The Effect of a Hip Fragility Pathway on Outcomes of Ground Level Falls in the Elderly

Fragility hip fractures result from low energy mechanisms and are associated with morbidity and mortality, especially in the elderly. We examined outcomes 2 years before and after implementation of a fragility fracture program. The pathway involves emergency department clearance and admission by a medical service with orthopedic consultation. Demographics include age, gender, fracture location, injury severity score (ISS), and ASA. Outcomes include DVT/PE, mortality, disposition, non-operative rate, ICU admission, time to surgery (TTS), length of stay (LOS), and admission service. 777 patients were included (383 PRE/394 POS). POS patients were slightly younger. Trauma admission decreased and LOS and TTS increased. There were no other demographic or outcome differences. Although TTS increased, it remained under 48 hours. Length of stay increase was possibly a reflection of COVID-19. Decreased trauma admission demonstrates pathway adherence. Further studies need to be conducted to verify that quality care can be maintained after initiation of a hip fragility pathway.

Enhanced Notification of Radiographic Incidental Findings in Trauma Does Not Guarantee Follow-Up Compliance

OBJECTIVES

Follow-up care for incidental findings (IFs) on trauma computed tomography scans is a component of comprehensive healthcare. Our objective was to assess the effectiveness of our IF predischarge disclosure practice guideline and identify factors contributing to follow-up failure.

METHODS

This was a secondary analysis of a prospective observational database: 615 patients with IFs from November 2019 to February 2020. Follow-up compliance was determined by electronic medical record review and/or a telephone call after a mail-out request for voluntary participation. Volunteers answered a predetermined questionnaire regarding follow-up care.

RESULTS

A total of 115 patients (19%) had computed tomography-based IFs recommending additional imaging or other follow-ups. Seventy-four (64%) patients were lost to inclusion as a result of death (12.1%), inability to contact (51.3%), or noninterest (5.2%). Of the remaining 36 patients, 19 received follow-up care (52.7%) and 17 did not (47.2%). No statistical differences existed among groups in age, sex, mechanism of injury, Glasgow Coma Scale score, whether informed by physicians or midlevel providers, or type of IF. A total of 15 (88%) nonfollow-up patients did not recall the disclosure or discharge paperwork instructions. Of 19 compliant patients: 9 had additional imaging only, 5 had biopsies and/or surgical intervention (n = 3 cancer, n = 2 benign), 3 had primary care advice against additional studies and 2 were referred to specialists.

CONCLUSIONS

Predischarge disclosure of IFs can contribute significantly to overall patient health. Nonetheless, fewer than half of patients do not pursue follow-up recommendations, most often citing failure to recall verbal/written instructions. More effective communication with attention to health literacy, follow-up telephone calls, and postdischarge appointments are potential catalysts for improved patient compliance.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Intravenous Lidocaine for Rib Fractures: Effect on Pain Control and Outcome

BACKGROUND

Multimodal analgesia in rib fractures (RFs) is designed to maximize pain control while minimizing narcotics. Prior research with intravenous lidocaine (IVL) efficacy produced conflicting results. We hypothesized IVL infusion reduces opioid utilization and pain scores.

METHODS

A retrospective review of RF patients at an ACS-verified Level I trauma center from April 2018 to 2/2020 was conducted. Patients (pts) stratified as receiving IVL vs no IVL. Initial lidocaine dose: 1 mg/kg/hr with a maximum of 3 mg/kg/hr. Duration of infusion: 48 h. Pain quantified by the Stanford Pain Score system (PS). Bivariate and multivariate analyses of variables were performed on SPSS, version 21 (IBM Corp).

RESULTS

414 pts met inclusion criteria: 254 males and 160 females. The average age for the non-IVL = 67.4 ± 15.2 years vs IVL = 58.3 ± 17.1 years (P < .001). There were no statistically significant differences between groups for ISS, PS for initial 48 h, and ICU length of stay (LOS). There was a difference in morphine equivalents per hour: non-IVL = 1.25 vs IVL = 1.72 (P = .004) and LOS non-IVL = 10.2+/-7.6 vs IVL = 7.82+/-4.94. By analyzing IVL pts in a crossover comparison before and after IVL, there was reduction in opiates: 3.01 vs 1.72 (P < .001) and PS: 7.0 vs 4.9 (P < .001). Stanford Pain Score system reduction in the IVL = 48.3 ± 23.9%, but less effective in narcotic dependency (27 ± 22.9%, P = .035); IVL pts had hospital cost reduction: $82,927 vs $118,202 (P < .01).

