Virtual management of clinically suspected scaphoid fractures

AIMS

The aim of this study was to describe the introduction of a virtual pathway for the management of patients with a suspected fracture of the scaphoid, and to report patient-reported outcome measures (PROMs) and satisfaction following treatment using this service.

METHODS

All adult patients who presented with a clinically suspected scaphoid fracture that was not visible on radiographs at the time of presentation during a one-year period were eligible for inclusion in the pathway. Demographic details, findings on examination, and routine four-view radiographs at the time of presentation were collected. All radiographs were reviewed virtually by a single consultant hand surgeon, with patient-initiated follow-up on request. PROMs were assessed at a minimum of one year after presentation and included the abbreviated version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the EuroQol five-dimension five-level health questionnaire (EQ-5D-5L), the Net Promoter Score (NPS), and return to work.

RESULTS

A total of 221 patients were referred to the virtual pathway. Their mean age was 41 years (range 16 to 87) and there were 99 male patients (45%). A total of 189 patients (86%) were discharged with advice and 19 (9%) were recalled for clinical review: seven with an undisplaced scaphoid fracture, six with another fracture of the hand or wrist, two with a scapholunate ligament injury, and four in whom no abnormality was detected. A total of 13 patients (6%) initiated follow-up with the hand service: no fracture or ligament injury was identified in this group. PROMs were available for 179 patients (81%) at a mean follow-up of 19 months (range 13 to 33). The median QuickDASH score was 2.3 (interquartile range (IQR) 0 to 15.9), the median EQ-5D-5L was 0.85 (IQR 0.73 to 1.00), the NPS was 76, and 173 patients (97%) were satisfied with their treatment. There were no documented cases of symptomatic nonunion one year following injury.

CONCLUSION

We describe the introduction of a virtual pathway for the management of patients with a suspected scaphoid fracture. We found high levels of patient satisfaction, excellent PROMs, and no detrimental effects in the vast majority of cases. Cite this article: Bone Joint J 2022;104-B(6):709-714.

The prevalence, mortality, and associated risk factors for developing COVID-19 in hip fracture patients: a systematic review and meta-analysis

AIMS

The aims of this meta-analysis were to assess: 1) the prevalence of coronavirus disease 2019 (COVID-19) in hip fracture patients; 2) the associated mortality rate and risk associated with COVID-19; 3) the patient demographics associated with COVID-19; 4) time of diagnosis; and 5) length of follow-up after diagnosis of COVID-19.

METHODS

Searches of PubMed, Medline, and Google Scholar were performed in October 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Search terms included "hip", "fracture", and "COVID-19". The criteria for inclusion were published clinical articles reporting the mortality rate associated with COVID-19 in hip fracture patients. In total, 53 articles were identified and following full text screening 28 articles satisfied the inclusion criteria.

RESULTS

A total of 28 studies reported the mortality of COVID-19-positive patients, of which 21 studies reported the prevalence of COVID-19-positive patients and compared the mortality rate to COVID-19-negative patients. The prevalence of COVID-19 was 13% (95% confidence interval (CI) 11% to 16%) and was associated with a crude mortality rate of 35% (95% CI 32% to 39%), which was a significantly increased risk compared to those patients without COVID-19 (odds ratio (OR) 7.11, 95% CI 5.04 to 10.04; p < 0.001). COVID-19-positive patients were more likely to be male (OR 1.51, 95% CI 1.16 to 1.96; p = 0.002). The duration of follow-up was reported in 20 (71.4%) studies. A total of 17 studies reported whether a patient presented with COVID-19 (n = 108 patients, 35.1%) or developed COVID-19 following admission (n = 200, 64.9%), of which six studies reported a mean time to diagnosis of post-admission COVID-19 at 15 days (2 to 25).

CONCLUSION

The prevalence of COVID-19 was 13%, of which approximately one-third of patients were diagnosed on admission, and was associated with male sex. COVID-19-positive patients had a crude mortality rate of 35%, being seven times greater than those without COVID-19. Due to the heterogenicity of the reported data minimum reporting standards of outcomes associated with COVID-19 are suggested. Cite this article: Bone Joint Res 2020;9(12):873-883.

