Orthogeriatric activity in a general hospital of Castilla-La Mancha, Spain | Revista Española de Cirugía Ortopédica y Traumatología (English Edition)

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Fernández-Ibáñez, M.C. Morales-Ballesteros, E. Crespo-Romero, S. Gómez-Gómez, M.D. Fraga-Fuentes, J. Cruz-Tejado, P.A. Hernández-Zegarra, Á. Arias-Arias, M.M. García-Baltasar" "autores" => array:9 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Fernández-Ibáñez" "email" => array:1 [ 0 => "jmfernandezi@sescam.jccm.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.C." "apellidos" => "Morales-Ballesteros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Crespo-Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "S." 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"apellidos" => "García-Baltasar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Sección de Geriatría, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Traumatología, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Farmacia, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anestesia, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Investigación, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Trabajo Social, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actividad ortogeriátrica en un hospital general de Castilla-La Mancha" ] ] "textoCompleto" => "IntroductionHip fracture (HF) is a serious problem in medical, healthcare, economic and social terms.More than 85% of HF occur in patients older than 65 years old.<a class="elsevierStyleCrossRef" href="#bib0180">1</a> In Spain from 50,000 to 60,000 HF occur per year. This incidence is rising and it is estimated that it will have doubled by 2050.<a class="elsevierStyleCrossRef" href="#bib0185">2</a> In Castile-La Mancha the rate of incidence adjusted for both sexes stands at 734 per 100,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0190">3</a>The direct costs of treating each HF in Spain vary from 3000 to 5200 Euros, depending on hospital and autonomous region, and overall costs amount to 300–860 million Euros, without counting additional indirect expenses such as carers, old people's homes and rehabilitation.<a class="elsevierStyleCrossRef" href="#bib0190">3</a>All of the guides analysed recommend that the geriatric and orthopaedic departments cooperate in treating the elderly with HF.<a class="elsevierStyleCrossRefs" href="#bib0190">3–7</a> This includes the acute phase during hospitalisation, rehabilitation, convalescence and support.The most widespread model is currently to have a Consultant Geriatrician for hospitalised patients in orthopaedic beds. This co-working strategy has been shown to reduce hospital stay prior to surgery, reduce complications, improve functional results, reducing mortality and the duration of hospitalisation as well as treatment costs.<a class="elsevierStyleCrossRefs" href="#bib0215">8–11</a>A programme was established in our centre in 2008 for internal consultation with the Geriatric Department for all HF patients over the age of 65 years old. This coincided with the hospital contracting geriatricians.In a study published in Spain, Sáez López et al. and the Orthogeriatric Working Group of Castile y León describe orthogeriatric working in the public hospitals of Castile y León, comparing it with the guides on clinical practice and other publications in this field. They conclude that orthogeriatric cooperation is a habitual practice, as is following the recommendations of clinical practice guides for treating HF in geriatric patients. They found that clinical care and rehabilitation were areas that should be improved.<a class="elsevierStyleCrossRef" href="#bib0235">12</a>This work studies how the most common clinical problems are managed in elderly HF patients who are admitted to the Orthopaedic Department of our hospital in cooperation with the Geriatric Department. It is based on the recommendations of the main clinical practice guides<a class="elsevierStyleCrossRefs" href="#bib0190">3–7</a> and the results published in the relevant literature.Material and methodsPatients and designThis study is descriptive and observational. All of the HF patients over the age of 65 years old admitted to the orthopaedic department and also seen by the geriatric department were included prospectively and consecutively, from April to December 2015.The Mancha Centro Hospital is a general hospital located in Alcázar de San Juan, Ciudad Real. It has a total of 343 hospital beds for a catchment area of 125,610 inhabitants who live in 21 municipalities in the provinces of Ciudad Real, Cuenca and Toledo. This area contains 18 old people's homes.Patients are admitted to the Orthopaedic Department from the A&E Department. Once in the ward they are evaluated by geriatricians in interconsultation. The geriatrician evaluates them and prepares a plan for care on admission, as well as for postoperative care after surgery. The orthopaedic surgeon and anaesthetist decide when to operate, depending on the availability of the emergency operating theatre and the clinical state of the patient, but always as soon as possible. Partial prostheses have been used for intracapsular fractures, together with intramedullary osteosynthesis or percutaneous extramedullary osteosynthesis for pertrochantheric fractures and intramedullary osteosynthesis for subtrochanteric ones.<a class="elsevierStyleCrossRef" href="#bib0240">13</a> Evaluation for rehabilitation is decided on by the orthopaedic surgeon or geriatrician through interconsultation. When social resources are required, such as assisted homes or home-help, social workers are requested to intervene.Description of variablesThe following data are recorded at admission: date of birth, sex, date and time of the first evaluation by the orthopaedic surgeon, previous Barthel score, Charlson score, history of cognitive deterioration, nutritional parameters (albumin, total protein, total cholesterol and number of lymphocytes), malnutrition according to the SENPE<a class="elsevierStyleCrossRef" href="#bib0245">14</a> criteria, vitamin D level, number of drugs taken at admission and whether they include any psychiatric medication, previous ingestion of vitamin D, calcium or bisphosphonates, and fracture type.The following data are recorded at discharge: date and time of the operation, delay (more than 48h after the first examination by the orthopaedic surgeon), cause of delay, type of anaesthesia, date and reason for discharge, medical complications during hospitalisation, whether treatment for osteoporosis is prescribed (calcium, vitamin D or bisphosphonates), whether the patient received iron treatment or a transfusion, if they received dietary supplements, if they were examined by the rehabilitation department, type of osteosynthesis used for the fracture, complications connected with surgery and destination on discharge (home, home with assistance, previously institutionalised, temporary stay).We evaluate the actions taken to care for elderly HF patients based on the recommendations of the main clinical practice guides for this.<a class="elsevierStyleCrossRefs" href="#bib0190">3–7</a>Statistical analysisQualitative variables are described using absolute and relative frequencies, while quantitative ones are described using central tendency measures (average or mean) together with dispersion measurements (standard deviation or interquartile range) depending on whether variables are distributed normally or not. Comparative analysis is performed using Chi-squared tests (or Fisher's exact test when appropriate) for qualitative variables, and comparisons between groups are made using the Student's t test for quantitative variables. A level of significance of 0.05 was selected. All calculations were carried out using the SPSS v18 program.Results773 patients were admitted to the orthopaedic surgery department during the period studied, of which 137 were HF cases, representing 18% of total admissions.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the main characteristics of the patients at the moment of admissions. They had a high average age (84.2±6.3 years old) and were mainly women (76%). They had a mild level of functional dependency on the Barthel index and low comorbidity measured using Charlson's scale. A high proportion of the patients presented cognitive deterioration in their medical history. Their consumption of several types of medication stands out (more than 7 drugs on average per patient), and 56.6% of the patients were taking psychiatric medication. Those patients who were taking more than 6 drugs prior to admission were found to progress significantly less favourably (dying or being transferred to another department due to complications) (27.4% vs. 11.9%, P=.028). More than 90% of the patients presented vitamin D deficit, and less than 20% received calcium and vitamin D treatment. More than 20% were taking anticoagulant pharmaceuticals and aggregation inhibitors, while the analytical data of more than 80% showed signs of malnutrition according to the standard SENPE<a class="elsevierStyleCrossRef" href="#bib0245">14</a> criteria. The majority of our patients originate in the community. Extracapsular fractures were the most frequent type (56.2%) and of these, pertrochanteric fractures were the most common (46% of the total).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the variables recorded at discharge. The majority of patients were operated in the first 48h (64.9%) after being examined by the orthopaedic surgeon, and the average hospitalisation before surgery was 48±39h. The most frequent cause of delayed surgery (>48h) was the consumption of oral anticoagulants (3.6±1.2 days) and secondly taking Clopidogrel (5±1.6 days). The patients who underwent longer admission prior to surgery (>48h) presented more medical complications that led to their transfer to another department, although this difference was not significant (21.3% vs 14.3%, P=.288). The type of anaesthesia used the most widely was spinal or intradural anaesthesia in 93.4% of patients, and no epidural technique was used. 53.5% of the patients received i.v. or oral iron after the operation, and even so more than 50% of them received a transfusion. The average total duration of admission was 10.3±8.2 days. 17.3% of the patients operated were transferred to another department due to medical complications. Of these, the most frequent complications were pneumonia (21.4%), heart failure (17.3%) and respiratory failure (8.9%). 42.1% suffered delirium or confusional syndrome, above all among patients with cognitive deterioration (64.7%) with which the association was significant (P<.001). Delirium was found to be more strongly associated with a worse functional situation on admission (Barthel < 60) compared to those patients with a better functional situation (58.5% vs 33.3%; P=.007). Delirium was significantly associated with increased patient transfer to temporary stay facilities (P=.04). It was also associated (although not significantly so) with more medical complications that led to transfer to another department, a longer period of hospitalisation and greater functional deterioration at discharge. Intrahospital mortality was 5.8%. The causes of death were: heart failure (n=4), kidney failure (n=1), pneumonia (n=1), bronchoaspiration (n=1) and diverticulitis (n=1). More than 80% of the patients were given dietary supplements during their stay, and the majority were prescribed calcium and vitamin D at discharge. Fewer than 40% of the patients were evaluated by the rehabilitation department. Only 4.8% of patients regained their previous functional situation after discharge (5 points less than their previous Barthel score), while 16.7% did so partially (20 points less than their Barthel score at admission). 55% of the patients returned to their home at discharge, while 22% were sent to a temporary stay facility.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The type of osteosynthesis used the most often was intramedullary osteosynthesis (43.5%), followed by cemented partial prosthesis (38%) and percutaneous extramedullary osteosynthesis (13.2%).Peri-implant infections occurred in 3% of the patients (2 partial cemented prostheses, one intramedullary pin and one plate). Mortality in patients with a peri-implant infection was 50%.DiscussionGeneral dataIn line with Ministry of Health and Consumption data, our HF patients had an average age above 80 years old, and they were mainly women.<a class="elsevierStyleCrossRef" href="#bib0185">2</a>A finding that stands out in comparison with other studies is that in spite of the advanced age of the patients and a high proportion of cognitive deterioration, they had low rates of comorbidity and dependency. These data agree with the fact that the majority of the patients here were from the community, while other studies include more patients who were previously institutionalised and therefore more dependent and with greater comorbidity.