20 Incidence of Acute Kidney Injury in Neck of Femur Fracture Patients During the COVID-19 Pandemic in Princess Royal Hospital, Telford

Aim

Patients undergoing surgical repair of neck-of-femur (NOF) fractures are at higher risk of acute kidney injury (AKI). NICE and BOAST have published guidelines to help prevent the occurrence of AKI, including adequate fluid resuscitation pre- and post-operatively. An audit was conducted during the COVID-19 pandemic to explore whether the department was adhering to NICE guidelines.

Method

AKI was defined, as per NICE Clinical Knowledge Summaries, as an increase in serum creatinine levels by 26 µmol/L or greater. Data was collected prospectively starting from December 2020 to February 2021 in the Princess Royal Hospital during the COVID-19 pandemic. All patients with NOFs were included and data on sex, age, comorbidities, and type of surgery were collected.

Results

In total, 32 patients were included in the audit with an average age of 82 years; of these, eleven patients had dynamic hip screws and eighteen patients had hemiarthroplasties. Five patients had chronic kidney disease, six patients had previous myocardial infarctions and thirteen patients had hypertension. Two patients (6.3%) were found to have an AKI post-surgery with increased creatinine levels of 27 and 28 µmol/L. Both had hypertension and underwent hemiarthroplasties.

Conclusions

Complications such as AKIs are reversible and preventable. Especially during the COVID-19 pandemic such complications can increase morbidity and mortality of patients suffering from NOF leading to longer hospital stays. The low rate of AKI following NOF repair in our Department of Trauma and Orthopaedic is attributable to adherence to NICE and BOAST fluid resuscitation guidelines.

19 Plain Film X-Ray Reporting in Orthopaedic Patients: A Reaudit in a District General Hospital

Aim

To assess clinical evaluation of plain film x-rays requested for patients in the orthopaedic department (clinic and ward)

Standards:

Ionising radiation (medical exposure) regulations irmer 2017 procedure j: recording clinical exposure, national guideline and local guidance is in keeping with irmer and good clinical practice.

Method

50 plain films of randomly selected (using random number generator) who had attended new patient fracture clinic and ward. An initial audit was done in June and an reaudit in September.

The radiology system, clinical notes and clinic letters were reviewed to obtain the relevant data.

Results

Audit: 20 films were documented

30 were not documented

Reaudit

32 films were documented by referring clinician

18 films were not documented by referring clinician

Audit:

Clinical evaluation documented 18

Clinical evaluation not documented 32

Reaudit:

Clinical evaluation documented - 29

Clinical evaluation not documented - 21

Discussion

Whose responsibility? Radiographs commented on in trauma meetings not documented. New radiographs not commented on in clinic.

Limitations - access to more notes from ward.

Conclusions

As outlined in guidance orthopaedic and fracture clinic plain films should be reported by referring clinician or their team. Currently this is being done 64% of the time, significant improvement was seen. This may have medicolegal consequences as it does not follow GMC guidance for good medical practise.

Recommendations

Clinicians to specifically dictate x-ray findings in fracture clinic. Junior staff to take responsibility for documenting x-ray findings as discussed with senior clinicians for trauma patients. Junior staff to review post-op x-rays for all patients and to document.

Subglottic cysts: The Great Ormond Street experience in 105 patients

PURPOSE

The aim of the study was to assess the contemporary presentation and management of subglottic cysts and make recommendations on the treatment of these patients.

METHODS

Retrospective case series of 105 patients between October 1999 and November 2017 from a paediatric teaching hospital.

RESULTS

Ninety-one percentage (n = 96) had a history of prematurity, with a mean gestation of 27.2 weeks (SD ± 4.1). A history of intubation was found in 99% (n = 104) of cases [median 18 days (range = 1-176)]. Presenting symptoms were: Stridor 57.1%, (n = 60), difficult intubation 14% (n = 15), recurrent croup 11.4% (n = 12), failed extubation 7.6%, (n = 8), hoarseness/weak cry 10.5% (n = 10). Ninety percentage (n = 94) underwent intervention for management of SGCs with 86% (n = 81) treated with cold steel marsupialisation and 14% (n = 13) with CO ₂ laser. Recurrent cysts occurred in 56% (n = 53) of cases. Treatment modality did not affect recurrence (p = 0.594 ^Δ). Sixty-six percentage (n = 69/105) of patients had one or more concurrent airway pathology at MLB. Most frequent was subglottic stenosis 47% (n = 49), with 16% (n = 8) subsequently requiring open reconstructive airway surgery. Mean duration of follow-up was 47.6 months (SD ± 38.3).