The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre

Objectives

The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison.

Methods

A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison.

Results

The initial intraclass correlation (ICC) on the first 15 sets of radiographs was 0.67 (95% CI 0.63 to 0.71). However, the original description was being interpreted in different ways. After agreeing on the interpretation, the ICC on the second cohort improved to 0.75. The ICC improved even further to 0.79, when the baseline post-operative radiographs were available for comparison.

Conclusion

This study demonstrates that the RUST scoring system is a reliable and repeatable outcome measure for assessing tibial fracture healing. Further improvement in the reliability of the scoring system can be obtained if the radiographs are compared with the baseline post-operative radiographs.

Cite this article: Mr J.M. Leow. The radiographic union scale in tibial (RUST) fractures: Reliability of the outcome measure at an independent centre. Bone Joint Res 2016;5:116–121. DOI: 10.1302/2046-3758.54.2000628.

A retrospective study of suicides in a rural health district over ten years

The suicides over a 10-year period in a rural area were examined. There was no overall increase in suicide rate, but more violent methods were used.

Home-based care and standard hospital care for patients with severe mental illness: a randomised controlled trial

"OBJECTIVE--To compare the efficacy of home based care with standard hospital care in treating serious mental illness. DESIGN--Randomised controlled trial. SETTING--South Southwark, London. PATIENTS--189 patients aged 18-64 living in catchment area. 92 were randomised to home based care (daily living programme) and 97 to standard hospital care. At three months' follow up 68 home care and 60 hospital patients were evaluated. MAIN OUTCOME MEASURES--Use of hospital beds, psychiatric diagnosis, social functioning, patients' and relatives' satisfaction, and activity of daily living programme staff. RESULTS--Home care reduced hospital stay by 80% (median stay 6 days in home care group, 53 days in hospital group) and did not increase the number of admissions compared with hospital care. On clinical and social outcome there was a non-significant trend in favour of home care, but both groups showed big improvements. On the global adjustment scale home care patients improved by 26.8 points and the hospital group by 21.6 points (difference 5.2; 95% confidence interval--1.5 to 12). Other rating scales showed similar trends. Home care patients required a wide range of support in areas such as housing, finance, and work. Only three patients dropped out from the programme. CONCLUSIONS--Home based care may offer some slight advantages over hospital based care for patients with serious mental illness and their relatives. The care is intensive, but the low drop out rate suggests appreciation. Changes to traditional training for mental health workers are required."

Isolation and sequence of a cDNA encoding human platelet phosphofructokinase

A cDNA encoding human platelet 6-phosphofructokinase (PFK; EC 2.7.1.11) has been isolated from a human lymphocyte Raji cell line cDNA library using a cDNA for human muscle PFK as a probe. The platelet cDNA contains 900bp of carboxy terminal coding sequence and 238bp of downstream untranslated region. The deduced amino acid sequence shows 71% identity to the amino acid sequence for the human muscle isoenzyme and 63% identity to the human liver isoenzyme. Almost all of the amino acid residues contributing to catalytic and effector sites in the three isoenzymes are conserved. The platelet gene has been assigned to chromosome 10p15.2-p15.3 by using the cDNA clone as a biotinylated probe against human chromosome spreads (Morrison et al. 1991, submitted to Human Genetics).

Binding of zinc and calcium to inositol phosphates (phytate) in vitro

Inositol compounds with three to five phosphate groups (IP3-IP5) were produced by hydrolysis of phytate (inositol hexaphosphate, IP6) and their binding affinities for calcium and zinc investigated at neutral pH with relative concentrations that had been found in a range of students' meals. Zn solubility was negligible at many of these concentrations, with less Zn bound to precipitates of Ca-IP6 than Ca-IP5. The capacity to precipitate Zn at these ratios fell between IP5 and IP3. Zn was partially desorbed by soluble chelators (histidine and picolinate), especially when it had been adsorbed to preformed Ca-IP precipitates. A lower proportion of Zn was accessible to soluble chelators from Ca-IP4 than the other compounds. IP3-IP4 were hydrolysed by phytase more readily than IP5-IP6.