<a class="elsevierStyleCrossRefs" href="#bib0215">8,11</a>The average length of hospitalisation in our study was 10.3 days, which is shorter than the national average, which varies from 12 to 24 days.<a class="elsevierStyleCrossRef" href="#bib0185">2</a>Intrahospital mortality in our hospital among HF elderly patients is 5.8%. This is within the average rage in Spain, which stands at 5% and varies from 2–3% to 7–8%.<a class="elsevierStyleCrossRef" href="#bib0185">2</a>Preoperative careThe time for surgeryAll of the guides recommend prompt surgery, some in the first 24h,<a class="elsevierStyleCrossRefs" href="#bib0195">4,5</a> from 24 to 36h<a class="elsevierStyleCrossRef" href="#bib0190">3</a> or at 48h.<a class="elsevierStyleCrossRef" href="#bib0205">6</a> As is the case in a recent study,<a class="elsevierStyleCrossRef" href="#bib0250">15</a> the most frequent cause of delayed surgery in our hospital was that the patient was taking oral anticoagulants and aggregation inhibitors such as Clopidogrel at admission. Even so, the average duration of hospitalisation prior to surgery in our study is 48h. In agreement with other studies,<a class="elsevierStyleCrossRef" href="#bib0255">16</a> patients who were hospitalised for more than 48h prior to surgery went on to suffer more postoperative complications, although the differences were not significant.Recommendations for anticoagulated patientsWhen patients have been taking vitamin K antagonist oral anticoagulants (VKA) the guides recommend delaying surgery until their INR<1.5 for surgery under general anaesthetic or an INR≤1.3 for neuroaxial anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0260">17</a> The SIGN recommends withdrawing VKA and reversing the anticoagulation with i.v. vitamin K after the diagnosis of the fracture to prevent delaying surgery.<a class="elsevierStyleCrossRef" href="#bib0195">4</a> In patients with high risk of thrombosis (<3 months after a cerebrovascular accidents, valve prosthesis or serious thrombophilia) bridging therapy is recommended using low molecular weight heparin (LMWH).<a class="elsevierStyleCrossRef" href="#bib0265">18</a>When patients are taking one of the new direct action oral anticoagulants (DAOA), and considering that HF surgery is urgent and delayable, surgery should be delayed if possible by at least 24–36h after the administration of the last dose of the same. This is specifically equivalent to 2 half-lives in each case: from the 27h for Rivaroxaban, to the 36h for Apixaban and the 48h for Dabigatran in patients with functioning kidneys. The systematic prophylactic administration of haemostatic drugs is not recommended.<a class="elsevierStyleCrossRef" href="#bib0270">19</a>Recommendations for patients taking aggregation inhibitor drugsAccording to current guides, elderly patients with HF and taking aggregation inhibitor drugs, 100mg/d acetylsalicylic acid (ASA) or 300mg/d triflusal do not contraindicate surgery, while 300mg/d ASA is substituted by 100mg/d and no delay in surgery is required. Clopidogrel will be suspended 3–7 days before surgery, depending on the risk of thrombosis or haemorrhaging. Aggregation inhibitor treatment will be resumed as soon as possible after the operation, once haemostasis has been ensured (6–48h): aspirin can be given 6h after the end of surgery, while Clopidogrel can be given in the first 24h afterwards. ASA and triflusal do not contraindicate neuroaxial anaesthesia. Clopidogrel will be suspended 7 days before surgery, although recent evidence indicates that 5 days may be sufficient. Evaluate the substitution of Clopidogrel with 100mg/d ASA if there are no contraindications.<a class="elsevierStyleCrossRefs" href="#bib0190">3,20</a>In our sample patients with Clopidogrel as aggregation inhibitor treatment waited for 5±1.6 days before surgery, which is in line with the recommendations of the guides.AnaesthesiaWithin neuroaxial anaesthesia, spinal anaesthesia tends to be selected for elderly HF patients. This is associated with a lower rate of mortality 1 month after surgery, and also with fewer cardiovascular complications than is the case with general anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0280">21</a> According to the recommendations of the guides, spinal anaesthesia must be considered for all HF patients unless it is contraindicated.<a class="elsevierStyleCrossRefs" href="#bib0190">3–5</a> In our hospital more than 90% of the elderly HF patients are operated with spinal anaesthesia, and only 4.4% are operated under general anaesthetic.Although spinal haematoma after spinal anaesthesia is a rare complication, antithrombotic drugs may increase the risk of haemorrhage in the spinal canal, so that if this technique is used in patients taking aggregation inhibitor drugs, we will follow the recommendations given in the previous section.The treatment of habitual clinical problemsDeliriumOne of the most common complications during hospitalisation for HF is the appearance of delirium or acute confusional syndrome, which is associated with a worse prognosis. The guides recommend prevention and early treatment of its causes, together with hydration and suitable oral ingestion and the control of symptoms to reduce its incidence and severity.<a class="elsevierStyleCrossRefs" href="#bib0195">4,5,22</a>The incidence of delirium in our hospital was 42.1%, which is a similar value to those published by other authors in our country (34.6–45.2%).<a class="elsevierStyleCrossRefs" href="#bib0225">10,15</a> As in other studies, we found that predisposing factors to delirium include cognitive deterioration and a poorer functional situation at admission.<a class="elsevierStyleCrossRef" href="#bib0290">23</a> Delirium is significantly associated with increased transfer to temporary stay facilities. A higher frequency of medical complications is also observed, although this was not significant, as well as longer hospitalisation and greater functional deterioration.AnaemiaAccording to studies, around 50% of HF patients require a postoperative blood transfusion.<a class="elsevierStyleCrossRef" href="#bib0295">24</a> In our hospital 54.7% of elderly HF patients receive a transfusion after the operation. In accordance with the recommendations of the majority of guide, in our hospital a transfusion is indicated when haemoglobin (Hb) levels are <8g/dl or from 8g/dl to 10g/dl if the patient has cardiorrespiratory or cerebrovascular pathology.<a class="elsevierStyleCrossRefs" href="#bib0195">4,25</a>In some studies HF patients benefit from treatment with i.v. iron, reducing the rates of transfusion and postoperative morbimortality.<a class="elsevierStyleCrossRef" href="#bib0305">26</a>In the updated version of the Seville Consensus Document non-anaemic HF patients or those with a subcapital fracture, the preoperative administration of i.v. iron is a grade 2B recommendation (moderate quality evidence). In anaemic HF patients the combined administration of i.v. iron and recombinant human erythroprotein (a dose of 40,000UI) seems more effective in reducing the rate of transfusions than only i.v. iron. Postoperative treatment with i.v. iron is a 2C recommendation (low quality evidence). There is no recommendation to give oral iron in the postoperative period (grade 1B).<a class="elsevierStyleCrossRef" href="#bib0310">27</a> A guide for the clinical management of anaemia in HF patients could be: at admission if Hb<13g/dl and ferritin<100, unless there is a contraindication, administer parenteral 20mg/kg i.v. iron up to a maximum o f 1000mg if it is a carboximaltose or isomaltose iron preparation, as these make it possible to give high doses, and 12mg i.v. calcium folinate plus 1mg intramuscular cyanocobalamin (if levels are low or have not been measured). 200mg of sacarose iron may be given every 48h as an alternative to i.v. iron, as due to its stability it is possible to give high doses, without surpassing 600mg/week.<a class="elsevierStyleCrossRef" href="#bib0315">28</a>We found no differences in our study in the percentage of postoperative transfusions between patients who had received i.v. iron and those who received oral iron or no treatment. This could be explained by the lack of a protocol for managing anaemia in elderly HF patients.Malnutrition and the use of nutritional supplementsMany authors describe a high prevalence of malnutrition among HF patients, at from 31% to 88%, depending on the criteria used.<a class="elsevierStyleCrossRefs" href="#bib0320">29,30</a> Almost all guides recommend the use of nutritional supplements to reduce mortality, the appearance of complications and the average duration of hospitalisation.<a class="elsevierStyleCrossRefs" href="#bib0195">4–6</a> In our hospital a very high percentage of elderly HF patients suffer malnutrition on admission (87.6%). More than 80% of patients are prescribed oral nutritional supplements before and after surgery.PolypharmacyPolypharmacy stands out in our study, and this increases the possibility of interactions between drugs during surgery. Patients who consume more than 6 pharmaceuticals at admission evolve less favourably. Additionally there is high consumption of psychiatric drugs, and this increases the risk of falls and fractures.<a class="elsevierStyleCrossRef" href="#bib0330">31</a>OsteoporosisThe treatment of osteoporosis using calcium and vitamin D with antiresorptive medication is supported by current scientific evidence.<a class="elsevierStyleCrossRef" href="#bib0335">32</a>Data in our study show that only 19.3% of the elderly patients who were admitted to our hospital due to HF had previously been treated for osteoporosis. When patients are discharged they are usually prescribed calcium and vitamin D. The fact that bisphosphonates are rarely prescribed is probably due to the lack in our hospital of a treatment protocol for osteoporosis. There is also a certain reluctance to prescribe bisphosphonates because of their side effects<a class="elsevierStyleCrossRefs" href="#bib0340">33,34</a> (maxillary osteonecrosis and atypical fractures), as well as the need to monitor and re-evaluate the patients treated with these drugs.<a class="elsevierStyleCrossRef" href="#bib0350">35</a>RehabilitationAll of the guides underline the importance of rehabilitation to achieve the functional recovery of patients, shortening their hospital stay and preventing medical complications and institutionalisation.<a class="elsevierStyleCrossRefs" href="#bib0190">3–5</a>In other studies 73–92.7% of patients treated by the orthopaedic surgery department received rehabilitation in the acute phase of HF, recovering their previous functional situation partially or fully at discharge in 62–74.3% of cases. 22% of patients are discharged to their home, 20% to functional recovery units and 51% to homes or long stay units.<a class="elsevierStyleCrossRefs" href="#bib0215">8,10,16</a>The percentage of patients who receive rehabilitation in the acute phase of HF in our hospital is low (36%) in comparison with other hospitals, and only 21.5% of patients recover their previous functional situation partially or completely. This low percentage may be connected with the fact that in our hospital HF is managed as a condition that is basically acute.One limitation of our study is the lack of standardised protocols in our centre for the treatment of elderly patients with HF. However, in spite of this and according to the data shown, these patients are treated according to the recommendations of the main guides in this field. Another limitation is that patients were not followed-up over time after discharge from hospital, so that we cannot add results on mortality and functioning over the longer term to compare them with other studies. Respecting delay to surgery, organisational factors such as the availability of operating theatres were not recorded. Nevertheless, the average length of stay prior to surgery fits the recommendations of the guides.ConclusionsThe majority of the elderly patients admitted to our hospital due to HF live in the community and present low levels of comorbidity and dependency. They stand out for a high level of polypharmacy and malnutrition, together with vitamin D deficit. The overall average duration of hospitalisation and stay prior to surgery are relatively short in comparison with other studies in our country. Delirium is common and is associated with worse evolution and a higher likelihood of being discharged to a temporary stay facility. In general the recommendations in guides to clinical practice are followed in the treatment of elderly HF patients. The areas for improvement are the management of anaemia and rehabilitation during admission. Treatment of osteoporosis using bisphosphonates on discharge should be considered. The creation of a protocol should be considered for the management of the main problems which elderly HF patients may present on admission to our hospital, with the aim of improving these deficient areas.Level of evidenceLevel of evidence IV.Ethical disclosuresProtection of people and animalsThe authors declare that no experiments took place in human beings or animals for this research.Confidentiality of dataThe authors declare that they followed the protocols of their centre of work governing patient data publication.Right to privacy and informed consentThe authors declare that no patient data are shown in this paper.