Use of Ceftriaxone and Benzylpenicillin in Outpatient Parenteral Antimicrobial Therapy: Spectrum vs Cost

Background

The application of antimicrobial stewardship (AMS) principles may entail increased cost to allow for narrower-spectrum therapy. Prescribing benzylpenicillin (BP) and ceftriaxone (CRO) for outpatient parenteral antimicrobial therapy (OPAT) demonstrates the complex challenge of this principle. The aim of this study is to analyze the use of BP and CRO in our OPAT program, including indications and relative cost.

Methods

We analyzed all adult patients in our OPAT program who received intravenous BP or CRO over 1 year. We identified a "crossover group" of patients who could have received either agent. Economic comparison was based on acquisition cost of the therapy (drug, infuser, and preparation costs).

Results

Of 105 eligible patients, 54 (51%) and 51 (49%) received BP and CRO, respectively. Forty (38%) patients were suitable for either agent; of these, the majority (n = 31, 78%) were treated with BP. Economic analysis demonstrated that the average daily cost of BP therapy was $93.76/d (AUD) vs $1.23/d for CRO. Thus, across our OPAT programs, we had an additional average cost of $92.53/patient/d to use BP instead of CRO. Program-wide the annual additional cost of using BP and thus applying this AMS strategy was $68 386.12.

Conclusions

BP is often selected over CRO by clinicians, where possible, as recommended by the Australian guidelines; however, BP is associated with higher daily acquisition costs. More broadly, a number of narrower-spectrum agents may involve significantly higher costs than comparators; as such, the $92.53/d to prevent CRO exposure can be considered when applying other antimicrobial-substitution AMS interventions in an acute health care setting.

TERFs aren't feminists: lesbians stand against trans exclusion

In this article, I examine lesbians' solidarity with trans people in the United States. Trans exclusionary radical feminists (TERFs) are feminists who believe that there is a stark difference between the biological reality of sex and the socially constructed nature of gender. They argue that sex is essential and innate. This leads some feminists to the argument that trans people are trying to infiltrate sex exclusive spaces. While TERFs are not always lesbians, lesbians are assumed to make up a large proportion of TERFs. As Thomsen and Essig argue that current ideologies within the media are allowing for the slippage between the terms "lesbian," "feminist," and "TERFs." Some scholars are suggesting that equating lesbian identities with transphobia and trans exclusion is but a new form of lesbian marginalization. I utilize 49 in-depth, qualitative interviews with lesbians across the United States to interrogate the stereotype that lesbians are largely TERFs. Through the voices of lesbians across the United States, I illustrate how many lesbians despise TERF ideology and argue that lesbians must stand in solidarity with trans people in the fight for social justice.

Outness, Discrimination, and Psychological Distress Among LGBTQ+ People Living in the Southern United States

Purpose: Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people face mental health disparities. These disparities are amplified in the Southern regions of the United States. This study assessed the role of outness, discrimination, and other demographic variables on possible serious mental illness (SMI) among LGBTQ+ Southerners. Methods: This study used data from the 2017 LGBT Institute Southern Survey, a cross-sectional convenience sample of 6502 LGBTQ+ adults living in 14 Southern states. Multivariable logistic regression was performed to examine differences between those with and without possible SMI. Results: Outness was associated with a lower likelihood of possible SMI (odds ratio [OR]: 0.696, 95% confidence interval [CI]: 0.574-0.844, p = 0.001), especially when controlling for discrimination in the past 12 months (OR: 0.693, 95% CI: 0.576-0.834, p ≤ 0.001) and lifetime discrimination (OR: 0.678, 95% CI: 0.554-0.829, p = 0.001). Lifetime discrimination was associated with a higher likelihood of possible SMI (OR: 1.413, 95% CI: 1.034-1.932, p = 0.033), as was discrimination experienced in the past 12 months (OR: 1.626, 95% CI: 1.408-1.877, p ≤ 0.001). Black/African American respondents had the lowest percentage of possible SMI (21.0%) compared with other races, despite having lower or comparable rates of outness. Conclusion: These results indicate a possible promotive effect of outness against possible SMI among LGBTQ+ Southerners, as well as possible promotive group-level factors among Black/African American LGBTQ+ Southerners. Policies and interventions that address discrimination against LGBTQ+ Southerners should be expanded, and future research should address how the relationships between outness, discrimination, and mental health outcomes may vary by subgroup.