The chronically mentally ill in community facilities. A study of quality of life

The quality of life of chronically mentally ill patients in acute wards in a district general hospital, a hostel ward and group homes was compared. Within the spectrum of care of these patients, the severity of psychopathology corresponded to their placement. Analysis, including adjustments for the influence of psychopathology, showed differences between the three types of facility. Although differences existed between all types of care, residents in group homes and the hostel ward shared more similarities in quality of life than those in the district general hospital. Problems of caring for the chronically mentally ill on acute wards are highlighted.

The phlebotome in the management of incompetent perforating veins and venous ulceration

A shearing operation using a phlebotome has been used on 26 limbs of 24 patients with venous ulceration to deal with incompetent perforating veins. Only one ulcer has failed to heal or remain healed at mean operative follow-up of 24 months. Numbness, usually transient, and haematoma formation have been the only recorded complications. This procedure is recommended in the management of incompetent perforating veins associated with venous ulceration.

Electrodermal response as a monitor in electroconvulsive therapy

A study comparing the use of electrodermal response with the cuff technique and clinical judgment as monitors in electroconvulsive therapy is reported. A sensitivity of 90.5% and a specificity of 41.7% were found and it is, therefore, suggested that this method is not used routinely.

Pre-operative intravenous cholangiography as an alternative to routine operative cholangiography in elective cholecystectomy

Pre-operative intravenous cholangiography as an alternative to routine operative cholangiography at elective cholecystectomy has been assessed in a retrospective manner in 286 patients. Most of the examinations were technically satisfactory (94.7%) and of these 1.8% proved incorrect. A small number of patients developed transient skin rashes (1.3%), the only side effect recorded. Preoperative intravenous cholangiography offers an alternative to routine operative cholangiography with the potential saving of both operating staff and radiologists' time, without sacrificing accuracy.

Effect of cimetidine on prognosis after simple closure of perforated duodenal ulcer

A prospective controlled study in 60 patients undergoing simple closure of perforated duodenal ulcer demonstrated a significant (P less than 0.05) benefit following postoperative cimetidine treatment, in terms of avoiding subsequent dyspeptic symptoms and complications of peptic ulcer disease. Thus cimetidine is recommended in the follow-up management of perforated duodenal ulcers.

The relationship between pre-operative anxiety and post-operative delirium

Forty five elderly patients undergoing total hip replacements were assessed one day before and two days after surgery in order to explore the relationship between pre-operative anxiety and post-operative delirium. Anxiety was measured by the State-Trait Anxiety Inventory and delirium was measured by a decrease in various measures of cognitive functioning. No relationship was found and this is discussed in the light of two theories which would have predicted one. Other secondary findings are reported and discussed.

Cystic degeneration of the popliteal artery in a female patient--case report

Adventitial cystic disease of the popliteal artery is an uncommon condition and is rare in females. We report a case in a female patient successfully managed by arterial reconstruction.

Meckel's diverticula in an adult surgical unit eleven years experience

A retrospective review of Meckel's diverticula over an 11-year period in a surgical unit, to which children were seldom admitted, revealed 28 diverticula, seven of which were symptomatic from inflammatory disease or obstruction. There was no morbidity nor mortality in this group. Twenty-one diverticula were removed as incidental findings, four patients dying from the cause of their symptoms. The complications of Meckel's diverticulum can be satisfactorily managed and are uncommon in the adult. Prophylactic diverticulectomy is difficult to justify.

The stigmata: pathology or miracle?

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Doctors and nurses use of the word confused

A questionnaire was sent to 274 doctors and nurses. The first section was to see if certain symptoms and signs elicited the description of patients as 'confused', and the second to discover the respondents' definitions. The results showed a marked discordance in health workers' understanding of this word 'confused' in reference to patients, and it is suggested that it should only be used if it is clearly defined.