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres824437" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec820941" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824436" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Discusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec820940" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients and design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Description of variables" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:3 [ "identificador" => "sec0035" "titulo" => "Discussion" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "General data" ] 1 => array:3 [ "identificador" => "sec0045" "titulo" => "Preoperative care" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "The time for surgery" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Recommendations for anticoagulated patients" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Recommendations for patients taking aggregation inhibitor drugs" ] ] ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Anaesthesia" ] 3 => array:3 [ "identificador" => "sec0070" "titulo" => "The treatment of habitual clinical problems" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Delirium" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Anaemia" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Malnutrition and the use of nutritional supplements" ] 3 => array:2 [ "identificador" => "sec0090" "titulo" => "Polypharmacy" ] 4 => array:2 [ "identificador" => "sec0095" "titulo" => "Osteoporosis" ] ] ] 4 => array:2 [ "identificador" => "sec0100" "titulo" => "Rehabilitation" ] ] ] 8 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0110" "titulo" => "Level of evidence" ] 10 => array:3 [ "identificador" => "sec0115" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0120" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0125" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0130" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0135" "titulo" => "Conflict of interests" ] 12 => array:2 [ "identificador" => "xack276490" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-29" "fechaAceptado" => "2016-11-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec820941" "palabras" => array:4 [ 0 => "Hip fracture" 1 => "Elderly patient" 2 => "Orthogeriatric" 3 => "Hospital care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec820940" "palabras" => array:4 [ 0 => "Fractura de cadera" 1 => "Ancianos" 2 => "Ortogeriatría" 3 => "Asistencia hospitalaria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "AimTo describe the orthogeriatric activity in the elderly with hip fractures in the Hospital Mancha Centro, based on the recommendations of the main guidelines. Material and methodObservational prospective study, comprising all patients over 65 years of age admitted to the Traumatology Unit with a hip fracture between April 2015 and December 2015. Patients were admitted under the care of the Traumatology Unit with cross-consultation carried out with the Geriatrics Department, which then carried out a pre-operative geriatric assessment and the post-operative follow-ups. ResultsThe mean pre-surgery waiting time was 48h and the overall time in hospital was 10.3±8.2 days. Patients who suffered from delirium (42.1%) did not improve as well, and were referred to nursing homes. Blood transfusions were received by 54.7% of the patients, despite 53.5% of them having received intravenous and/or oral iron after the surgery. Treatment with calcium and vitamin D was prescribed in 79% of the patients on discharge. The Rehabilitation Unit assessed 36% of the patients, with 4.8% fully, and 16.7% partially recovering their prior functional status. Upon discharge, 55% of the patients returned to their homes, and 22% were referred to short-term assisted living facilities. DiscussionThis article describes how the main clinical problems are handled in the elderly with hip fractures in our hospital, based on recommendations of the main guidelines and publications. ConclusionsOur hospital follows the recommended guidelines. Aspects for improvement include the management of anaemia during admission and rehabilitation." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoDescribir la actividad ortogeriátrica en ancianos con fractura de cadera en el Hospital Mancha Centro basándonos en las recomendaciones de las principales guías clínicas. Material y métodoEstudio prospectivo observacional. Se incluyen todos los pacientes mayores de 65 años ingresados en traumatología con fractura de cadera desde abril de 2015 a diciembre de 2015. El paciente ingresa a cargo de traumatología y se interconsulta a geriatría, que realiza una valoración geriátrica preoperatoria y un seguimiento postoperatorio. ResultadosLa estancia media prequirúrgica fue de 48h y la estancia media global de 10,3±8,2 días. Los pacientes que sufrieron delirium (42,1%) evolucionaron peor y se derivaron más a residencias. Se transfundieron el 54,7% de los pacientes a pesar de que el 53,5% recibieron hierro intravenoso y/u oral en el postoperatorio. Al alta se pautó calcio y vitamina D al 79% de los pacientes. Fueron valorados por rehabilitación el 36% de los pacientes, recuperando su situación funcional previa el 4,8% y parcialmente el 16,7%. Al alta, un 55% de los pacientes volvieron a su domicilio y un 22% fueron derivados a estancias temporales. DiscusiónEn este artículo se detalla el manejo de los principales problemas clínicos en nuestro hospital en ancianos con fractura de cadera basándonos en las recomendaciones de las principales guías y resultados de publicaciones al respecto. ConclusionesEn nuestro hospital se siguen las recomendaciones de las guías. Aspectos a mejorar son el manejo de la anaemia durante el ingreso y la rehabilitación." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Discusión" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fernández-Ibáñez JM, Morales-Ballesteros MC, Crespo-Romero E, Gómez-Gómez S, Fraga-Fuentes MD, Cruz-Tejado J, et al. Actividad ortogeriátrica en un hospital general de Castilla-La Mancha. Rev Esp Cir Ortop Traumatol. 2017;61:88–95." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) n=137 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (Average in years±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84.2±6.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Women \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104 (76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Place of residence</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Private home \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 (77.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Old people's home \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (22.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (39) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson I. (average, points±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8±1.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous Barthel I. (average, points±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.7±28.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Malnutrition criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (87.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of drugs (average No.±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1±3.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psychiatric drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 (56.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vitamin D deficiency (<30ng/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115 (90.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe vitamin D deficiency (<10ng/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 (69.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Consumption of calcium and vitamin D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (12.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment with bisphosphonates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Previous anticoagulation/aggregation inhibitor</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clopidogrel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dicoumarol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (14.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New anticoagulants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of fracture</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intracapsular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 (41.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Extracapsular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 (56.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Periprosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386117.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The main patient characteristics at admission." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N (%) n=137 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients operated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">134 (97.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospitalisation prior to surgery (average in hours±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48±39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total hospitalisation (average in days±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3±8.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Barthel I. at discharge (average points±SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.2±17.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transfusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 (54.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Iron</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (45.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">i.v. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (29.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (24.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral supplements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 (80.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (17.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calcium±Vitamin D at discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 (79) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bisphosphonates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (8.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Delirium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 (42.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evaluated by rehabilitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 (35.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (5.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peri-implant infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of anaesthesia</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spinal or intradural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">128 (93.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">General \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (4.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Type of surgery</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Partial cemented hip prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (38) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total cemented prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteosynthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (56.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Destination at discharge</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Private home \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 (49.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Private home with assistance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temporary stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previously lived in an old people's home \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (22.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386118.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Description of the main orthogeriatric activity variables at discharge." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hip fracture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. 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Original Article

