Roland Biber

Considerations for the Development of an Undergraduate Curriculum in Geriatric Medicine

Background: Although the number of older patients is increasing in almost all medical specialties, the interest of medical students in geriatrics as a career is still low. Because quality of medical education and educators strongly influences student career decisions, it is important to develop curricula that motivate students to become self-directed, lifelong learners in the field of geriatric medicine. Objectives: We evaluated training aspects in terms of time, core content of teaching goals, and quality of undergraduate geriatric education in medical schools in Austria and Germany. Methods: A standardized paper questionnaire was sent to all 36 German and 4 Austrian medical faculties to evaluate quantitative aspects, content, and quality of pregraduate medical education in geriatrics. Results were compared to the recommendations of the Geriatric Medicine Section of the European Union of Medical Specialists (UEMS). Results: A total of 33/36 (92 of the German medical faculties) and 4/4 (100 of the Austrian medical faculties) responded to the questionnaire. In most of the faculties, geriatric medicine was taught as an independent discipline in the core curriculum, with learning objectives absent in almost one third of the faculties. A medical students first contact with geriatric medicine occurred on average during the second clinical year (median 8th semester). Although the content of geriatric curricula strongly varied among the faculties, core knowledge as recommended by the UEMS was integrated into most of the curricula. Teaching strategies regarding the development of attitudes and skills also recommended by the UEMS were identified in the curriculum of only some faculties. Conclusions: Geriatrics seems to be an established subject in most German and Austrian faculties. However, the current data clearly indicate highly variable quality in geriatric pregraduate training at German and Austrian universities. Because curricula should prepare young people using competence-based training and assessment methods, room for improvement remains not only in terms of structure, but also regarding quality of training to develop self-directed lifelong learners.

Diagnostic accuracy of three different methods of temperature measurement in acutely ill geriatric patients

OBJECTIVE we examined the diagnostic accuracy of different methods of body temperature measurement to diagnose infection in geriatric patients presenting to the emergency department (ED). METHODS this observational study was done in consecutive patients ≥75 years old presenting to the ED. Body temperature was determined by tympanal thermometry, temporal artery thermometry and rectal temperature measurement. Adjudicated final diagnosis of infection was done by two experts including patient history, clinical and laboratory findings as well as radiographic studies. RESULTS a total of 427 patients were included in the data analysis (age: 82.7 ± 5.1 years). Infection was present in 105 patients (24.6%). Respiratory rate, heart rate and body temperature were significantly higher in patients with infection, blood pressure was lower (P < 0.01). Body temperature measured by tympanal and temporal artery thermometry was correlated with rectal thermometry. Body temperature was significantly higher in patients with infection compared with those without infection independent of the method of body temperature measurement (P < 0.001). The diagnostic accuracy for infection quantified by the area under curve (AUC) was comparable among rectal [AUC: 0.72 (95% CI: 0.65-0.80)] and tympanal thermometry [AUC: 0.73 (95% CI: 0.66-0.81)], but significantly lower in temporal artery thermometry [AUC: 0.65 (95% CI: 0.57-0.73; P < 0.001)]. Compared with rectal measurement tympanal thermometry showed a higher bias than temporal artery thermometry (0.54 versus 0.03°C), while its limits of agreement were more narrow (-0.14 to 1.21°C versus -0.94-1.01°C). CONCLUSION diagnostic accuracy for the identification of infection was comparable among tympanal and rectal thermometry and lower for temporal artery thermometry. Different cut-off points should be used to identify infection using tympanal (37.3°C) or rectal (37.9°C) thermometry. In general, temperature measurement is an insensitive method to identify geriatric patients with infection. Registration number clinicaltrials.com: KSMC-tempger-1.

Incisional negative pressure wound therapy after hemiarthroplasty for femoral neck fractures – reduction of wound complications