DISCUSSION

In a crossover analysis, IVL is effective for reduction of PS and opiate use and reduces hospital LOS and costs. Patient age may confound interpretation of results. Our data support IVL use in multimodal pain regimens. Future prospective study is warranted.

Age of thawed plasma does not affect clinical outcomes or biomarker expression in patients receiving prehospital thawed plasma: a PAMPer secondary analysis

Background

Prehospital plasma administration during air medical transport reduces the endotheliopathy of trauma, circulating pro-inflammatory cytokines, and 30-day mortality among traumatically injured patients at risk of hemorrhagic shock. No clinical data currently exists evaluating the age of thawed plasma and its association with clinical outcomes and biomarker expression post-injury.

Methods

We performed a secondary analysis from the prehospital plasma administration randomized controlled trial, PAMPer. We dichotomized the age of thawed plasma creating three groups: standard-care, YOUNG (day 0-1) plasma, and OLD (day 2-5) plasma. We generated HRs and 95% CIs for mortality. Among all patients randomized to plasma, we compared predicted biomarker values at hospital admission (T0) and 24 hours later (T24) controlling for key difference between groups with a multivariable linear regression. Analyses were repeated in a severely injured subgroup.

Results

Two hundred and seventy-one patients were randomized to standard-care and 230 to plasma (40% YOUNG, 60% OLD). There were no clinically or statistically significant differences in demographics, injury, admission vital signs, or laboratory values including thromboelastography between YOUNG and OLD. Compared with standard-care, YOUNG (HR 0.66 (95% CI 0.41 to 1.07), p=0.09) and OLD (HR 0.64 (95% CI 0.42 to 0.96), p=0.03) plasma demonstrated reduced 30-day mortality. Among those randomized to plasma, plasma age did not affect mortality (HR 1.04 (95% CI 0.60 to 1.82), p=0.90) and/or adjusted serum markers by plasma age at T0 or T24 (p>0.05). However, among the severely injured subgroup, OLD plasma was significantly associated with increased adjusted inflammatory and decreased adjusted endothelial biomarkers at T0.

Discussion

Age of thawed plasma does not result in clinical outcome or biomarker expression differences in the overall PAMPer study cohort. There were biomarker expression differences in those patients with severe injury. Definitive investigation is needed to determine if the age of thawed plasma is associated with biomarker expression and outcome differences following traumatic injury.

Level of evidence

II.

Plate of ribs: single institution's matched comparison of patients managed operatively and non-operatively for rib fractures

Background

Rib fractures are associated with significant morbidity and mortality in polytraumatized patients. There is considerable variability in the management (operative vs. non-operative) and timing of operative intervention. Although Eastern Association for the Surgery of Trauma (EAST) guidelines recommend early operative intervention in patients with flail chest, there are no strong recommendations regarding operative fixation in patients with a non-flail chest rib fracture pattern.

Methods

We reviewed our Trauma Quality Improvement Program database for patients aged 18 to 99 who underwent operative intervention of ribs from January 2016 to July 2019. We examined hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, Injury Severity Score, age, discharge disposition and packed red blood cell transfusions. Similarly, we collected data from patients aged 18 to 99 who had one or more rib fractures in this time frame. We compared results in a 4:1 ratio of patients managed non-operatively to patients managed operatively. The patient groups were matched based on age, number of rib fractures and presence of bilateral rib fractures.