Expanding Our View: Demographic, Behavioral, and Contextual Factors in College Sexual Victimization

Despite efforts on some college campuses to address the issue of sexual victimization, the numbers have not changed much over the last four decades. The purpose of this study is to examine how demographic, contextual, and behavioral factors influence sexual victimization on college campuses. Using data from the Fall 2011 National College Health Assessment/American College Health Association survey, we examine three hypotheses: (1) contextual factors will have a greater effect on the likelihood of victimization than behavioral factors; (2) demographic factors will have a greater effect on the likelihood of victimization than behavioral factors; and (3) contextual factors for men will have a greater effect than contextual factors for women. While previous studies have tackled portions of these larger objectives, few studies have focused on all three sets of factors of analysis simultaneously. Overall, we find that behavioral factors predict sexual victimization better than either demographic or contextual factors for both men and women. However, we also find that some contextual factors are significant, including variables not generally discussed in the literature, such as perception of typical student behaviors and dissemination of violence prevention programming and information. In addition, we add to the literature by showing how demographic, behavioral, and contextual factors of sexual victimization vary in significance for men and women. These findings support the calls for more sexual violence prevention programming on college campuses that is more intersectional and addresses the issue of sexual violence based on the knowledge we have gained about individual, interactional, and institutional factors that contribute to this problem.

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study

PURPOSE

Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.

METHODS

A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019.

RESULTS

Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification.

CONCLUSION

COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Common barriers to healthcare for transgender people in the U.S. Southeast

Background: Transgender and non-binary people are more likely to face barriers to healthcare than their cisgender counterparts. The majority of work in this area centers on the experiences of transgender people in northern cities and urban enclaves, yet over 500,000 transgender people live in the U.S. Southeast. Aims: The purpose of this study is to explore barriers to healthcare among transgender people in the U.S. Southeast. Methods: The research team conducted four 120-minute focus groups (eligibility criteria: 18 years or older, self-identify as transgender, live in the U.S. Southeast). Participants completed a demographic questionnaire prior to the start of the focus group. Each focus group explored access to and experiences of receiving basic healthcare as a transgender person in the U.S. Southeast. Established qualitative methods were used to conduct the focus groups and data analysis. Results: Participants (n = 48) ranged in age from 19 to 65, with the majority identifying as trans women (43.8%) and non-binary (33.3%). The sample was racially diverse: White (50%), Black (37.5%), and Latinx or Multiracial (12.5%). Multiple barriers to care were identified: (1) fear and mistrust of providers; (2) inconsistency in access to healthcare; (3) disrespect from providers; and, (4) mistreatment due to intersecting experiences of gender, race, class, and location. Discussion: Transgender Southerners face barriers to care at the structural, cultural, and interpersonal levels. The study results have implications for researchers, as well as providers, practices, and health care systems throughout the region.

Optimising antimicrobial therapy through the use of Bayesian dosing programs

The optimisation of antibiotic dosing therapy with therapeutic drug monitoring is widely recommended. The aim of therapeutic drug monitoring is to help the clinician to achieve target pharmacokinetic/pharmacodynamic parameters, maximising efficacy and minimising toxicity. Computerised programs, utilising the Bayesian estimation procedures, are able to achieve target concentrations in a greater percentage of patients earlier in the course of therapy compared to linear regression analysis and population methods. This article summarises various methods for dose optimisation of antibiotics with a focus on Bayesian programs.

Does a dedicated hip fracture unit improve clinical outcomes? A five-year case series

INTRODUCTION

The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures.

MATERIALS AND METHODS

This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust's submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre.

RESULTS

A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015).

DISCUSSION

The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed.