Orthogeriatric activity in a general hospital of Castilla-La Mancha, Spain

Actividad ortogeriátrica en un hospital general de Castilla-La Mancha

J.M. Fernández-Ibáñeza,

Corresponding author

jmfernandezi@sescam.jccm.es

Corresponding author.

, M.C. Morales-Ballesterosa, E. Crespo-Romerob, S. Gómez-Gómezb, M.D. Fraga-Fuentesc, J. Cruz-Tejadod, P.A. Hernández-Zegarraa, Á. Arias-Ariase, M.M. García-Baltasarf

a Sección de Geriatría, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain

b Servicio de Traumatología, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain

c Servicio de Farmacia, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain

d Servicio de Anestesia, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain

e Unidad de Investigación, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain

f Servicio de Trabajo Social, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hip fracture &#40;HF&#41; is a serious problem in medical&#44; healthcare&#44; economic and social terms&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">More than 85&#37; of HF occur in patients older than 65 years old&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a> In Spain from 50&#44;000 to 60&#44;000 HF occur per year&#46; This incidence is rising and it is estimated that it will have doubled by 2050&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a> In Castile-La Mancha the rate of incidence adjusted for both sexes stands at 734 per 100&#44;000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The direct costs of treating each HF in Spain vary from 3000 to 5200 Euros&#44; depending on hospital and autonomous region&#44; and overall costs amount to 300&#8211;860 million Euros&#44; without counting additional indirect expenses such as carers&#44; old people&#39;s homes and rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">All of the guides analysed recommend that the geriatric and orthopaedic departments cooperate in treating the elderly with HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#8211;7</span></a> This includes the acute phase during hospitalisation&#44; rehabilitation&#44; convalescence and support&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The most widespread model is currently to have a Consultant Geriatrician for hospitalised patients in orthopaedic beds&#46; This co-working strategy has been shown to reduce hospital stay prior to surgery&#44; reduce complications&#44; improve functional results&#44; reducing mortality and the duration of hospitalisation as well as treatment costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#8211;11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A programme was established in our centre in 2008 for internal consultation with the Geriatric Department for all HF patients over the age of 65 years old&#46; This coincided with the hospital contracting geriatricians&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In a study published in Spain&#44; S&#225;ez L&#243;pez et al&#46; and the Orthogeriatric Working Group of Castile y Le&#243;n describe orthogeriatric working in the public hospitals of Castile y Le&#243;n&#44; comparing it with the guides on clinical practice and other publications in this field&#46; They conclude that orthogeriatric cooperation is a habitual practice&#44; as is following the recommendations of clinical practice guides for treating HF in geriatric patients&#46; They found that clinical care and rehabilitation were areas that should be improved&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This work studies how the most common clinical problems are managed in elderly HF patients who are admitted to the Orthopaedic Department of our hospital in cooperation with the Geriatric Department&#46; It is based on the recommendations of the main clinical practice guides<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#8211;7</span></a> and the results published in the relevant literature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients and design</span><p id="par0045" class="elsevierStylePara elsevierViewall">This study is descriptive and observational&#46; All of the HF patients over the age of 65 years old admitted to the orthopaedic department and also seen by the geriatric department were included prospectively and consecutively&#44; from April to December 2015&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The Mancha Centro Hospital is a general hospital located in Alc&#225;zar de San Juan&#44; Ciudad Real&#46; It has a total of 343 hospital beds for a catchment area of 125&#44;610 inhabitants who live in 21 municipalities in the provinces of Ciudad Real&#44; Cuenca and Toledo&#46; This area contains 18 old people&#39;s homes&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Patients are admitted to the Orthopaedic Department from the A&#38;E Department&#46; Once in the ward they are evaluated by geriatricians in interconsultation&#46; The geriatrician evaluates them and prepares a plan for care on admission&#44; as well as for postoperative care after surgery&#46; The orthopaedic surgeon and anaesthetist decide when to operate&#44; depending on the availability of the emergency operating theatre and the clinical state of the patient&#44; but always as soon as possible&#46; Partial prostheses have been used for intracapsular fractures&#44; together with intramedullary osteosynthesis or percutaneous extramedullary osteosynthesis for pertrochantheric fractures and intramedullary osteosynthesis for subtrochanteric ones&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> Evaluation for rehabilitation is decided on by the orthopaedic surgeon or geriatrician through interconsultation&#46; When social resources are required&#44; such as assisted homes or home-help&#44; social workers are requested to intervene&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Description of variables</span><p id="par0060" class="elsevierStylePara elsevierViewall">The following data are recorded at admission&#58; date of birth&#44; sex&#44; date and time of the first evaluation by the orthopaedic surgeon&#44; previous Barthel score&#44; Charlson score&#44; history of cognitive deterioration&#44; nutritional parameters &#40;albumin&#44; total protein&#44; total cholesterol and number of lymphocytes&#41;&#44; malnutrition according to the SENPE<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> criteria&#44; vitamin D level&#44; number of drugs taken at admission and whether they include any psychiatric medication&#44; previous ingestion of vitamin D&#44; calcium or bisphosphonates&#44; and fracture type&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The following data are recorded at discharge&#58; date and time of the operation&#44; delay &#40;more than 48<span class="elsevierStyleHsp" style=""></span>h after the first examination by the orthopaedic surgeon&#41;&#44; cause of delay&#44; type of anaesthesia&#44; date and reason for discharge&#44; medical complications during hospitalisation&#44; whether treatment for osteoporosis is prescribed &#40;calcium&#44; vitamin D or bisphosphonates&#41;&#44; whether the patient received iron treatment or a transfusion&#44; if they received dietary supplements&#44; if they were examined by the rehabilitation department&#44; type of osteosynthesis used for the fracture&#44; complications connected with surgery and destination on discharge &#40;home&#44; home with assistance&#44; previously institutionalised&#44; temporary stay&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We evaluate the actions taken to care for elderly HF patients based on the recommendations of the main clinical practice guides for this&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#8211;7</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Qualitative variables are described using absolute and relative frequencies&#44; while quantitative ones are described using central tendency measures &#40;average or mean&#41; together with dispersion measurements &#40;standard deviation or interquartile range&#41; depending on whether variables are distributed normally or not&#46; Comparative analysis is performed using Chi-squared tests &#40;or Fisher&#39;s exact test when appropriate&#41; for qualitative variables&#44; and comparisons between groups are made using the Student&#39;s <span class="elsevierStyleItalic">t</span> test for quantitative variables&#46; A level of significance of 0&#46;05 was selected&#46; All calculations were carried out using the SPSS v18 program&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">773 patients were admitted to the orthopaedic surgery department during the period studied&#44; of which 137 were HF cases&#44; representing 18&#37; of total admissions&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the main characteristics of the patients at the moment of admissions&#46; They had a high average age &#40;84&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;3 years old&#41; and were mainly women &#40;76&#37;&#41;&#46; They had a mild level of functional dependency on the Barthel index and low comorbidity measured using Charlson&#39;s scale&#46; A high proportion of the patients presented cognitive deterioration in their medical history&#46; Their consumption of several types of medication stands out &#40;more than 7 drugs on average per patient&#41;&#44; and 56&#46;6&#37; of the patients were taking psychiatric medication&#46; Those patients who were taking more than 6 drugs prior to admission were found to progress significantly less favourably &#40;dying or being transferred to another department due to complications&#41; &#40;27&#46;4&#37; vs&#46; 11&#46;9&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;028&#41;&#46; More than 90&#37; of the patients presented vitamin D deficit&#44; and less than 20&#37; received calcium and vitamin D treatment&#46; More than 20&#37; were taking anticoagulant pharmaceuticals and aggregation inhibitors&#44; while the analytical data of more than 80&#37; showed signs of malnutrition according to the standard SENPE<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> criteria&#46; The majority of our patients originate in the community&#46; Extracapsular fractures were the most frequent type &#40;56&#46;2&#37;&#41; and of these&#44; pertrochanteric fractures were the most common &#40;46&#37; of the total&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the variables recorded at discharge&#46; The majority of patients were operated in the first 48<span class="elsevierStyleHsp" style=""></span>h &#40;64&#46;9&#37;&#41; after being examined by the orthopaedic surgeon&#44; and the average hospitalisation before surgery was 48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39<span class="elsevierStyleHsp" style=""></span>h&#46; The most frequent cause of delayed surgery &#40;&#62;48<span class="elsevierStyleHsp" style=""></span>h&#41; was the consumption of oral anticoagulants &#40;3&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;2 