Results

Between January 2016 and July 2019, 33 of 4189 total patients diagnosed with rib fractures underwent operative fixation; the matched non-operative group consisted of 132 patients. The statistically significant differences included presence of bilateral rib fractures, displaced rib fractures and flail chest segments. The median ICU days were longer in the operative group (6.0 vs. 3.5 days). A subgroup analysis of patients without flail segments demonstrated a significant presence of displaced rib fractures.Our single-institution matched comparison of outcomes in operative intervention versus Non-operative Management (NOM) of rib fractures found an increased median number of ICU days. Patients who underwent operative intervention often stayed in the ICU preoperatively and postoperatively for aggressive pulmonary hygiene and pain control, suggesting observer bias. The increased incidence of displaced rib fractures and the presence of a flail segment in the operative group demonstrate congruence with EAST guidelines. A subgroup analysis of patients without flail segment did not demonstrate differences in outcomes nor shoulder girdle injury characteristics.

Level of evidence

This article presents level III evidence that can be used by other clinicians to analyze eligibility for patients to undergo surgical stabilization of rib fracture (SSRF) and to provide counterarguments for performing SSRF in a heterogenous group of patients.

Administering DVT Prophylaxis Sooner Than 48 Hours Does Not Increase Failure of Nonoperative Management of High-Grade (Grades III-V) Splenic Injuries

Splenic injuries are mostly treated with nonoperative management (NOM) with observation to monitor for continued hemorrhage and holding early chemical DVT prophylaxis to reduce the risk of NOM failure. Eberle et al demonstrated chemoprophylaxis prior to 72 hours didn’t increase failure rate of NOM. We chose to extrapolate this finding and compare outcomes in high-grade splenic injuries (HGSI) with chemoprophylaxis before and after 48 hours. From January 2013 to December 2017, 104 patients with HGSI received chemoprophylaxis with unfractionated heparin (UH) or low molecular weight heparin (LMWH) within 72 hours of diagnosis. Of these, 8 patients received chemoprophylaxis within 24 hours, 46 between 24 and 48 hours, and 50 patients between 48 and 72 hours. This population consisted of 70 males and 34 females, with an average age of 40.1 years. The average ISS was 23 and the majority (77%) were grade 3 injuries. We observed 6 failures of NOM: 1 in the <24 hour group, 3 in the 24-48 hour group, and 2 in the 48-72 hour group. There was no statistically significant difference between the <24 hour and >24 groups or between the <48 hour and 48-72 hour groups. A linear regression analysis created a model describing the time to initiation of DVT prophylaxis using age, sex, splenic injury grade, and ISS; the failure rate decreased by 0.00002% for each hour prior to giving DVT prophylaxis, with a P value of .111. We conclude a noninferiority statement that DVT prophylaxis prior to 48 hours does not increase the risk of NOM failure.

Effect of Enhanced Recovery After Surgery Protocol Implementation on Cost and Outcomes by Type of Colectomy Performed

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are widely utilized for elective colorectal surgery to improve outcomes and decrease costs, but few studies have evaluated the impact of ERAS protocols on cost with respect to anatomic site of resection. This study evaluated the impact of ERAS protocol on elective colon resections by site and longitudinal impact over time.

METHODS

A single-center retrospective cohort study of 598 consecutive patients undergoing elective colorectal resection before and after implementation of ERAS protocol from 2013 to 2017 was performed. The primary outcomes were length of stay (LOS) and cost. Comparative and multivariate inferential statistics were used to assess additional outcomes.

RESULTS

A total of 598 patients (100 pre-ERAS vs 498 post-ERAS) were evaluated with an overall median LOS of 4 days for right and left colectomies and 3 days for transverse colectomies. When comparing type of resection before and after ERAS protocol introduction, an increased LOS for left hemicolectomies from 3.09 to 4.03 days (P = .047) was noted, with all other comparisons failing to reach statistical significance. Over time, an initial decrease in LOS for MIS approach after protocol introduction was observed; however, this effect diminished in the ensuing years and had no significant effect overall. Total cost of care was significantly increased post-ERAS for all cohorts except transverse colectomies. No further statistically significant differences were found.

CONCLUSION

After an initial improvement in outcomes, continued utilization of ERAS protocols demonstrated no improvement in LOS compared to pre-ERAS data and increased cost overall for patients regardless of site of resection.