CONCLUSION

While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

Factors affecting planned return to work after trauma: A prospective descriptive qualitative and quantitative study

The use of patient reported outcome measures (PROMs) in trauma is limited. The aim of this pilot study is to evaluate qualitative responses and factors affecting planned return to work following significant trauma, for which there is currently a poor evidence base. National ethical approval was obtained for routine prospective PROMs data collection, including EQ-5D, between Sept 2013 and March 2015 for trauma patients admitted to the Sussex Major Trauma Centre (n=92). 84 trauma patients disclosed their intended return to work at discharge. Additional open questions asked 'things done well' and 'things to be improved'. EQ-5D responses were valued using the time trade-off method. Statistical analysis between multiple variables was completed by ANOVA, and with categorical categories by Chi squared analysis. Only 18/68 of patients working at admission anticipated returning to work within 14days post-discharge. The injury severity scores (ISS) of those predicting return to work within two weeks and those predicting return to work longer than two weeks were 14.17 and 13.59, respectively. Increased physicality of work showed a trend towards poorer return to work outcomes, although non-significant in Chi-squared test in groups predicting return in less than or greater than two weeks (4.621, p=0.2017ns). No significant difference was demonstrated in the comparative incomes of patients with different estimated return to work outcomes (ANOVA r²=0.001, P=0.9590ns). EQ-5D scores were higher in those predicting return to work within two weeks when compared to greater than two weeks. Qualitative thematic content analysis of open responses was possible for 66/92 of respondents. Prominent positive themes were: care, staff, professionalism, and communication. Prominent negative themes were: food, ward response time, and communication. This pilot study highlights the importance of qualitative PROMs analysis in leading patient-driven improvements in trauma care. We provide standard deviations for ISS scores and EQ-5D scores in our general trauma cohort, for use in sample size calculations for further studies analysing factors affecting return to work after trauma.

Trauma-related amputations in war and at a civilian major trauma centre-comparison of care, outcome and the challenges ahead

The Afghanistan conflict has resulted in a large number of service personnel sustaining amputations. Whilst obvious differences exist between military and civilian trauma-related amputations both settings result in life changing injuries. Comparisons offer the potential of advancement and protection of the knowledge gained during the last 12 years. This paper compares the military and civilian trauma-related amputee cohorts' demographics, management and rehabilitation outcomes measures. The UK military Joint Theatre Trauma Registry and a civilian major trauma centre database of trauma-related amputees were analysed. 255 military and 24 civilian amputees were identified. A significant difference (p>0.05) was seen in median age (24, range 18-43, vs. 48, range 24-87 years), mean number of amputations per casualty (1.6±SD 0.678 vs. 1±SD 0.0), mean ISS (22±SD 12.8 vs. 14.7±SD 15.7) and gender (99% males vs. 78%). Rehabilitation outcome measures recorded included the Special Interest Group in Amputee Medicine score where the military group demonstrated significantly better scores (91% Grade E+ compared to 19%). Differences in patients underlying physiology and psychology, the military trauma system and a huge sustained investment in rehabilitation are all contributing factors for these differing outcomes. However the authors also believe that the use of a consultant-led MDT and central rehabilitation have benefited the military cohort in the acute rehabilitation stage and is reflected in the good short-term outcomes.

Perioperative management of traumatic limb amputations due to civilian trauma: current practice and future directions

Traumatic limb amputations are serious injuries. They require urgent multidisciplinary management and emergency surgical intervention to save life and, where possible, preserve limb function. It is therefore vital that perioperative management follows established evidence-based principles to optimise outcomes. In recent years a vast quantity of research on traumatic amputations in the military setting has been published, but civilian injuries, which often have strikingly different mechanisms, have been neglected. This article reviews existing information on epidemiology, pathophysiology, perioperative management strategies, outcomes and future directions in the field.

Temporal variation in major trauma admissions

INTRODUCTION

Trauma is a significant cause of morbidity and mortality in the UK. Since the inception of the trauma networks, little is known of the temporal pattern of trauma admissions.

METHODS

Trauma Audit and Research Network data for 1 April 2011 to 31 March 2013 were collated from two large major trauma centres (MTCs) in the South East of England: Brighton and Sussex University Hospitals NHS Trust (BSUH) and St George's University Hospitals NHS Foundation Trust (SGU). The number of admissions and the injury severity score by time of admission, by weekdays versus weekend and by month/season were analysed.