days&#41; and secondly taking Clopidogrel &#40;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6 days&#41;&#46; The patients who underwent longer admission prior to surgery &#40;&#62;48<span class="elsevierStyleHsp" style=""></span>h&#41; presented more medical complications that led to their transfer to another department&#44; although this difference was not significant &#40;21&#46;3&#37; vs 14&#46;3&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;288&#41;&#46; The type of anaesthesia used the most widely was spinal or intradural anaesthesia in 93&#46;4&#37; of patients&#44; and no epidural technique was used&#46; 53&#46;5&#37; of the patients received i&#46;v&#46; or oral iron after the operation&#44; and even so more than 50&#37; of them received a transfusion&#46; The average total duration of admission was 10&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;2 days&#46; 17&#46;3&#37; of the patients operated were transferred to another department due to medical complications&#46; Of these&#44; the most frequent complications were pneumonia &#40;21&#46;4&#37;&#41;&#44; heart failure &#40;17&#46;3&#37;&#41; and respiratory failure &#40;8&#46;9&#37;&#41;&#46; 42&#46;1&#37; suffered delirium or confusional syndrome&#44; above all among patients with cognitive deterioration &#40;64&#46;7&#37;&#41; with which the association was significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Delirium was found to be more strongly associated with a worse functional situation on admission &#40;Barthel &#60; 60&#41; compared to those patients with a better functional situation &#40;58&#46;5&#37; vs 33&#46;3&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;007&#41;&#46; Delirium was significantly associated with increased patient transfer to temporary stay facilities &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#46; It was also associated &#40;although not significantly so&#41; with more medical complications that led to transfer to another department&#44; a longer period of hospitalisation and greater functional deterioration at discharge&#46; Intrahospital mortality was 5&#46;8&#37;&#46; The causes of death were&#58; heart failure &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; kidney failure &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; pneumonia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; bronchoaspiration &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and diverticulitis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; More than 80&#37; of the patients were given dietary supplements during their stay&#44; and the majority were prescribed calcium and vitamin D at discharge&#46; Fewer than 40&#37; of the patients were evaluated by the rehabilitation department&#46; Only 4&#46;8&#37; of patients regained their previous functional situation after discharge &#40;5 points less than their previous Barthel score&#41;&#44; while 16&#46;7&#37; did so partially &#40;20 points less than their Barthel score at admission&#41;&#46; 55&#37; of the patients returned to their home at discharge&#44; while 22&#37; were sent to a temporary stay facility&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The type of osteosynthesis used the most often was intramedullary osteosynthesis &#40;43&#46;5&#37;&#41;&#44; followed by cemented partial prosthesis &#40;38&#37;&#41; and percutaneous extramedullary osteosynthesis &#40;13&#46;2&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Peri-implant infections occurred in 3&#37; of the patients &#40;2 partial cemented prostheses&#44; one intramedullary pin and one plate&#41;&#46; Mortality in patients with a peri-implant infection was 50&#37;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">General data</span><p id="par0105" class="elsevierStylePara elsevierViewall">In line with Ministry of Health and Consumption data&#44; our HF patients had an average age above 80 years old&#44; and they were mainly women&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">A finding that stands out in comparison with other studies is that in spite of the advanced age of the patients and a high proportion of cognitive deterioration&#44; they had low rates of comorbidity and dependency&#46; These data agree with the fact that the majority of the patients here were from the community&#44; while other studies include more patients who were previously institutionalised and therefore more dependent and with greater comorbidity&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#44;11</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The average length of hospitalisation in our study was 10&#46;3 days&#44; which is shorter than the national average&#44; which varies from 12 to 24 days&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Intrahospital mortality in our hospital among HF elderly patients is 5&#46;8&#37;&#46; This is within the average rage in Spain&#44; which stands at 5&#37; and varies from 2&#8211;3&#37; to 7&#8211;8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Preoperative care</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">The time for surgery</span><p id="par0125" class="elsevierStylePara elsevierViewall">All of the guides recommend prompt surgery&#44; some in the first 24<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">4&#44;5</span></a> from 24 to 36<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">3</span></a> or at 48<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">6</span></a> As is the case in a recent study&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">15</span></a> the most frequent cause of delayed surgery in our hospital was that the patient was taking oral anticoagulants and aggregation inhibitors such as Clopidogrel at admission&#46; Even so&#44; the average duration of hospitalisation prior to surgery in our study is 48<span class="elsevierStyleHsp" style=""></span>h&#46; In agreement with other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a> patients who were hospitalised for more than 48<span class="elsevierStyleHsp" style=""></span>h prior to surgery went on to suffer more postoperative complications&#44; although the differences were not significant&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Recommendations for anticoagulated patients</span><p id="par0130" class="elsevierStylePara elsevierViewall">When patients have been taking vitamin K antagonist oral anticoagulants &#40;VKA&#41; the guides recommend delaying surgery until their INR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#46;5 for surgery under general anaesthetic or an INR<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>1&#46;3 for neuroaxial anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">17</span></a> The SIGN recommends withdrawing VKA and reversing the anticoagulation with i&#46;v&#46; vitamin K after the diagnosis of the fracture to prevent delaying surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">4</span></a> In patients with high risk of thrombosis &#40;&#60;3 months after a cerebrovascular accidents&#44; valve prosthesis or serious thrombophilia&#41; bridging therapy is recommended using low molecular weight heparin &#40;LMWH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">When patients are taking one of the new direct action oral anticoagulants &#40;DAOA&#41;&#44; and considering that HF surgery is urgent and delayable&#44; surgery should be delayed if possible by at least 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h after the administration of the last dose of the same&#46; This is specifically equivalent to 2 half-lives in each case&#58; from the 27<span class="elsevierStyleHsp" style=""></span>h for Rivaroxaban&#44; to the 36<span class="elsevierStyleHsp" style=""></span>h for Apixaban and the 48<span class="elsevierStyleHsp" style=""></span>h for Dabigatran in patients with functioning kidneys&#46; The systematic prophylactic administration of haemostatic drugs is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Recommendations for patients taking aggregation inhibitor drugs</span><p id="par0140" class="elsevierStylePara elsevierViewall">According to current guides&#44; elderly patients with HF and taking aggregation inhibitor drugs&#44; 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d acetylsalicylic acid &#40;ASA&#41; or 300<span class="elsevierStyleHsp" style=""></span>mg&#47;d triflusal do not contraindicate surgery&#44; while 300<span class="elsevierStyleHsp" style=""></span>mg&#47;d ASA is substituted by 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d and no delay in surgery is required&#46; Clopidogrel will be suspended 3&#8211;7 days before surgery&#44; depending on the risk of thrombosis or haemorrhaging&#46; Aggregation inhibitor treatment will be resumed as soon as possible after the operation&#44; once haemostasis has been ensured &#40;6&#8211;48<span class="elsevierStyleHsp" style=""></span>h&#41;&#58; aspirin can be given 6<span class="elsevierStyleHsp" style=""></span>h after the end of surgery&#44; while Clopidogrel can be given in the first 24<span class="elsevierStyleHsp" style=""></span>h afterwards&#46; ASA and triflusal do not contraindicate neuroaxial anaesthesia&#46; Clopidogrel will be suspended 7 days before surgery&#44; although recent evidence indicates that 5 days may be sufficient&#46; Evaluate the substitution of Clopidogrel with 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d ASA if there are no contraindications&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#44;20</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In our sample patients with Clopidogrel as aggregation inhibitor treatment waited for 5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6 days before surgery&#44; which is in line with the recommendations of the guides&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Anaesthesia</span><p id="par0150" class="elsevierStylePara elsevierViewall">Within neuroaxial anaesthesia&#44; spinal anaesthesia tends to be selected for elderly HF patients&#46; This is associated with a lower rate of mortality 1 month after surgery&#44; and also with fewer cardiovascular complications than is the case with general anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a> According to the recommendations of the guides&#44; spinal anaesthesia must be considered for all HF patients unless it is contraindicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#8211;5</span></a> In our hospital more than 90&#37; of the elderly HF patients are operated with spinal anaesthesia&#44; and only 4&#46;4&#37; are operated under general anaesthetic&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Although spinal haematoma after spinal anaesthesia is a rare complication&#44; antithrombotic drugs may increase the risk of haemorrhage in the spinal canal&#44; so that if this technique is used in patients taking aggregation inhibitor drugs&#44; we will follow the recommendations given in the previous