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Published 3/1/2011

Second Look— Clinical News and Views

If you missed these Headline News Now items the first time around, AAOS Now gives you a second chance to review them. Headline News Now brings you the latest on clinical, socioeconomic, and political issues three times a week, as well as important announcements from AAOS.

MRSA in ED patients
According to online data from Annals of Emergency Medicine, methicillin-resistant Staphylococcus aureus (MRSA) was present in 5 percent of patients who came to the emergency department (ED) at a single facility. The research team performed active surveillance for methicillin-susceptible S aureus (MSSA) and MRSA colonization in 400 people and found that the prevalence of colonization with MSSA was 39 percent, while the prevalence of colonization with MRSA was 5 percent. An extranasal site tested positive in 80 percent of MRSA-colonized patients, and 45 percent had exclusive extranasal colonization. The main risk factors for MRSA colonization included HIV infection, diabetes, and participation in contact sports.

NFL players and lumbar disk herniation surgery
Linemen in the National Football League (NFL) are often able to return to play after surgical treatment for lumbar disk herniation, according to online data from the American Journal of Sports Medicine. Of 66 linemen diagnosed with lumbar disk herniation who met inclusion criteria, 52 were treated surgically and 14 nonsurgically. Although 80.8 percent (42/52) of players treated surgically successfully returned to play an average of 33 games over 3.0 years, just 28.6 percent (4/14) of patients with nonsurgical treatment successfully returned to play.

Partner violence common
Research in the Journal of Bone & Joint Surgery—American (JBJS-A) (Jan. 19) suggests that nearly one third of women presenting with orthopaedic fractures at trauma centers in Canada may be victims of abuse. A cross-sectional study of 282 injured women who visited one of two Level-I trauma centers during a 12-month period found that 32 percent of patients reported some form of intimate partner violence (IPV), defined as physical, sexual, or emotional abuse, in response to self-reported written questionnaires on abuse and partner violence. Overall, 24 (8.5 percent) of the injured women disclosed a history of physical abuse in the past year, and seven patients indicated that the cause for their current visit was directly related to physical abuse, but only four had been asked about IPV by a physician; none had been asked about IPV by the treating orthopaedic surgeon. Ethnicity, socioeconomic status, and injury patterns were not associated with abuse.

For more on IPV, see Surgeons underestimate domestic violence.

Contributing factors for prescribing errors
A study in the Journal of Pain (January) reported that 40 percent of analgesic medication errors have one or more of the following characteristics: availability in dose forms for multiple routes of administration, modified dosage forms, atypical dosage regimens, sound-alike drug names, and analgesic use on an ongoing scheduled basis. The systematic evaluation of 2,044 “near miss” analgesic prescribing errors at a single teaching hospital found the overall error rate to be 2.87 errors per 1,000 orders, with a potentially serious prescribing error rate of 0.63 per 1,000 orders. The error rate for pediatric patients was more than twice as high as that for adults, and pediatric drug errors accounted for about 14 percent of potentially serious mistakes overall.

Predisposition to lumbar disk disease may be inherited
Research published in JBJS-A (Feb. 2) suggests that hereditary factors may increase the likelihood of development of symptomatic lumbar disk disease. The authors used diagnosis codes to identify 1,264 patients in the Utah Population Database who had been diagnosed with either lumbar disk herniation or lumbar disk degeneration. Based on the Genealogical Index of Familiality test, they found significantly elevated risk for lumbar disk disease among both first-degree and third-degree relatives.

Contaminated coats?
An online study in the Journal of Hospital Medicine suggests that there may be little difference in bacterial contamination between newly laundered short-sleeved uniforms and infrequently laundered white coats. The prospective, randomized controlled trial found no significant difference in bacterial or MRSA contamination between white coats and newly laundered uniforms after 8 hours of use or in contamination of the skin at the wrists of physicians wearing them. Eight of 50 physicians (16 percent) in white coats registered MRSA contamination from cultures, compared with 10 of 50 physicians (20 percent) wearing short-sleeved uniforms.

Low back pain and imaging
Based on a systematic review and subsequent meta-analysis, the American College of Physicians (ACP) states that diagnostic imaging, including radiograph, magnetic resonance, or computed tomography, is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. In addition, the ACP recommends that decisions for repeat imaging should be based on the development of new symptoms or changes in current symptoms. The recommendations are in the Annals of Internal Medicine (Feb. 1).

Bisphosphonates may reduce mortality risk
According to an Australian study published online in the Journal of Clinical Endocrinology and Metabolism, treatment with bisphosphonates (BPs) may be associated with a reduction in mortality among osteoporosis patients. The prospective cohort study of 1,223 women and 819 men aged 60 years and older living in a single community found that 325 women and 37 men received treatment with either BP (106 women, 15 men), hormone therapy (HT; 77 women, 0 men), or calcium and/or vitamin D only (CaD; 142 women, 22 men). Mortality rates among women receiving no treatment were 3.5/100 person-years, but among those receiving BP, mortality rates were just 0.8/100 person-years. Women receiving HT also had lower mortality rates (1.2/100 person-years), but mortality rates for those receiving CaD (3.2/100 person-years) were comparable to those receiving no treatment. After accounting for age, fracture occurrence, comorbidities, quadriceps strength, and bone mineral density, the mortality risk remained lower for women on BP, but not for those on HT.

Nails, plates have similar outcomes
Both locking intramedullary nails and locking plates can provide satisfactory outcomes for patients with proximal humeral fractures, according to a study published in JBJS-A (Jan. 19). The prospective, randomized study of 51 consecutive patients who were treated with either IM nails (n = 25) or locking plates (n = 26) found that all patients achieved fracture union within 3 months after surgery. At 1-year follow-up, the locking plate group had a higher complication rate (31 percent) compared to the IM nail group (4 percent), yet the average ASES score, median VAS score, and average strength of the supraspinatus were significantly better in the locking plate group. No significant differences between the two groups were found at 3-year follow-up.

Motorcycle helmets and CSI
According to a study published online in the Journal of the American College of Surgeons, motorcyclists wearing helmets are less likely than those without helmets to sustain a cervical spine injury after a motorcycle collision. A review of 40,588 motorcycle collision cases entered into the National Trauma Databank from 2002 to 2006 found that helmeted riders had a lower adjusted odds ratio and a lower proportion of cervical spine injury compared with nonhelmeted riders.

Osteoporosis screening guidelines
The U.S. Preventive Services Task Force has expanded its osteoporosis screening recommendation to include all women age 65 years or older, as well as younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. The task force also stated that current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.