CONCLUSION

SGC are an uncommon, reversible cause of upper airway obstruction and should be considered in the list of differential diagnoses in patients with a history of prematurity and perinatal intubation, presenting with stridor. While concurrent SGS is common, adequate symptom improvement in such cases may be achieved with SGC removal alone. Management is by surgical marsupialisation. Recurrence and additional airway pathologies are common and may necessitate longer-term treatment in centres with paediatric airway expertise.

Adverse effects of anti-epileptics in trigeminal neuralgiform pain

BACKGROUND

Side effects of anti-epileptic drugs (AEDs) have not been adequately documented in trigeminal neuralgia and its variants. The aim of this observational cross-sectional study was to compare the A-B Neuropsychological Assessment Schedule (ABNAS), which measures cognitive side effects to the Adverse Events Profile (AEP), which looks at a broader range of side effects, and to investigate drug/dosage relationships with questionnaire scores to help determine a point at which a drug change would be indicated.

METHODS

One hundred five patients were recruited from a facial pain clinic, over a 10-month period. Self-complete questionnaire scores were compared between patients using different AEDs.

RESULTS

A-B Neuropsychological Assessment Schedule score correlated well with AEP indicating that cognitive side effects were a significant burden. Toxic range on the ABNAS was estimated to occur when scores were >43/72 (95% CI: 37.4-48.6). Polytherapy is weakly associated with the higher scores. Oxcarbazepine dosage was found to linearly correlate with AEP and ABNAS scores, better than carbamazepine dosage. Memory alteration was least common with lamotrigine and oxcarbazepine, and there was less association between fatigues with oxcarbazepine/pregabalin.

CONCLUSION

Anti-epileptic drugs have significant side effects. The ABNAS questionnaire is a useful tool along with the AEP to recognize and monitor AEDs' side effects and to help to adjust medications to optimal dosage.

Lateral plantar nerve injury following steroid injection for plantar fasciitis

A 41 year old man presented with pain and numbness affecting the lateral aspect of his foot after a steroid injection for plantar fasciitis. Examination confirmed numbness and motor impairment of the lateral plantar nerve. The findings were confirmed by electromyographic studies. The anatomy of the lateral plantar nerve and correct technique for injection to treat plantar fasciitis are discussed.

High rates of multiple antibiotic resistance in Streptococcus pneumoniae from healthy children living in isolated rural communities: association with cephalosporin use and intrafamilial transmission

OBJECTIVE

Streptococcus pneumoniae is one of the most clinically significant pathogens with emerging antibiotic resistance. We performed a surveillance study in isolated rural populations of healthy children to estimate the prevalence of pneumococcal resistance and to contrast factors that predict pneumococcal carriage with those that specifically predict resistant pneumococcal carriage.

METHODS

The study was conducted in 1998 in 2 rural communities in Utah. Families were recruited directly for participation through community canvassing. Surveillance nasopharyngeal cultures were obtained from children who were younger than 8 years. Antibiotic usage and information on other potential risk factors were obtained from questionnaires and local pharmacy records. Resistance was determined by testing isolates for susceptibility to penicillin, cefaclor, trimethoprim-sulfamethoxazole, erythromycin, ceftriaxone, and trovafloxacin. Selected resistant isolates were characterized further by serotyping, pulsed field gel electrophoresis, and Southern blot with DNA probes specific for the pneumococcal lytA gene and for antibiotic resistance genes.

