The costs of late detection of developmental dysplasia of the hip

PURPOSE

Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants.

METHODS

A prospective study of infant hip dysplasia over the period of 1998-2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality. The involved screening programme utilised universal clinical screening of all infants and selective ultrasound screening of at-risk infants.

RESULTS

One hundred and seventy-nine infants (4.8/1,000) presented with hip dysplasia. Thirty-four infants presented late (> 3 months of age) and required closed or open reduction. One hundred and forty-five infants presented at < 3 months of age, 14 of whom failed early Pavlik harness treatment. A detailed cost analysis revealed: 131 early presenters with successful management in a Pavlik harness at a cost of £601/child; 34 late presenters who required surgery (36 hips, 19 closed/17 open reductions, one revision procedure) at a cost of £4,352/child; and 14 early presenters with failed management in a Pavlik harness requiring more protracted surgery (18 hips, four closed/14 open reductions, seven revision procedures) at a cost of £7,052/child.

CONCLUSIONS

Late detection causes increased treatment complexity and a sevenfold increase in the short-term costs of treatment, compared to early detection and successful management in a Pavlik harness.

DISCUSSION

Improved strategies are needed for the 10 % of early presenting infants who fail Pavlik harness treatment and require the most complex and costly interventions.

Isolation of the Phytoalexin Medicarpin from Leaflets of Arachis hypogaea and Related Species of the Tribe Aeschynomeneae

A phytoalexin produced by the leaflets of seven cultivars of Arachis hypogaea (groundnut) after natural infection by Cercospora arachidicola or Phoma arachidicola has been characterised as the isoflavonoid (+)-medicarpin (3-hydroxy-9-methoxypterocarpan). Treatment of excised ground­nut leaflets with an aqueous solution of CuSO4 or with a spore suspension of the fungus Helmin-thosporium carbonum has also been found to stimulate medicarpin biosynthesis.

Flow metering characterization within an electrical cell counting microfluidic device

Microfluidic devices based on the Coulter principle require a small aperture for cell counting. For applications using such cell counting devices, the volume of the sample also needs to be metered to determine the absolute cell count in a specific volume. Hence, integrated methods to characterize and meter the volume of a fluid are required in these microfluidic devices. Here, we present fluid flow characterization and electrically-based sample metering results of blood through a measurement channel with a cross-section of 15 μm × 15 μm (i.e. the Coulter aperture). Red blood cells in whole blood are lysed and the remaining fluid, consisting of leukocytes, erythrocyte cell lysate and various reagents, is flown at different flow rates through the measurement aperture. The change in impedance across the electrodes embedded in the counting channel shows a linear relationship with the increase in the fluid flow rate. We also show that the fluid volume can be determined by measuring the decrease in pulse width, and increase in number of cells as they pass through the counting channel per unit time.

Identifying the factors affecting the implementation of strategies to promote a safer environment for patients with learning disabilities in NHS hospitals: a mixed-methods study

Background

There has been consistent evidence that people with learning disabilities experience health inequalities and poor NHS health-care provision, leading to avoidable harm and premature, avoidable death.

Objectives

To describe the factors in NHS hospitals that promote or compromise a safe environment for patients with learning disabilities, in the light of national recommendations that hospitals should (1) identify patients with learning disabilities, (2) provide reasonably adjusted services, (3) involve carers as partners in care and (4) include patient and carer views in service development.

Design

A 21-month mixed-method study carried out between 2011 and 2013, using questionnaire surveys, interviews, observation and monitoring of safety incidents.

Setting

Six NHS hospitals in the south of England.

Methods

The study employed mixed methodologies in three stages. Stage I involved mapping the systems and structural changes within each hospital site, with senior strategic managers asked to provide data on relevant policies. Stage II examined the effectiveness of implemented measures. Methods for this stage included an electronic questionnaire survey sent to all clinical staff (n = 990); face-to-face semi-structured interviews with clinical staff and strategic hospital managers (n = 68); semi-structured face-to-face interviews with adults with learning disabilities who had used the hospital in a 12-month period (n = 33); questionnaire survey (n = 88) and semi-structured interviews (n = 37) with carers of patients with learning disabilities who had been a patient during the 12-month period; and participant observation with patients (n = 8). Stage III assessed generalisability to other vulnerable patient groups and involved expert panel discussions with senior managers and senior clinicians at four sites (n = 42).

Results

Examples of good practice were not consistently replicated hospital-wide. The most common safety issues were delays and omissions of treatment and basic care. The main barriers to better and safer hospital care for people with learning disabilities were (1) the invisibility of patients with learning disabilities within hospitals, owing to a lack of effective flagging systems and a lack of staff knowledge and willingness to flag this group; (2) poor staff understanding of the specific vulnerabilities of people with learning disabilities, the reasonable adjustments to services that these patients may need and the Mental Capacity Act (Great Britain.Mental Capacity Act 2005. Chapter 9. London: The Stationery Office; 2005); (3) a lack of consistent and effective carer involvement and misunderstanding by staff of the carer role; and (4) a lack of clear lines of responsibility and accountability for the care of each patient with learning disabilities. The main enablers were the learning disability liaison nurse (LDLN), provided that this role was properly supported by senior management and carried sufficient authority to change practice; and ward managers who facilitated a positive ward culture and ensured consistent implementation of reasonable adjustments.

Conclusions

The vulnerabilities of people with learning disabilities can, and do, lead to compromised patient safety in NHS hospitals. Further research is needed as follows: (1) identifying the most frequently needed reasonable adjustments within the hospital care pathways of people with learning disabilities and their cost implications; (2) identifying the most effective structures for ensuring clear lines of responsibility and accountability for the care of patients with learning disabilities, including support needed by ward managers in order to carry day-to-day accountability; (3) investigating practical and effective ways of flagging patients with learning disabilities across NHS services and within NHS hospitals; (4) investigating, implementing and evaluating protocols for shared care; (5) evaluating LDLN posts nationwide; and (6) extending research recommendations (1) and (3) to patients with dementia and those with mental health problems.

Study registration

Comprehensive Clinical Research Network Portfolio, 10998; Integrated Research Application System Coordinated System for gaining NHS Permission, 74907.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.