section&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">The treatment of habitual clinical problems</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Delirium</span><p id="par0160" class="elsevierStylePara elsevierViewall">One of the most common complications during hospitalisation for HF is the appearance of delirium or acute confusional syndrome&#44; which is associated with a worse prognosis&#46; The guides recommend prevention and early treatment of its causes&#44; together with hydration and suitable oral ingestion and the control of symptoms to reduce its incidence and severity&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">4&#44;5&#44;22</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The incidence of delirium in our hospital was 42&#46;1&#37;&#44; which is a similar value to those published by other authors in our country &#40;34&#46;6&#8211;45&#46;2&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10&#44;15</span></a> As in other studies&#44; we found that predisposing factors to delirium include cognitive deterioration and a poorer functional situation at admission&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a> Delirium is significantly associated with increased transfer to temporary stay facilities&#46; A higher frequency of medical complications is also observed&#44; although this was not significant&#44; as well as longer hospitalisation and greater functional deterioration&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Anaemia</span><p id="par0170" class="elsevierStylePara elsevierViewall">According to studies&#44; around 50&#37; of HF patients require a postoperative blood transfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> In our hospital 54&#46;7&#37; of elderly HF patients receive a transfusion after the operation&#46; In accordance with the recommendations of the majority of guide&#44; in our hospital a transfusion is indicated when haemoglobin &#40;Hb&#41; levels are &#60;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl or from 8<span class="elsevierStyleHsp" style=""></span>g&#47;dl to 10<span class="elsevierStyleHsp" style=""></span>g&#47;dl if the patient has cardiorrespiratory or cerebrovascular pathology&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">4&#44;25</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In some studies HF patients benefit from treatment with i&#46;v&#46; iron&#44; reducing the rates of transfusion and postoperative morbimortality&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In the updated version of the Seville Consensus Document non-anaemic HF patients or those with a subcapital fracture&#44; the preoperative administration of i&#46;v&#46; iron is a grade 2B recommendation &#40;moderate quality evidence&#41;&#46; In anaemic HF patients the combined administration of i&#46;v&#46; iron and recombinant human erythroprotein &#40;a dose of 40&#44;000<span class="elsevierStyleHsp" style=""></span>UI&#41; seems more effective in reducing the rate of transfusions than only i&#46;v&#46; iron&#46; Postoperative treatment with i&#46;v&#46; iron is a 2C recommendation &#40;low quality evidence&#41;&#46; There is no recommendation to give oral iron in the postoperative period &#40;grade 1B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a> A guide for the clinical management of anaemia in HF patients could be&#58; at admission if Hb<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>g&#47;dl and ferritin<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&#44; unless there is a contraindication&#44; administer parenteral 20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg i&#46;v&#46; iron up to a maximum o f 1000<span class="elsevierStyleHsp" style=""></span>mg if it is a carboximaltose or isomaltose iron preparation&#44; as these make it possible to give high doses&#44; and 12<span class="elsevierStyleHsp" style=""></span>mg i&#46;v&#46; calcium folinate plus 1<span class="elsevierStyleHsp" style=""></span>mg intramuscular cyanocobalamin &#40;if levels are low or have not been measured&#41;&#46; 200<span class="elsevierStyleHsp" style=""></span>mg of sacarose iron may be given every 48<span class="elsevierStyleHsp" style=""></span>h as an alternative to i&#46;v&#46; iron&#44; as due to its stability it is possible to give high doses&#44; without surpassing 600<span class="elsevierStyleHsp" style=""></span>mg&#47;week&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">28</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">We found no differences in our study in the percentage of postoperative transfusions between patients who had received i&#46;v&#46; iron and those who received oral iron or no treatment&#46; This could be explained by the lack of a protocol for managing anaemia in elderly HF patients&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Malnutrition and the use of nutritional supplements</span><p id="par0190" class="elsevierStylePara elsevierViewall">Many authors describe a high prevalence of malnutrition among HF patients&#44; at from 31&#37; to 88&#37;&#44; depending on the criteria used&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">29&#44;30</span></a> Almost all guides recommend the use of nutritional supplements to reduce mortality&#44; the appearance of complications and the average duration of hospitalisation&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">4&#8211;6</span></a> In our hospital a very high percentage of elderly HF patients suffer malnutrition on admission &#40;87&#46;6&#37;&#41;&#46; More than 80&#37; of patients are prescribed oral nutritional supplements before and after surgery&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Polypharmacy</span><p id="par0195" class="elsevierStylePara elsevierViewall">Polypharmacy stands out in our study&#44; and this increases the possibility of interactions between drugs during surgery&#46; Patients who consume more than 6 pharmaceuticals at admission evolve less favourably&#46; Additionally there is high consumption of psychiatric drugs&#44; and this increases the risk of falls and fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Osteoporosis</span><p id="par0200" class="elsevierStylePara elsevierViewall">The treatment of osteoporosis using calcium and vitamin D with antiresorptive medication is supported by current scientific evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">32</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Data in our study show that only 19&#46;3&#37; of the elderly patients who were admitted to our hospital due to HF had previously been treated for osteoporosis&#46; When patients are discharged they are usually prescribed calcium and vitamin D&#46; The fact that bisphosphonates are rarely prescribed is probably due to the lack in our hospital of a treatment protocol for osteoporosis&#46; There is also a certain reluctance to prescribe bisphosphonates because of their side effects<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">33&#44;34</span></a> &#40;maxillary osteonecrosis and atypical fractures&#41;&#44; as well as the need to monitor and re-evaluate the patients treated with these drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Rehabilitation</span><p id="par0210" class="elsevierStylePara elsevierViewall">All of the guides underline the importance of rehabilitation to achieve the functional recovery of patients&#44; shortening their hospital stay and preventing medical complications and institutionalisation&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In other studies 73&#8211;92&#46;7&#37; of patients treated by the orthopaedic surgery department received rehabilitation in the acute phase of HF&#44; recovering their previous functional situation partially or fully at discharge in 62&#8211;74&#46;3&#37; of cases&#46; 22&#37; of patients are discharged to their home&#44; 20&#37; to functional recovery units and 51&#37; to homes or long stay units&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">8&#44;10&#44;16</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The percentage of patients who receive rehabilitation in the acute phase of HF in our hospital is low &#40;36&#37;&#41; in comparison with other hospitals&#44; and only 21&#46;5&#37; of patients recover their previous functional situation partially or completely&#46; This low percentage may be connected with the fact that in our hospital HF is managed as a condition that is basically acute&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">One limitation of our study is the lack of standardised protocols in our centre for the treatment of elderly patients with HF&#46; However&#44; in spite of this and according to the data shown&#44; these patients are treated according to the recommendations of the main guides in this field&#46; Another limitation is that patients were not followed-up over time after discharge from hospital&#44; so that we cannot add results on mortality and functioning over the longer term to compare them with other studies&#46; Respecting delay to surgery&#44; organisational factors such as the availability of operating theatres were not recorded&#46; Nevertheless&#44; the average length of stay prior to surgery fits the recommendations of the guides&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusions</span><p id="par0230" class="elsevierStylePara elsevierViewall">The majority of the elderly patients admitted to our hospital due to HF live in the community and present low levels of comorbidity and dependency&#46; They stand out for a high level of polypharmacy and malnutrition&#44; together with vitamin D deficit&#46; The overall average duration of hospitalisation and stay prior to surgery are relatively short in comparison with other studies in our country&#46; Delirium is common and is associated with worse evolution and a higher likelihood of being discharged to a temporary stay facility&#46; In general the recommendations in guides to clinical practice are followed in the treatment of elderly HF patients&#46; The areas for improvement are the management of anaemia and rehabilitation during admission&#46; Treatment of osteoporosis using bisphosphonates on discharge should be considered&#46; The creation of a protocol should be considered for the management of the main problems which elderly HF patients may present on admission to our hospital&#44; with the aim of improving these deficient areas&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Level of evidence</span><p id="par0235" class="elsevierStylePara elsevierViewall">Level of evidence IV&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Ethical disclosures</span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Protection of people and animals</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that no experiments took place in human beings or animals for this research&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Confidentiality of data</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare that they followed the protocols of their centre of work governing patient data publication&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Right to privacy and informed consent</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that no patient data are shown in this paper&#46;</p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Conflict of interests</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2016-04-29"
