Delirium is probably the most common presenting symptom of disease in old age. Delirium, as defined in DSM-IV, is a neuropsychiatric syndrome characterized by disturbance in attention and consciousness, which develops over a short period of time and where the symptoms tend to fluctuate during the course of the day. The overall aim was to increase knowledge about the risk factors and outcome of delirium in old patients with femoral neck fracture and to develop and evaluate a multi-factorial intervention program for prevention and treatment of delirium in these patients. In a prospective study of 101 consecutive patients with a femoral neck fracture, 29.7% were delirious before surgery and another 18.8% developed delirium postoperatively. Of those who were delirious preoperatively all but one remained delirious postoperatively. The majority of those delirious before surgery were demented, treated with drugs with anticholinergic properties (mainly neuroleptics), had had previous episodes of delirium and had fallen indoors. Patients who developed postoperative delirium had perioperative falls in blood pressure and seemed to have more postoperative complications, such as infections. Patients with preoperative delirium had a poorer walking ability on discharge compared to patients with postoperative delirium only. In a five-year prospective follow up study 30 out of 78 (38.5%) non-demented patients with a femoral neck fracture developed dementia. Twenty out of 29 (69%) who were delirious postoperatively developed dementia compared to 10 out of 49 (20%) who were not delirious during hospitalization (p<0.001). Twenty-one (72.4%) of those with postoperative delirium died within 5 years compared to 17/49 (34.7%) of those who remained lucid postoperatively (p=0.001). A non-randomized multi-factorial intervention study with the aim of preventing and treating delirium among patients with femoral neck fracture (n=49) showed that the incidence of delirium was significantly lower than reported in previously published studies. The incidence of other postoperative complications was also lower and a larger proportion of the patients regained independent walking ability and could return to their previous living conditions on discharge. A similar multi-factorial intervention program evaluated as a randomized controlled trial including 199 femoral neck fracture patients showed that fewer intervention patients than controls suffered postoperative delirium (56/102, 55% vs. 73/97, 75%, p=0.003). For intervention patients the postoperative delirium was also of shorter duration (5.0±7.1 days vs. 10.2±13.3 days, p=0.009). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from significantly fewer in-hospital complications, such as decubital ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0±17.9 days vs. 38.0±40.6 days, p=0.028). In conclusion, pre- and postoperative delirium is common and seems to be associated with various risk factors, which require different strategies for prevention and treatment. Delirium is also associated with the development of dementia and a higher mortality rate. Multifactorial intervention programs can successfully be implemented and result in the reduction of delirium, fewer complications and shorter hospitalization.

Ziel der vorliegenden Arbeit war es, retrospektiv die Ergebnisse der bei medialer Schenkelhalsfraktur mittels 3-fach Verschraubung osteosynthetisch versorgten Patienten zu ermitteln und die Ergebnisse im aktuellen Kontext im Vergleich zu den Ergebnissen anderer Studien darzustellen. Aufgrund der zunehmenden sozioökonomischen Bedeutung der Therapie der medialen Schenkelhalsfraktur ist es im Prozess des Findens einer optimalen Versorgung der betroffenen Patienten erforderlich, die aktuell angewandten Therapieverfahren klinischen Studien zu unterziehen, um für künftige Patienten eine fundierte Entscheidung für das entsprechende Therapieverfahren treffen zu können. Die retrospektive Arbeit bezog sich auf 86 Patienten, welche auf Grund einer medialen Schenkelhalsfraktur durch 3-fach Verschraubung versorgt worden sind. Es wurden entscheidende präoperative Daten, wie der präoperative Zustand des Patienten, deren Alter, Geschlecht, Frakturklassifikation und die Zeit zwischen Aufnahme in der Unfallambulanz und Operation erfasst. Zusätzlich wurden postoperative Daten zu Komplikationen erhoben und Langzeitergebnisse im Rahmen einer klinischen Nachuntersuchung erfasst. Bei einem Frauenanteil von 63% hatte das Patientenkollektiv ein Durchschnittsalter von 73 Jahren. Zum Zeitpunkt der Nachuntersuchung waren 38,4% der Patienten verstorben. Insgesamt kam es bei 10,5% der Patienten zu einer Redislokation, wobei der Anteil der Redislokationen bei den Patienten mit einer dislozierten Fraktur 26% und bei den Patienten mit einer nicht dislozierten Fraktur 3,4% betrug. Im Patientenkollektiv entwickelten 4,7% der Patienten eine Pseudarthrose und bei 5,8% der Patienten konnte die Entstehung einer Hüftkopfnekrose beobachtet werden. Bei den 24 nachuntersuchten Patienten konnte ein durchschnittlicher Harris Hip Score von 89,5 Punkten ermittelt werden.