The aim of the study was to evaluate the use of incisional negative pressure wound therapy (iNPWT) in wound healing after femoral neck fracture (FNF) treated with hip hemiarthroplasty (HA) and its influence on postoperative seromas, wound secretion, as well as time and material consumption for dressing changes. The study is a prospective randomised evaluation of iNPWT in patients with large surgical wounds after FNF. Patients were randomised either to be treated by iNPWT (group A) or a standard wound dressing (group B). Follow‐up included ultrasound measurements of seroma volumes on postoperative days 5 and 10, duration of wound secretion, and time and material spent for wound dressing changes. For comparison of the means, we used the t‐test for independent samples, P > 0·05 was considered significant. There were 21 patients randomised in this study. Group A (11 patients, 81·6 ± 5·2 years of age) developed a seroma of 0·257 ± 0·75 cm3 after 5 days and had a secretion of 0·9 ± 1·0 days, and the total time for dressing changes was 14·8 ± 3·9 minutes, whereas group B (ten patients, 82·6 ± 8·6 years of age) developed a seroma of 3·995 ± 5·01 cm3 after 5 days and had a secretion of 4·3 ± 2·45 days, and the total time for dressing changes was 42·9 ± 11·0 minutes. All mentioned differences were significant. iNPWT has been used on many different types of traumatic and non‐traumatic wounds. This prospective, randomised study has demonstrated decreased development of postoperative seromas, reduction of total wound secretion days and reduction of needed time for dressing changes.

Negative pressure wound therapy for seroma prevention and surgical incision treatment in spinal fracture care

To evaluate the clinical use and economic aspects of negative pressure wound therapy (NPWT) after dorsal stabilisation of spinal fractures. This study is a prospective randomised evaluation of NPWT in patients with large surgical wounds after surgical stabilisation of spinal fractures by internal fixation. Patients were randomised to either standard wound dressing treatment (group A) or NPWT (group B). The wound area was examined by ultrasound to measure seroma volumes in both groups on the 5th and 10th day after surgery. Furthermore, data on economic aspects such as nursing time for wound care and material used for wound dressing were evaluated. A total of 20 patients (10 in each group) were enrolled. Throughout the whole study, mean seroma volume was significantly higher in group A than that in group B (day 5: 1·9 ml versus 0 ml; P = 0·0007; day 10: 1·6 ml versus 0·5 ml; P <0·024). Furthermore, patients of group A required more wound care time (group A: 31 ± 10 minutes; group B 13·8 ± 6 minutes; P = 0·0005) and more number of compresses (total number; group A 35 ± 15; group B 11 ± 3; P = 0·0376). NPWT reduced the development of postoperative seroma, reduced nursing time and reduced material required for wound care.

Correlation between Age, Emergency Department Length of Stay and Hospital Admission Rate in Emergency Department Patients Aged ≥70 Years

Background: Interdisciplinary emergency departments (EDs) are confronted with trauma and nontrauma patients of any age group. Length of stay (LOS) and admission rates reflect both disease complexity and severity. Objective: To evaluate LOS and admission rates in different age groups according to traumatic and nontraumatic etiologies. Patients and Methods: During May 2011 a total of 4,653 adult patients (defined as ≥18 years old) seen in the ED of our municipal hospital were evaluated for their primary problem, Emergency Severity Index, LOS and admission rate. 1,841 trauma patients (mean age: 51.9 years; SD 22.5 years) and 2,812 nontrauma patients (mean age: 60.0 years; SD 20.4 years) were included. Results: Median LOS in the ED was 1:41 h (trauma) and 1:52 h (nontrauma). Trauma patients aged ≥70 years spent more time in the ED than nontrauma patients of this age group (patients aged ≥70 years median: 2:08 vs. 1:56 h; p < 0.0001). However, no significant difference was found in patients aged <70 years (1:33 vs. 1:48 h; p = 0.64). Comparing older with younger patients, median LOS within the ED was about 8 min longer in nontrauma patients aged ≥70 years (p = 0.22) and about 35 min longer in trauma patients aged ≥70 years (p < 0.00001). Conclusions: The correlation between age and LOS is stronger for trauma patients, which might indicate a special need for geriatric expertise in elderly trauma ED patients. Thus an interdisciplinary approach including surgical and geriatric expertise may be advantageous.

Magnesium-Based Absorbable Metal Screws for Intra-Articular Fracture Fixation

MAGNEZIX® (Syntellix AG, Hanover, Germany) is a biodegradable magnesium-based alloy (MgYREZr) which is currently used to manufacture bioabsorbable compression screws. To date, there are very few studies reporting on a limited number of elective foot surgeries using this innovative implant. This case report describes the application of this screw for osteochondral fracture fixation at the humeral capitulum next to a loose radial head prosthesis, which was revised at the same time. The clinical course was uneventful. Degradation of the magnesium alloy did not interfere with fracture healing. Showing an excellent clinical result and free range-of-motion, the contour of the implant was still visible in a one-year follow-up.