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            0 => "Hip fracture"
            1 => "Elderly patient"
            2 => "Orthogeriatric"
            3 => "Hospital care"
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          "palabras" => array:4 [
            0 => "Fractura de cadera"
            1 => "Ancianos"
            2 => "Ortogeriatr&#237;a"
            3 => "Asistencia hospitalaria"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the orthogeriatric activity in the elderly with hip fractures in the <span class="elsevierStyleItalic">Hospital Mancha Centro</span>&#44; based on the recommendations of the main guidelines&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Observational prospective study&#44; comprising all patients over 65 years of age admitted to the Traumatology Unit with a hip fracture between April 2015 and December 2015&#46; Patients were admitted under the care of the Traumatology Unit with cross-consultation carried out with the Geriatrics Department&#44; which then carried out a pre-operative geriatric assessment and the post-operative follow-ups&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean pre-surgery waiting time was 48<span class="elsevierStyleHsp" style=""></span>h and the overall time in hospital was 10&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;2 days&#46; Patients who suffered from delirium &#40;42&#46;1&#37;&#41; did not improve as well&#44; and were referred to nursing homes&#46; Blood transfusions were received by 54&#46;7&#37; of the patients&#44; despite 53&#46;5&#37; of them having received intravenous and&#47;or oral iron after the surgery&#46; Treatment with calcium and vitamin D was prescribed in 79&#37; of the patients on discharge&#46; The Rehabilitation Unit assessed 36&#37; of the patients&#44; with 4&#46;8&#37; fully&#44; and 16&#46;7&#37; partially recovering their prior functional status&#46; Upon discharge&#44; 55&#37; of the patients returned to their homes&#44; and 22&#37; were referred to short-term assisted living facilities&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This article describes how the main clinical problems are handled in the elderly with hip fractures in our hospital&#44; based on recommendations of the main guidelines and publications&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Our hospital follows the recommended guidelines&#46; Aspects for improvement include the management of anaemia during admission and rehabilitation&#46;</p></span>"
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          2 => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Describir la actividad ortogeri&#225;trica en ancianos con fractura de cadera en el Hospital Mancha Centro bas&#225;ndonos en las recomendaciones de las principales gu&#237;as cl&#237;nicas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo observacional&#46; Se incluyen todos los pacientes mayores de 65 a&#241;os ingresados en traumatolog&#237;a con fractura de cadera desde abril de 2015 a diciembre de 2015&#46; El paciente ingresa a cargo de traumatolog&#237;a y se interconsulta a geriatr&#237;a&#44; que realiza una valoraci&#243;n geri&#225;trica preoperatoria y un seguimiento postoperatorio&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La estancia media prequir&#250;rgica fue de 48<span class="elsevierStyleHsp" style=""></span>h y la estancia media global de 10&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;2 d&#237;as&#46; Los pacientes que sufrieron delirium &#40;42&#44;1&#37;&#41; evolucionaron peor y se derivaron m&#225;s a residencias&#46; Se transfundieron el 54&#44;7&#37; de los pacientes a pesar de que el 53&#44;5&#37; recibieron hierro intravenoso y&#47;u oral en el postoperatorio&#46; Al alta se paut&#243; calcio y vitamina D al 79&#37; de los pacientes&#46; Fueron valorados por rehabilitaci&#243;n el 36&#37; de los pacientes&#44; recuperando su situaci&#243;n funcional previa el 4&#44;8&#37; y parcialmente el 16&#44;7&#37;&#46; Al alta&#44; un 55&#37; de los pacientes volvieron a su domicilio y un 22&#37; fueron derivados a estancias temporales&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discusi&#243;n</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En este art&#237;culo se detalla el manejo de los principales problemas cl&#237;nicos en nuestro hospital en ancianos con fractura de cadera bas&#225;ndonos en las recomendaciones de las principales gu&#237;as y resultados de publicaciones al respecto&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En nuestro hospital se siguen las recomendaciones de las gu&#237;as&#46; Aspectos a mejorar son el manejo de la anaemia durante el ingreso y la rehabilitaci&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fern&#225;ndez-Ib&#225;&#241;ez JM&#44; Morales-Ballesteros MC&#44; Crespo-Romero E&#44; G&#243;mez-G&#243;mez S&#44; Fraga-Fuentes MD&#44; Cruz-Tejado J&#44; et al&#46; Actividad ortogeri&#225;trica en un hospital general de Castilla-La Mancha&#46; Rev Esp Cir Ortop Traumatol&#46; 2017&#59;61&#58;88&#8211;95&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;Average in years</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Women</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">104 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Place of residence</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Private home&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95 &#40;77&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Old people&#39;s home&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;22&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous dementia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Charlson I&#46; &#40;average&#44; points</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous Barthel I&#46; &#40;average&#44; points</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Malnutrition criteria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120 &#40;87&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Number of drugs &#40;average No&#46;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Psychiatric drugs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;56&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Vitamin D deficiency &#40;&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">30</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ng&#47;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">115 &#40;90&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Severe vitamin D deficiency &#40;&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">10</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ng&#47;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88 &#40;69&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Consumption of calcium and vitamin D</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;12&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Treatment with bisphosphonates</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Previous anticoagulation&#47;aggregation inhibitor</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clopidogrel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dicoumarol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;14&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>New anticoagulants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of fracture</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intracapsular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57 &#40;41&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extracapsular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;56&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Periprosthesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>137&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients operated</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">134 &#40;97&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hospitalisation prior to surgery &#40;average in hours</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Total hospitalisation &#40;average in days</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Barthel I&#46; at discharge &#40;average points</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Transfusion</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#40;54&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Iron</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;45&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>i&#46;v&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;29&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;24&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Oral supplements</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96 &#40;80&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Complications</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;17&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Calcium</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vitamin D at discharge</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Bisphosphonates</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Delirium</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;42&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Evaluated by rehabilitation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47 &#40;35&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mortality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;5&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Peri-implant infection</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Type of anaesthesia</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spinal or intradural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">128 &#40;93&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>General&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;4&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;56&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Destination at discharge</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Private home&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61 &#40;49&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Private home with assistance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;5&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Temporary stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Previously lived in an old people&#39;s home&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;22&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 19888856
Original language: English