RESULTS

There were 1,223 admissions at BSUH and 1,241 at SGU. There was significant variation by time of admission; there were more admissions in the afternoons (BSUH p<0.001) and evenings (SGU p<0.001). There were proportionally more admissions at the weekends than on weekdays (BSUH p<0.001, SGU p=0.028). There was significant seasonal variation in admissions at BSUH (p<0.001) with more admissions in summer and autumn. No significant seasonal variation was observed at SGU (p=0.543).

CONCLUSIONS

The temporal patterns observed were different for each MTC with important implications for resource planning of trauma care. This study identified differing needs for different MTCs and resource planning should be individualised to the network.

Renal replacement therapy: implications for the surgeon

Renal replacement therapy comprises peritoneal dialysis, haemodialysis and renal transplantation. Patients undergoing renal replacement therapy often require surgery for a number of different reasons. This review summarizes likely surgical procedures for these patients and some of the common complications.

Power tool injuries to the hand and wrist

Power tool injuries to the hand and wrist are complex injuries which can have a profound impact on the function of the patient. This article gives an overview of the principles, and provides a systematic approach, to the management and rehabilitation of the injured limb and patient required to minimize future disability.

Segmental proximal femoral bone loss and revision total hip replacement in patients with developmental dysplasia of the hip: the role of allograft prosthesis composite

The treatment of substantial proximal femoral bone loss in young patients with developmental dysplasia of the hip (DDH) is challenging. We retrospectively analysed the outcome of 28 patients (30 hips) with DDH who underwent revision total hip replacement (THR) in the presence of a deficient proximal femur, which was reconstructed with an allograft prosthetic composite. The mean follow-up was 15 years (8.5 to 25.5). The mean number of previous THRs was three (1 to 8). The mean age at primary THR and at the index reconstruction was 41 years (18 to 61) and 58.1 years (32 to 72), respectively. The indication for revision included mechanical loosening in 24 hips, infection in three and peri-prosthetic fracture in three. Six patients required removal and replacement of the allograft prosthetic composite, five for mechanical loosening and one for infection. The survivorship at ten, 15 and 20 years was 93% (95% confidence interval (CI) 91 to 100), 75.5% (95% CI 60 to 95) and 75.5% (95% CI 60 to 95), respectively, with 25, eight, and four patients at risk, respectively. Additionally, two junctional nonunions between the allograft and host femur required bone grafting and plating. An allograft prosthetic composite affords a good long-term outcome in the management of proximal femoral bone loss in revision THR in patients with DDH, while preserving distal host bone.

Reducing mortality for high risk surgical patients in the UK

Over 40 million surgical procedures are performed per annum in the USA and Europe, including several million patients who are considered to be high risk (Bennett-Guerrero et al 2003). Overall, the risk of death or major complications after surgery in the general surgical patient population is low, with a post-operative mortality rate of less than1% during the same hospital admission (Niskanen et al 2001).

Current use of aminoglycosides: indications, pharmacokinetics and monitoring for toxicity

The new Australian Therapeutic Guidelines: Antibiotic, version 14 have revised the recommendations for the use and monitoring of aminoglycosides. The guidelines have clear distinctions between empirical and directed therapy as well as revised recommendations about the monitoring of aminoglycosides. This has led many clinicians to review their current practice with regard to the use of aminoglycosides. This review summarizes why aminoglycosides are still a valid treatment option and discusses the rationale for current dosing regimens in Gram-negative infections. In particular it focuses on the various methods for monitoring aminoglycosides that are currently being used. The aminoglycoside monitoring methods can be categorized into three groups: linear regression analysis (one compartment model), population methods and Bayesian estimation procedures. Although the population methods are easy to use and require minimal resources they can recommend clinically inappropriate doses as they have constant pharmacokinetic parameters and are not valid in special population groups, that is, renal impairment. The linear regression and Bayesian methods recommend more accurate dosage regimens; however, they require additional resources, such as information technology and healthcare personnel with background training in pharmacokinetics. The Bayesian methods offer additional advantages, such as calculation of doses based on a single serum concentration and optimization of the patient's previous pharmacokinetic data, in order to determine subsequent dosage regimens. We recommend the Bayesian estimation procedures be used, wherever feasible. However, they require the expertise of healthcare practitioners with a good understanding of pharmacokinetic principles, such as clinical pharmacists/clinical pharmacologists, in order to make appropriate recommendations.