Refeeding Syndrome in the Critically Ill: a Literature Review and Clinician's Guide

PURPOSE OF REVIEW

To provide an overview of current methods of diagnosis and management of refeeding syndrome in the critically ill patient population.

RECENT FINDINGS

Despite recent publications indicating refeeding syndrome (RFS) is an ongoing problem in critically ill patients, there is no standard for the diagnosis and management of this life-threatening condition. There is not a "gold standard" nutrition assessment tool for the critically ill. Currently, the National Institute for Health and Clinical Excellence criteria represent the best clinical assessment tool for RFS. Diagnosis and management with the help of a multidisciplinary metabolic team can decrease morbidity and mortality. Although a universal definition of RFS has yet to be defined, the diagnosis is made in patients with moderate to severe malnutrition who develop electrolyte imbalance after beginning nutritional support. The imbalances potentially can lead to cardiac, pulmonary, and gastrointestinal complications and failure. Standardizing a multidisciplinary nutrition care plan and formulating a protocol for critically ill patients who develop RFS can potentially decrease complication rates and overall mortality.

A qualitative evaluation of medical student learning with concept maps

PURPOSE AND AIMS

The purpose of this study was to investigate the ways in which the use of concept maps influenced the learning processes of third year internal medicine students in the context of medical education. Reported here are the qualitative results of this study.

METHODS

One-hundred thirty four medical students were taught to use concept mapping as a learning strategy at the beginning of their internal medicine rotations. Upon completion of the internal medicine rotation students were asked to evaluate how concept maps fostered the process of linking theoretical information to clinical practice. Additionally, students described how concept maps impacted their learning.

RESULTS

In this study, concept maps fostered a positive connection between theory and practice. Additionally, students described three major themes impacting their learning: concept mapping as a facilitator of knowledge integration and critical thinking, as a teaching methodology and finally, as a learning method.

CONCLUSIONS

This study suggests concept maps may be an instructional method to foster the learning and thinking process of medical students.

Wear debris from hip or knee replacements causes chromosomal damage in human cells in tissue culture

Wear debris was extracted from 21 worn hip and knee replacements. Its mutagenic effects were tested on human cells in tissue culture using the micronucleus assay and fluorescent in situ hybridisation. The extracted wear debris increased the level of micronuclei in a linear dose-dependent manner but with a tenfold difference between samples. The concentration of titanium +/- vanadium and aluminium within the wear debris was linearly related both to the level of centromere-positive micronuclei in tissue culture, indicating an aneuploid event, and to the level of aneuploidy in vivo in peripheral blood lymphocytes. The concentration of cobalt and chromium +/- nickel and molybdenum in the wear debris correlated with the total index of micronuclei in tissue culture, both centromere-positive and centromere-negative i.e. both chromosomal breakage and aneuploidy events. The results show that wear debris can damage chromosomes in a dose-dependent manner which is specific to the type of metal. The results from studies in vitro correlate with those in vivo and suggest that the wear debris from a worn implant is at least partly responsible for the chromosomal damage which is seen in vivo.

Wear debris from hip or knee replacements causes chromosomal damage in human cells in tissue culture

Wear debris was extracted from 21 worn hip and knee replacements. Its mutagenic effects were tested on human cells in tissue culture using the micronucleus assay and fluorescent in situ hybridisation.

The extracted wear debris increased the level of micronuclei in a linear dose-dependent manner but with a tenfold difference between samples. The concentration of titanium +/− vanadium and aluminium within the wear debris was linearly related both to the level of centromere-positive micronuclei in tissue culture, indicating an aneuploid event, and to the level of aneuploidy in vivo in peripheral blood lymphocytes. The concentration of cobalt and chromium +/− nickel and molybdenum in the wear debris correlated with the total index of micronuclei in tissue culture, both centromere-positive and centromere-negative i.e. both chromosomal breakage and aneuploidy events.

The results show that wear debris can damage chromosomes in a dose-dependent manner which is specific to the type of metal. The results from studies in vitro correlate with those in vivo and suggest that the wear debris from a worn implant is at least partly responsible for the chromosomal damage which is seen in vivo.