DOI:10.1016/j.recote.2016.11.007

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Year/Month	Html	Pdf	Total

2024 November	3	0	3
2024 October	13	4	17
2024 September	21	6	27
2024 August	15	6	21
2024 July	13	8	21
2024 June	14	3	17
2024 May	15	7	22
2024 April	23	5	28
2024 March	18	4	22
2024 February	18	7	25
2024 January	32	6	38
2023 December	40	19	59
2023 November	13	6	19
2023 October	20	7	27
2023 September	11	5	16
2023 August	17	5	22
2023 July	17	6	23
2023 June	36	5	41
2023 May	56	8	64
2023 April	63	4	67
2023 March	26	2	28
2023 February	28	1	29
2023 January	18	9	27
2022 December	14	6	20
2022 November	22	4	26
2022 October	23	11	34
2022 September	16	14	30
2022 August	26	12	38
2022 July	16	9	25
2022 June	15	17	32
2022 May	12	5	17
2022 April	16	15	31
2022 March	41	4	45
2022 February	48	5	53
2022 January	42	5	47
2021 December	38	12	50
2021 November	36	8	44
2021 October	46	12	58
2021 September	36	15	51
2021 August	46	9	55
2021 July	24	9	33
2021 June	12	8	20
2021 May	17	9	26
2021 April	37	19	56
2021 March	17	12	29
2021 February	18	4	22
2021 January	18	4	22
2019 May	3	2	5

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