Using patient-reported outcome measures to assess health-care quality

The transparency of surgical outcomes data and the drive for quality has been highlighted since the public inquiry, led by Professor Ian Kennedy, into children's heart surgery at the Bristol Royal Infirmary. This was formalized in Lord Darzi's 2008 report High Quality Care for All, that proposed the NHS should: 'systematically measure and publish information about the quality of care'. Subsequently the NHS White paper, Equity and Excellence: Liberating the NHS (Department of Health, 2010), set out the ambitions and aims of the NHS and in particular that it should provide: '...a service that offers care that is safe and of the highest quality.'

Is there adequate provision of venous thromboembolism prophylaxis following hip arthroplasty? An audit and international survey

INTRODUCTION

The peak incidence of venous thrombo-embolism (VTE) occurs 3 weeks following hip arthroplasty surgery and current guidelines proposing VTE prophylaxis continuing for 4 weeks after surgery. This study first compares the duration of treatment and satisfaction between patients prescribed low molecular weight heparin (LMWH) and rivaroxaban, a new oral Factor Xa inhibitor, following elective hip arthroplasty; and second, surveys the duration of LMWH use in other units.

SUBJECTS AND METHODS

An international survey detailing the use of LMWH was performed. A prospective audit was performed of 100 hip replacements, with 50 prescribed 40 mg once daily of subcutaneous enoxaparin and subsequently 50 patients prescribed 10 mg once daily of oral rivaroxaban. The duration of treatment, patient satisfaction and complications for both cohorts was quantified and compared against published evidence-based guidelines.

RESULTS

The survey demonstrated that four out of 39 (10.2%) units that routinely prescribe LMWH do so for at least 4 weeks following surgery. The audit demonstrated that rivaroxaban afforded a superior mean duration of postoperative VTE prophylaxis (35 days vs 5.4 days; P < 0.05) and superior patient satisfaction. There was no difference in the incidence of bleeding, wound infection or thrombotic complications.

CONCLUSIONS

This study demonstrates that patients are exposed to an increased VTE risk following hip replacement surgery due to the inadequate prescription of LMWH. This is poor clinical practice, contrary to current evidence-based guidelines and has potential medicolegal implications. The prescription of rivaroxaban affords a superior patient compliance compared with subcutaneous LMWH, thus ensuring that patients receive VTE prophylaxis for the current recommend period of time.

Diagnosis and management of degenerative neck pain

Neck pain is a common presenting complaint, but the precise patho-aetiology is often unclear. Broadly speaking, the cause of neck pain can be considered as degenerative or non-degenerative (Table 1). While detailing the important non-degenerative causes the clinician should not miss, this article reviews the diagnosis and management of the common degenerative orthopaedic causes of neck pain.

The surgical management of patients who deliberately self-harm

INTRODUCTION

Deliberate self-harm is a common problem that often requires orthopaedic treatment. Patients with injuries due to deliberate self-harm are often referred to our unit. This study assessed the type of treatment required and the cost of treatment.

PATIENTS AND METHODS

We undertook a retrospective survey of deliberate self-harm patients with known ICD-10 psychiatric disorders admitted for orthopaedic care from a medium-secure, female-only, psychiatric unit. Data were collected on admission rate, duration of stay, surgical interventions and complications.

RESULTS

Over a 36-month period there were 73 admissions for 15 patients (mean age, 25.1 years) requiring 65 operative interventions, a mean of 4.3 (range, 0-9) per patient. Over 50% of patients were admitted more than 3 times, totalling 416 hospital bed-days and 80% had methicillin-resistant Staphylococcus aureus (MRSA) isolated. The orthopaedic treatment costs for these patients was 453,000 pounds during the period studied.

DISCUSSION

The significant resources required to manage this patient cohort demonstrates the need for a co-ordinated management policy. We recommend day-case surgery for infected wounds only. Postoperatively, wounds should be protected with plaster of Paris. All patients with deliberate self-harm should be regarded as being infected with MRSA.