Diss. (sammanfattning) Umeå : Univ. / Härtill 4 uppsatser.

Diss. (sammanfattning) Umeå : Univ., 2007. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.

Thesis (Ph. D.)--University of Washington, 1998. / Vita. Includes bibliographical references (leaves [102]-108).

Thesis (D. Sc. P.T.)--University of Alabama at Birmingham, 2007. / Title from first page of PDF file (viewed Oct. 30, 2007). Includes bibliographical references (p. 18-20).

Thesis (Ph. D.)--University of Alabama at Birmingham, 2007. / Description based on contents viewed June 24, 2007; title from title screen. Includes bibliographical references (p. 76-80).

O desenvolvimento de próteses nacionais de qualidade duvidosa e a insuficiência de normas e rotinas objetivas de garantia de qualidade de implantes médicos no país tornaram as próteses importadas sinônimo de qualidade, acarretando atraso tecnológico pontual nesta área no Brasil. O presente estudo é a aplicação de ensaios laboratoriais sugeridos pelo Food and Drug Administration (FDA) para revisão sistemática do processo de fabricação, material, características e desempenho de uma prótese de fêmur proximal não cimentada. Foram enfatisados os testes de aferição da qualidade e segurança do implante. O objetivo do estudo foi determinar a exeqüibilidade de desenvolvimento de uma prótese brasileira que atenda padrões internacionais de garantia de qualidade. Em 2001, a partir da idéia conceitual do autor, foi desenvolvido, com a ferramenta AutoCad 2000, um protótipo virtual de prótese de fêmur proximal em forma de dupla cunha quadrangular. A seguir utilizou-se o Método de Elementos Finitos (MEF), para simular o carregamento representado por um individuo de 120kg. As simulações da viabilidade mecânica do protótipo, em liga de titânio, demonstrou uma tensão de von Mises 8.1 vezes menor que a tensão necessária para atingir o ponto de escoamento do material. Uma vez aprovado o projeto virtual, a prótese foi fabricada e os primeiros protótipos e corpos-de-prova foram encaminhados aos Laboratórios de Caracterização para serem submetidos à revisão sistemática de ensaios e testes conforme normas da International Organization Standardization (ISO) e da American Society for Tchiniques and Materiasl (ASTM), segundo lista sugerida pelo FDA para validação da garantia de qualidade.Na determinação dos constituintes metálicos, os resultados dos testes expressos em percentuais foram de Fe=0,06%, Al=6,20%, V=3,57%, O=0,115%, N=0,003%, e H=0,010%, peso e valores dentro dos limites máximo e mínimo. Assim também, a composição química qualitativa e quantitativa do metal base bem como da camada porosa da prótese revelaram ausência de contaminações por metais pesados à espectrometria por energia dispersa (EDS), com picos concentrados em energias menores que 6 keV. Na avaliação das propriedades elásto-plásticas da amostra o valor médio de dureza foi de 4,45 (3,92 a 4,79) GPA e o módulo de elasticidade das amostras medidas variaram de 112,12 a 140,77 GPA (média=134,33 GPA). Na análise da rugosidade superficial, o coeficiente de rugosidade médio (DP) no cone foi de 0,60 (0,03) μm; na região jateada de 12,2 (0,8) μm e na ponta de 0,41 (0,01) μm. Na região porosa os valores pontuais variaram entre 15 e 30μm. No ensaio de fadiga com torção da prótese não foram observadas fissuras, fraturas, deformações ou afrouxamentos do meio de embutimento, assim como não houve alterações de medidas (deformação plástica) em nenhuma prótese analisada por microscopia eletrônica. No teste de corrosão da haste não ocorreu qualquer alteração do aspecto visual da superfície de teste após 64 dias de ensaio. Na análise granulométrica do pó do material depositado, conforme norma ASTM B 214-92 foi verificada predominância de partículas de tamanho variando entre 75μm e 180μm, correspondendo a 84% do total da amostra. A espessura da camada do material depositado apresentou valor médio de 52,7μm, mínimo de zero e máximo de 318 μm. A porosidade média foi de 16% (variando de 3% a 41%) e os poros apresentavam diâmetro médio de 88,5 μm e profundidade média de 28,2 μm. A força de adesão da camada porosa depositada revelou valores de 5 a 7 MPA na termo-aspersão realizada inicialmente. Posteriormente, após a modificação da técnica de aspersão, obteve-se valores entre 15 a 17 MPA, comparáveis aos valores da adesão referidos