Value of incisional negative pressure wound therapy in orthopaedic surgery

Soft tissue and wound treatment after orthopaedic interventions (especially after trauma) is still an enormously challenging situation for every surgeon. Since development of negative pressure wound therapy (NPWT), new indications have been consistently added to the original field of application. Recently, NPWT has been applied directly over high‐risk closed surgical incisions. Review of the literature indicates that this therapy has shown positive effects on incisions after total ankle replacement or calcaneal fractures, preventing haematoma and wound dehiscence. In those cases reduced swelling, decreased pain and healing time of the wound were seen. Additionally, NPWT applied on incisions after acetabular fractures showed a decreased rate of infection and wound healing problems compared with published infection rates. Even after total hip arthroplasty, incisional NPWT reduced incidence of postoperative seroma and improved wound healing. In patients with tibial plateau, pilon or calcaneus fractures requiring surgical stabilisation after blunt trauma, reduced risk of developing acute and chronic wound dehiscence and infection was observed when using incisional NPWT. To conclude, incisional NPWT can help to reduce risk of delayed wound healing and infection after severe trauma and orthopaedic interventions.

How to prevent cut-out and cut-through in biaxial proximal femoral nails: is there anything beyond lag screw positioning and tip–apex distance?

PurposeHip perforation is a major complication in proximal femoral nailing. For biaxial nails, knowledge of their biomechanics is limited. Besides re-evaluation of accepted risk factors like the tip–apex distance (TAD), we analysed the influence of anti-rotational pin length.MethodsWe compared 22 hip perforation cases to 50 randomly chosen controls. TAD, lag-screw position, angle between lag-screw and femoral neck axis, lag-screw gliding capacity, displacement and anti-rotational pin length were investigated.ResultsHip perforation was associated with a higher angle of deviation between lag-screw and femoral neck axis (p = 0.001), a lower telescoping capacity of the lag screw (p = 0.02), and higher TAD (p = 0.048). If the anti-rotational pin exceeded a line connecting the tip of the nail and the lag screw (NS line), hip perforation incidence was increased (p = 0.009). Inadequate pin length resulted in an odds ratio of 10.8 for hip perforation (p = 0.001).ConclusionsIn biaxial nails anti-rotational element positioning is underestimated, however, crucial.

The accelerating effect of negative pressure wound therapy with Prevena™ on the healing of a closed wound with persistent serous secretion

Negative pressure wound therapy has been lately used on closed incisions in the immediate postoperative period to accelerate wound healing. However, there are no data in the literature regarding the use of this type of therapy for wounds with persistent secretion in the early postoperative care. We present the first report of persistent postoperative serous wound secretion in a patient after femoral nailing treated successfully with Prevena™ (KCI), a closed incision negative pressure management system (CINPWT).

N-active: a new comanaged, orthogeriatric ward: observations and prospects.

The incidence of hip fractures increases with increasing age. Besides the actual trauma, it is mainly the comorbidities and an increased postoperative complication rate in old patients that lead to increased mortality in this patient population. Around 25% of patients who had previously been living independently continue to need long-term care after a hip fracture. Given this situation, the comanaged orthogeriatric unit “N-active” was opened at the Nuremberg Hospital in December 2010. The following article describes implementation of the ward and preliminary data. These show a positive impact of comanagement in terms of patient outcome, staff satisfaction, and also financial aspects.ZusammenfassungDie Inzidenz hüftgelenknaher Frakturen steigt mit zunehmendem Alter an. Neben dem eigentlichen Trauma führen bei den betagten Patienten vor allem die Komorbiditäten und eine erhöhte postoperative Komplikationsrate zu einer erhöhten Mortalität. Ein Viertel der zuvor selbstständig lebenden Patienten bleibt zudem langfristig pflegebedürftig. Vor diesem Hintergrund wurde am Klinikum Nürnberg im Dezember 2010 eine interdisziplinär (unfallchirurgisch-geriatrisch) geführte alterstraumatologische Station „N-Aktiv“ eröffnet. Der vorliegende Artikel beschreibt die Implementierung der Station sowie erste Daten. Diese zeigen einen positiven Effekt der unfallchirurgisch-geriatrischen Kooperation hinsichtlich Patientenoutcome, Mitarbeiterzufriedenheit sowie ökonomischer Aspekte.