An audit of orthopaedic referrals via Multi-Professional Triage Teams

INTRODUCTION

Multi-Professional Triage Teams (MPTTs) were created to reduce the caseload of hospital orthopaedic clinics and this prospective study evaluated referrals made to a district general hospital orthopaedic department from a lower limb MPTT clinic.

PATIENTS AND METHODS

Over 9 months, 277 referrals to a lower limb hospital orthopaedic clinic were assessed. The temporal delay to hospital clinic review between patients seen at the MPTT clinic and those referred directly by their general practitioner (GP) was analysed using an ANOVA test. A qualitative assessment of diagnoses given to patients reviewed at the MPTT clinic was performed.

RESULTS

The 132 patients initially reviewed at the MPTT clinic and subsequently referred to a hospital consultant waited significantly longer (140 days compared to 62 days by direct GP referral; P < 0.05) to see an orthopaedic consultant. Over three-quarters of this patient cohort incorrectly identified the healthcare professional conducting their consultation at the MPTT clinic. One-third of cases (31%) had no diagnosis made and 22% were assessed as having an incorrect diagnosis.

CONCLUSIONS

Time delays, patient confusion regarding professional roles and diagnostic indecision are significant problems for patients referred to hospital orthopaedic clinics from MPTT clinics. This risks sub-optimal patient care and may lead to future medicolegal implications.

Identification and treatment of anaemia in patients awaiting hip replacement

INTRODUCTION

The correction of anaemia prior to total hip arthroplasty reduces surgical risk, hospital stay and cost. This study considers the benefits of implementing a protocol of identifying and treating pre-operative anaemia whilst the patient is on the waiting list for surgery.

PATIENTS AND METHODS

From a prospective series of 322 patients undergoing elective total hip arthroplasty (THA), patients identified as anaemic (haemoglobin (Hb) < 12 g/dl) when initially placed upon the waiting list were appropriately investigated and treated. Pre- and postoperative Hb levels, need for transfusion, and length of hospital stay were collated for the entire patient cohort.

RESULTS

Of the cohort, 8.8% of patients were anaemic when initially placed upon the waiting list for THA and had a higher transfusion rate (23% versus 3%; P < 0.05) and longer hospital stay (7.5 days versus 6.6 days; P < 0.05). Over 40% of these patients responded to investigation and treatment whilst on the waiting list, showing a significant improvement in Hb level (10.1 g/dl to 12.7 g/dl) and improved transfusion rate.

CONCLUSIONS

Quantifying the haemoglobin level of patients when initially placed on the waiting list helps highlight those at risk of requiring a postoperative blood transfusion. Further, the early identification of anaemia allows for the utilisation of the waiting-list time to investigate and treat these patients. For patients who respond to treatment, there is a significant reduction in the need for blood transfusion with its inherent hazards.

Topographical variation in glycosaminoglycan content in human articular cartilage

The weight-bearing status of articular cartilage has been shown to affect its biochemical composition. We have investigated the topographical variation of sulphated glycosaminoglycan (GAG) relative to the DNA content of the chondrocyte in human distal femoral articular cartilage. Paired specimens of distal femoral articular cartilage, from weight-bearing and non-weight-bearing regions, were obtained from 13 patients undergoing above-knee amputation. After papain enzyme digestion, spectrophotometric GAG and fluorometric DNA assays assessed the biochemical composition of the samples. The results were analysed using a paired t-test. Although there were no significant differences in cell density between the regions, the weight-bearing areas showed a significantly higher concentration of GAG relative to DNA when compared with non-weight-bearing areas (p = 0.02). We conclude that chondrocytes are sensitive to their mechanical environment, and that local loading conditions influence the metabolism of the cells and hence the biochemical structure of the tissue.

Audit on the efficient use of cross-matched blood in elective total hip and total knee replacement

INTRODUCTION

This prospective audit studies the use of cross-matched blood in 301 patients over a 1-year period undergoing total knee (TKR) and total hip replacement (THR) surgery in an orthopaedic unit.