na literatura. Em todos os testes e ensaios acima descritos foram obtidos resultados de acordo com as normas e testes preconizados e padronizados internacionalmente para implantes metálicos em liga de titânio. Concluímos que é possível produzir uma prótese com tecnologia nacional de acordo com os padrões internacionais qualidade e segurança. / The development of national prostheses of doubtful quality and almost the absence of norms and routine quality control of medical implant devices in the country led to the belief of imported prostheses as a synonym of quality and safeness, resulting in a national technological impairment on this field. The present study is a systematic revision of the process of manufacturing a femoral prosthesis, for use without cement, with emphasis in tests assessing the design, quality and safeness of the implant. The aim of the study was to determine the feasibility of developing a Brazilian prosthesis would comply with international standards of quality assurance. On September, 2001 from the conception model idealized by the author, a virtual prototype of double tapered titanium femoral stem was developed with the AutoCad 2000 tool. After, the Finite Elements Model (FEM) was used for simulation and evaluation of the mechanical viability of the prototype and demonstrated a von Mises tension 8.1 folds lesser than needed to reach the deformation point of the material. Once manufactured the prosthesis, the first prototypes and sample parts for test were sent to the Laboratories of Characterization to be submitted to systematic revision of assays and tests in agreement with the norms from ISO and ASTM, as suggested by the FDA to validate the quality assurance of the non cemented prosthesis in titanium alloy. In determining the metallic components, the test results expressed in percentages were Fe=0.06%, Al=6.20%, V=3.57%, O=0.115%, N=0.003%, and H=0.010%, weight and values within the maximum and minimum established limits. Also, the qualitative and quantitative chemical composition of the basic metal as well as of the porous layer of the prosthesis have shown absence of any contamination due to heavy metals by energy dispersed spectrometry (EDS), with peaks concentrated in less than 6 keV. On evaluating the elasto-plastic properties of the sample the average value of hardness was 4.45 (3.92 to 4.79) GPA and the elasticity module of the measured samples varied from 112.12 to 140.77 GPA (mean=134.33 GPA). In the analysis of the superficial roughness, the average coefficient of roughness (dp) in the cone was 0.60 (0.03) μm; in the plasma spray coating region was 12.2 (0.8) μm and in the tip was 0.41 (0.01) μm. In the porous-coated region these values had varied between 15 and 30μm. In the assays for fatigue by twisting of prosthesis, breakings, deformations or loosening in the (specimen holder) have not been observed as well as alterations of measures (plastic deformation) in any prosthesis analyzed by electronic microscopy. On corrosion tests, no alteration of the visual aspect of the surface occurred after 64 days of assay. In the grain size analysis of the dust of the deposited material according to ASTM B 214-92 norm particle sizes predominantly varied between 75μm and 180μm; corresponding to 84% of the total of the sample. The thickness of the layer of the deposited material presented an average value of 52.7 μm (minimum of zero and maximum of 318 μm). The average porosity was 16% (varying from 3% to 41%) and the pores presented an average diameter of 88.5 μm and average depth of 28.2 μm. The force of adhesion of the deposited porous layer showed values of 5 to 7 MPA in the plasma spray coating process initially performed by a national company that later got values between 15 and 17 MPA, which were comparable to the values obtained when performed in a overseas company. Even though, all the tests and above described assays have demonstrated results in accordance with the norms and tests internationally recommended and standardized for metallic implants in titanium alloy. In conclusion, it is possible to produce a prosthesis with national technology in accordance with internationalstandards of design, quality and safeness. However, the national system of plasma spray needed adjustments to assure quality comparable to that of foreign companies.