The early diagnosis of acute gall-bladder disease: the accuracy of overnight eight-hour infusion cholangiography

The reliability of overnight 8-hour infusion cholangiography in confirming the diagnosis of acute cholecystitis or biliary colic was assessed by a prospective study in 100 patients. 55 positive infusion cholangiograms were subsequently confirmed at operation in 45 patients and by cholecystogram in 10 patients who did not have surgical treatment. The absence of false positive examinations is of fundamental importance if early cholecystectomy is to be performed without the risk of an unnecessary laparotomy. Infusion cholangiography proved to be a safe, simple and reliable investigation in the confirmation of acute gall-bladder disease.

Microcirculatory norepinephrine constrictor response in hemorrhagic shock

Hemorrhagic shock is characterized by a phase of compensation that preserves central blood flow and intravascular pressure through an integrated vasoconstrictor response mediated by catecholamines, particularly norepinephrine (NE). The skeletal muscle microcirculation is important in this response. Decompensation occurs when arteriolar vasodilation occurs despite continued hypovolemia and high circulatory levels of NE. Using an isolated decerebrate rat cremaster muscle, we measured constrictor response to NE (10(-7)M tissue concentration) in compensated and decompensated shock. Our data indicate that larger arterioles (143 to 152 microns) show persistent constrictor response with lowered sensitivity to NE. Smaller arterioles (11 to 22 microns) and all venules dilate late in shock but retain constrictor responses to NE. Dilator responses contribute to decompensation in small arterioles and venules but not because of altered NE constrictor response.

Metronidazole prophylaxis in colorectal surgery: the need for additional aminoglycoside?

A randomized double-blind trial was conducted in two phases to compare the efficacy of prophylactic oral and intravenous administration of kanamycin and metronidazole in preventing wound infection and other complications in patients undergoing colorectal surgery, and also to assess the need for inclusion of an aminoglycoside in the prophylactic regimen. Adequate prophylaxis did not depend on the route of antimicrobial administration, but wound infection rates were increased following exclusion of kanamycin.

Effect of bile salt perfusion and intraduct pressure on ionic flux and mucosal ultrastructure in the pancreatic duct of the cat

Net ionic flux and mucosal ultrastructure were examined following perfusion of the cat pancreatic duct with bicarbonate or sodium taurocholate solutions (5-40 mM). Taurocholate perfusion increased net Cl- gain, net HCO3- loss and net K+ gain and was associated with significant widening of lateral intercellular spaces and increased complexity of intercellular labyrinths. Increased perfusion pressure (30 mm Hg) did not affect flux or ultrastructure during perfusion with bicarbonate but increased net ion flux significantly during perfusion with 40 mM sodium taurocholate. Ultrastructural changes during perfusion of 40 mM taurocholate at increased pressure were not consistent but focal epithelial disruption and cell shedding were seen occasionally. The hypothesis is advanced that taurocholate perfusion triggers physiological transport mechanisms and may make the duct mucosa more vulnerable to other potentially harmful agents. The significance of these changes in the pathogenesis of acute pancreatitis in man remains uncertain and care must be exercised before extrapolating from observed net ion flux data in this animal model.

Guidelines for prevention of surgical wound infection

Despite the widespread use of antibiotics, surgical wound infections continue to cause patient discomfort and drain on health care finances. More serious local complications often develop concomitantly (eg, cellulitis) or later (eg, incisional hernia). Inadequate treatment of an illness or poor host defenses may lead to serious systemic complications (septicemic shock, multiple organ failure). Therefore, it is essential that every effort be made to minimize the likelihood of infection. The Centers for Disease Control in Atlanta convened a group of physicians and surgeons knowledgeable in the practice of infection control. This group developed a set of guidelines that is thought to reflect the state of the art in 1982. The trials, which were objective and preferably randomized or even blinded, determined present options for surgical infection control.

Infrapopliteal bypass grafts for severe ischaemia of the lower limb

A retrospective survey of 27 infrapopliteal bypass grafts performed for rest pain revealed a cumulative limb salvage rate of 65.3% with an overall operative mortality of 8%. When pre-operative angiography demonstrates a patent infrapopliteal artery, reversed saphenous vein bypass grafting offers a realistic alternative to primary amputation when femoropopliteal occlusion threatens limb viability.