PATIENTS AND METHODS

Analysis over the first 6 months revealed a high level of unnecessary cross-matched blood. The following interventions were introduced: (i) to cease routine cross-matching for THR; (ii) all patients to have a check full blood count on day 2 after surgery; and (iii) Hb < 8 g/dl to be considered as the trigger for transfusion in patients over 65 years and free from significant co-morbidity. These changes are in accordance with published national guidelines [Anon. Guidelines for the clinical use of red cell transfusions. Br J Haematol 2001; 113: 24-31].

RESULTS

In the next 6 months, the number of units cross-matched but not transfused fell by 96% for THR, and the cross-match transfusion (C:T) ratio reduced from 3.21 to 1.62. Reductions were also observed for the TKR cohort. These results provide evidence of a substantial risk and cost benefit in the use of this limited resource. A telephone survey of 44 hospitals revealed that 20 hospitals routinely cross-matched blood for THR and 11 do so for TKR.

CONCLUSIONS

Changes can be made to the Maximum Surgical Blood Ordering Schedules (MSBOS) in other orthopaedic units according to national guidelines.

Interobserver variation in the measurement of patellar height after total knee arthroplasty

We assessed the reproducibility and accuracy of four ratios used to measure patellar height, namely the Blackburne-Peel, Caton-Deschamps, Insall-Salvati and modified Insall-Salvati, before and after total knee arthroplasty. The patellar height was measured, by means of the four ratios, on the pre- and post-operative lateral radiographs of 44 patients (45 knees) who had undergone total knee arthroplasty. Two independent observers measured the films sequentially, in identical conditions, totalling 720 measurements per observer. Statistical analysis, comparing both observers and ratios, was carried out using the intraclass correlation coefficient.

Before operation there was greater interobserver variation using either the Insall-Salvati or modified Insall-Salvati ratios than when using the Caton-Deschamps or Blackburne-Peel methods. This was because of difficulty in identifying the insertion of the patellar tendon. Before operation, there was a minimal difference in reliability between these methods. After operation the interobserver difference was greatly reduced using both the Caton-Deschamps and Blackburne-Peel methods, which use the prosthetic joint line, compared with the Insall-Salvati and modified Insall-Salvati, which reference from the insertion of the patellar tendon.

The theoretical advantage of using the Insall-Salvati and modified Insall-Salvati ratios in measuring true patellar height after total knee arthroplasty needs to be balanced against their significant interobserver variability and inferior reliability when compared with other ratios.

Anxiety and depression after spinal cord injury: a longitudinal analysis

OBJECTIVE

To examine the prevalence of anxiety and depression longitudinally in a sample of patients with a spinal cord injury (SCI).

DESIGN

A prospective, longitudinal, multiple wave panel design with measures taken on 14 observational periods ranging from initial contact in the acute stages of hospitalization to 2 years' postdischarge to the community.

SETTING

The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK, and the general community.

PARTICIPANTS

The cohort consisted of 104 patients with traumatic SCI (19 women, 85 men), although the numbers assessed at each interval ranged from 5 to 85.

MAIN OUTCOME MEASURES

Measures included the Beck Depression Inventory, the Beck Hopelessness scale, the State Anxiety Inventory, the functional independence measure, and the Social Support Questionnaire.

RESULTS

When examined longitudinally, the data illustrate a consistent pattern of results across measures, with scores highest in the acute phase of the injury and during the months leading up to discharge.

CONCLUSION

The numbers of persons scoring above clinical cut-off scores for anxiety and depression highlight the need to continue to ensure that appropriate psychological care is available within SCI rehabilitation settings. Moreover, the nature of the longitudinal results provides an indicator of subtle changes in anxiety and depression over time.

Cephaloridine in vitro toxicity and accumulation in renal slices from normoglycemic and diabetic rats