Therapeutic touch, nursing practice and contemporary cutaneous wound healing research

The nursing profession is and always has been at the cutting edge of research and development into innovative and effective methods to treat, manage and enhance wound regeneration. One such method which was developed specifically for nursing science is a non-invasive, easily administered technique known as therapeutic touch (TT). Although there have been numerous anecdotal reports over the last two decades attesting to the efficacy of TT for cutaneous wounds, there have been only five experimental studies to date which have examined the phenomena in a scientifically rigorous manner. These five studies utilized randomized, double-blind, placebo controlled protocols to analyse the effect of an experimental derivative of TT-non-contact therapeutic touch (NCTT)-on the healing rate of surgically administered full thickness human dermal wounds. The experiments introduced many original concepts and approaches to healing research and nursing practice. The data from the five studies indicated a statistically significant accelerated rate of wound healing for the treatment group in the initial two experiments, and non-significant and reverse significant effects for the remaining three studies. Although, experimentally, these results are far from impressive, clinically, the significant results of the first two experiments should be enough to encourage the nurse clinician to explore and utilize a similar non-invasive TT treatment method for patients with dermal lacerations. While the results of the studies were inconsistent overall, the series of experiments nonetheless significantly expanded the theoretical boundaries and understanding of the TT process and, due to the rigorous, double-blind methodological protocols used, have established the critical groundwork and guidelines for future nursing science research in the area.

Early enteral feeding in postsurgical cancer patients. Fish oil structured lipid-based polymeric formula versus a standard polymeric formula

OBJECTIVES

The authors compared the safety, gastrointestinal tolerance, and clinical efficacy of feeding an enteral diet containing a fish oil/medium-chain triglyceride structured lipid (FOSL-HN) versus an isonitrogenous, isocaloric formula (O-HN) in patients undergoing major abdominal surgery for upper gastrointestinal malignancies.

SUMMARY BACKGROUND DATA

Previous studies suggest that feeding with n-3 fatty acids from fish oil can alter eicosanoid and cytokine production, yielding an improved immunocompetence and a reduced inflammatory response to injury. The use of n-3 fatty acids as a structured lipid can improve long-chain fatty acid absorption.

METHODS

This prospective, blinded, randomized trial was conducted in 50 adult patients who were jejunally fed either FOSL-HN or O-HN for 7 days. Serum chemistries, hematology, urinalysis, gastrointestinal complications, liver and renal function, plasma and erythrocyte fatty acid analysis, urinary prostaglandins, and outcome parameters were measured at baseline and on day 7. Comparisons were made in 18 and 17 evaluable patients based a priori on the ability to reach a tube feeding rate of 40 mL/hour.

RESULTS

Patients receiving FOSL-HN experienced no untoward side effects, significant incorporation of eicosapentaenoic acid into plasma and erythrocyte phospholipids, and a 50% decline in the total number of gastrointestinal complications and infections compared with patients given O-HN. The data strongly suggest improved liver and renal function during the postoperative period in the FOSL-HN group.

CONCLUSION

Early enteral feeding with FOSL-HN was safe and well tolerated. Results suggest that the use of such a formula during the postoperative period may reduce the number of infections and gastrointestinal complications per patient, as well as improve renal and liver function through modulation of urinary prostaglandin levels. Additional clinical trials to fully quantify clinical benefits and optimize nutritional support with FOSL-HN should be undertaken.

In-vitro activities of trospectomycin, cefpodoxime, and second-generation cephalosporins against Haemophilus influenzae type b

The in-vitro activities of trospectomycin, cefpodoxime, cefamandole, cefonicid, and cefuroxime against beta-lactamase-negative and -positive invasive clinical isolates of Haemophilus influenzae type b were determined by the agar dilution method. Trospectomycin and cefpodoxime inhibited 90% of the strains at concentrations of 5 and 0.06 mg/l, respectively, and no differences between the susceptibilities of the beta-lactamase-negative and -positive strains were noted. The activity of cefpodoxime was minimally affected by increased inoculum size, but significant inoculum effects were noted with cefamandole, cefonicid, and cefuroxime with beta-lactamase positive strains.