negatively with bone-specific alkaline phosphatase (BALP). Microstructure did not correlate with parathyroid hormone (PTH) levels. Cortical porosity correlated positively with "Kidney Disease: Improving Global Outcomes” working group PTH level categories (r = 0.36, p < 0.04). BMI correlated positively with trabecular number (r = 0.4, p < 0.02) and negatively with trabecular spacing (r = −0.37, p < 0.03) and trabecular network heterogeneity (r = −0.4, p < 0.02). Biomechanics positively correlated with BMI and negatively with BALP. Conclusion: Cortical and trabecular bone microstructure and calculated bone strength are altered in ESRD patients, predominantly in women. Bone microstructure and biomechanical assessment by HR-pQCT may be of major clinical relevance in the evaluation of bone fragility in ESRD patient

The family of quaternionic quasi-unitary Lie algebras and their central extensions

The family of quaternionic quasi-unitary (or quaternionic unitary Cayley--Klein algebras) is described in a unified setting. This family includes the simple algebras sp(N+1) and sp(p,q) in the Cartan series C_{N+1}, as well as many non-semisimple real Lie algebras which can be obtained from these simple algebras by particular contractions. The algebras in this family are realized here in relation with the groups of isometries of quaternionic hermitian spaces of constant holomorphic curvature. This common framework allows to perform the study of many properties for all these Lie algebras simultaneously. In this paper the central extensions for all quasi-simple Lie algebras of the quaternionic unitary Cayley--Klein family are completely determined in arbitrary dimension. It is shown that the second cohomology group is trivial for any Lie algebra of this family no matter of its dimension.Comment: 17 pages, LaTe

On Proper Polynomial Maps of C2.\mathbb{C}^2.

Two proper polynomial maps $f_1, f_2 \colon \mathbb{C}^2 \longrightarrow \mathbb{C}^2$ are said to be \emph{equivalent} if there exist $\Phi_1, \Phi_2 \in \textrm{Aut}(\mathbb{C}^2)$ such that $f_2=\Phi_2 \circ f_1 \circ \Phi_1$. We investigate proper polynomial maps of arbitrary topological degree $d \geq 2$ up to equivalence. Under the further assumption that the maps are Galois coverings we also provide the complete description of equivalence classes. This widely extends previous results obtained by Lamy in the case $d=2$.Comment: 15 pages. Final version, to appear in Journal of Geometric Analysi

A planar extrapolation of the correlation problem that permits pairing

It was observed previously that an SU(N) extension of the Hubbard model is dominated, at large N, by planar diagrams in the sense of 't Hooft, but the possibility of superconducting pairing got lost in this extrapolation. To allow for this possibility, we replace SU(N) by U(N,q), the unitary group in a vector space of quaternions. At the level of the free energy, the difference between the SU(N)and U(N,q) extrapolations appears only to first nonleading order in N.Comment: 8 pages, 2 figure

Revisiting Clifford algebras and spinors III: conformal structures and twistors in the paravector model of spacetime

This paper is the third of a series of three, and it is the continuation of math-ph/0412074 and math-ph/0412075. After reviewing the conformal spacetime structure, conformal maps are described in Minkowski spacetime as the twisted adjoint representation of the group Spin_+(2,4), acting on paravectors. Twistors are then presented via the paravector model of Clifford algebras and related to conformal maps in the Clifford algebra over the lorentzian R{4,1}$ spacetime. We construct twistors in Minkowski spacetime as algebraic spinors associated with the Dirac-Clifford algebra Cl(1,3)(C) using one lower spacetime dimension than standard Clifford algebra formulations, since for this purpose the Clifford algebra over R{4,1} is also used to describe conformal maps, instead of R{2,4}. Although some papers have already described twistors using the algebra Cl(1,3)(C), isomorphic to Cl(4,1), the present formulation sheds some new light on the use of the paravector model and generalizations.Comment: 17 page