Previous work has shown a reduction in cephaloridine nephrotoxicity in a diabetic rat model. The following studies examined in vitro cephaloridine toxicity in renal slices from normoglycemic and diabetic Fischer 344 rats. Diabetes was induced by acute intraperitoneal injection of 35 mg/kg streptozotocin. Renal cortical slices were isolated from normoglycemic and diabetic animals. Tissues were exposed to 0-5 mM cephaloridine for 15-120 min. Pyruvate-directed gluconeogenesis was diminished in all groups exposed to 2-5 mM cephaloridine for 60-120 min. Leakage of lactate dehydrogenase (LDH) was apparent only in the normoglycemic group in the presence of 4-5 mM cephaloridine for 120 min. LDH leakage was not increased at any cephaloridine concentration in the diabetic tissue. Total glutathione levels were compared in renal cortical slices exposed to cephaloridine for 30-120 min. Baseline values for glutathione were comparable between normoglycemic and diabetic tissue suggesting that the mechanism for reduced toxicity was not due to higher glutathione levels in diabetic tissue. Total glutathione levels were diminished more rapidly in normoglycemic than diabetic tissue by incubation with 5 mM cephaloridine. Comparison of cephaloridine accumulation indicated that diabetic tissue accumulated less cephaloridine than the normoglycemic group when tissues were incubated with 0-2 mM cephaloridine. However, renal slice accumulation was similar between normoglycemic and diabetic groups following in vitro incubation with 4-5 mM cephaloridine. These results suggest that the mechanism for reduced in vitro cephaloridine toxicity in diabetic tissue cannot be limited to differences in accumulation and must include an unidentified cellular component.

Characterization of methemoglobin formation induced by 3,5-dichloroaniline, 4-amino-2,6-dichlorophenol and 3,5-dichlorophenylhydroxylamine

3,5-Dichloroaniline is an intermediate in the production of certain fungicides. This study characterized the capacity of 3,5-dichloroaniline and two putative metabolites to induce methemoglobin formation. In vivo intraperitoneal (i.p.) administration of 0.8 mmol/kg 3,5-dichloroaniline resulted in elevated (P < 0.05) methemoglobin levels at 2 and 4 h after injection and returned to control values within 8 h. In vitro methemoglobin generation was monitored in washed erythrocytes incubated for 60 min at 37 degrees C with 4 and 8 mM 3,5-dichloroaniline. Methemoglobin generation in vitro was higher (P < 0.05) than control values in erythrocytes incubated for 30 min with 0.2-0.6 mM 4-amino-2,6-dichlorophenol or 5-100 microM 3,5-dichlorophenylhydroxylamine. The in vitro methemoglobin generating capacity in decreasing order was: 3,5-dichlorophenylhydroxylamine > 4-amino-2,6-dichlorophenol > > 3,5-dichloroaniline. The results of the in vitro studies further indicated that none of the compounds tested induced lipid peroxidation. Erythrocytes incubated with 5-100 microM 3,5-dichlorophenylhydroxylamine in vitro were associated with depletion of glutathione. These results indicated that: (a) 3,5-dichloroaniline and its metabolites can induce methemoglobin formation; (b) the N-hydroxy metabolite was the most potent inducer of hemoglobin oxidation and (c) glutathione depletion was associated with methemoglobin formation by 3,5-dichlorophenylhydroxylamine.

Comparison of cephaloridine renal accumulation and urinary excretion between normoglycemic and diabetic animals

The renal toxicity of cephaloridine is reduced in a streptozotocin diabetic rat model. This study tested the hypothesis that renal cortical cephaloridine accumulation was diminished in diabetic rats. The following studies also investigated whether renal excretion was enhanced in diabetic rats. Male Fischer 344 rats were randomly divided into normoglycemic or diabetic groups. Diabetes was induced by injection (intraperitoneal, i.p.) of 35 mg/kg streptozotocin. Normoglycemic and diabetic rats were injected (i.p.) with 1500 mg/kg cephaloridine. Peak plasma cephaloridine levels were similar in both groups. Renal cortical accumulation was diminished (P < 0.05) in the diabetic group 1 and 4 h after cephaloridine injection. Urinary cephaloridine excretion was enhanced (P < 0.05) in the diabetic group relative to the normoglycemic animals during the first 4 h after cephaloridine injection. Comparisons between normoglycemic and diabetic groups indicated renal cortical cephaloridine accumulation was lower in the diabetic group. These findings would support the hypothesis that reduced cephaloridine toxicity in diabetic animals was due to reduced renal cortical accumulation of the toxin. These data also demonstrate that cephaloridine excretion was enhanced in the diabetic group and may contribute to the diminished renal accumulation.