A aceleração da regeneração nervosa aliada à sua qualidade através da inoculação de células no sítio da lesão tem sido objeto de diversos estudos experimentais. Assim, o presente trabalho objetiva avaliar a regeneração nervosa associando a técnica de tubulização com a fração mononuclear autóloga de medula óssea em coelhos. Foram utilizados 28 coelhos da raça Nova Zelândia, hígidos, distribuídos em dois grupos: terapia (GT) e controle (GC), de igual número, subdivididos de acordo com o tempo de avaliação em 50 e 75 dias. Todos os animais foram anestesiados e submetidos a secção do nervo femoral direito com imediata neurorrafia utilizando tubo de silicone, deixando um intervalo de 5 mm entre os cotos nervosos, porém apenas o GT recebeu a terapia celular. A avaliação da regeneração foi realizada funcionalmente e histologicamente, sendo os dados de função obtidos por exame clínico neurológico realizado a cada dez dias de pós-operatório e eletrofisiologia nervosa realizada previamente a eutanásia aos 50 e 75 de pós-operatório. Na análise histológica constataram-se presença de ponte nervosa e boa regeneração das fibras em todos os animais. A eletrofisiologia nervosa demonstrou queda nos valores de amplitude e aumento da latência, independentemente dos grupos. Entretanto, na avaliação funcional da marcha, o GT apresentou melhor desempenho significativo nas três primeiras semanas de avaliação. Estes dados sugerem que a terapia celular associada à técnica de tubulização influencia beneficamente no início da regeneração nervosa, proporcionando retorno funcional do nervo mais precoce quando comparado a animais controle. / The acceleration of nerve regeneration combined with its quality by the inoculation of cells is the site of the injury has been the object of several experimental studies. This paper aims to evaluate the nerve regeneration using the tubulization technique associated with the transplantation of autologous mononuclear cell from bone marrow in rabbits. The study has used twenty-eight animals New Zealand, healthy, allocated in two groups with equal number: therapy group (TG) and control group (CG), divided according to the evaluation duration time at 50 and 75 days. All animals were anaesthetized and then had their right femoral nerve sectioned, followed by immediate neurorrhaphy with a silicon tube, leaving a 5mm gap between the nervous stumps, but only the GT received cell therapy. The evaluation of the regeneration was made histologically and functionally through clinical examination carried out each ten days postsurgery and through electrophysiology prior to euthanasia at 50 and 75 postsurgery in both groups. The histological analysis, showed the presence of nerve repair and good regeneration of fibers in both groups. The electrophysiology showed a reduction of the amplitude values and increased latency, irrespective of the group. However, the lameness analysis showed that the GT had significantly better performance on the first three weeks postoperatively. The results suggest that cell therapy associated with the silicon channels can be a good influence on the beginning of nerve regeneration, providing functional return of the nerve earlier when compared to control animals.