RESULTS

In April 1998, surveillance nasopharyngeal cultures were obtained from 368 children aged </=8 years in community A and 369 children in community B. The number of antibiotic courses per child within 1 year before culture was higher in community B than A (mean: 2.2 vs 1.7). Conversely, oral cephalosporins were more frequently used in community A than B (community A: 22% received cephalosporins within 4 months; community B: 12%). Colonization with S pneumoniae was detected in 24% of children in community A and 14% in community B; 36% of isolates from community A and 28% of isolates from community B were resistant or intermediately susceptible to at least 1 antibiotic tested. Reduced susceptibility was most common to trimethoprim-sulfamethoxazole and cefaclor (28% and 26%, respectively). Pneumococcal carriage (susceptible or resistant) was independently associated with age <5 years (odds ratio [OR]: 2.2), child care exposure (OR: 2.4), presence of a sibling with a positive culture (OR: 3.3), and residence in community A (OR: 1.7). Among carriers, age <2 years (OR: 2.6), use of cephalosporins within the preceding 4 months (OR: 2.7), and having a sibling colonized with resistant S pneumoniae (OR: 5.5) were independent predictors of reduced susceptibility or resistance. Each pair of resistant isolates from siblings was indistinguishable by pulsed field gel electrophoresis and other molecular typing techniques. Several pneumococcal isolates from these isolated rural areas had the molecular characteristics of international clones of multiple-drug-resistant pneumococci that have been associated with worldwide spread.

CONCLUSIONS

Young age and intrafamilial transmission were important risk factors for carriage of both susceptible and resistant S pneumoniae. In contrast, previous cephalosporin use was linked specifically to resistant pneumococcal carriage, which suggests that modifications in antibiotic usage patterns may have salutary effects on antimicrobial resistance. These results extend previous observations in large cities regarding the penetration of multiple-drug-resistant clones of pneumococci into community populations.

Probabilistic linkage of computerized ambulance and inpatient hospital discharge records: a potential tool for evaluation of emergency medical services

STUDY OBJECTIVES

Emergency medical services (EMS) is an important part of the health care system. The effect of EMS on morbidity, mortality, and costs of illness is difficult to evaluate because hospital information is not available in out-of-hospital databases. We used probabilistic linkage to create such a database from ambulance and inpatient data and demonstrate the potential for linkage to facilitate evaluation of EMS responses resulting in hospital admission.

METHODS

Statewide ambulance and inpatient hospital discharge records were available for 1994 through 1996. Ambulance records indicating admission to the emergency department or hospital (165,649 records) were linked to inpatient hospital records indicating emergency admission (146,292 records) by using probabilistic linkage. Out-of-hospital data (dispatch code, treatments rendered, and ages), linkage rates, and inpatient data (discharge status, charges, length of stay, and payer category) were analyzed.

RESULTS

We linked 24,299 (14.7%) ambulance events to inpatient hospital discharges. If we had used exact linkage methods, we would have only linked 14,621 record pairs, a loss of nearly 40%. Linkage rates were relatively constant between years (approximately 15%) but differed by ambulance dispatch codes. Out-of-hospital dispatch codes with high linkage rates included breathing problems (22.6%), chest pain (21.5%), diabetic problems (16.9%), drowning incidents (14.9%), falls (19.2%), strokes (32.8%), and unconsciousness or fainting episodes (16.1%). Linkage to the hospital record provided access to hospital outcome data. Inpatient mortality was 6.8%. Survivors were discharged home (60.7%), transferred to other acute-care facilities (3.6%) or intermediate-care facilities (23.3%), or discharged with home health care provision (4.9%). The median length of stay was 3 days, and median charges were $6,620; total inpatient charges were $286,737,067.

CONCLUSION

Probabilistic linkage enables ambulance and hospital discharge records to be linked together and potentially increases our ability to critically evaluate EMS by providing access to hospital-based outcomes. Such evaluation will be further improved by linking to ED, other outpatient, and other public health data sources.

Type 2 diabetes mellitus in Canada's first nations: status of an epidemic in progress

This review provides a status report on the epidemic of type 2 diabetes mellitus that is affecting many of Canada's First Nations. We focus on the published literature, especially reports published in the past 2 decades, and incorporate data from the Aboriginal Peoples Survey and the First Nations and Inuit Regional Health Survey. We look at the extent and magnitude of the problem, the causes and risk factors, primary prevention and screening, clinical care and education, and cultural concepts and traditional knowledge. The epidemic of type 2 diabetes is still on the upswing, with a trend toward earlier age at onset. Genetic-environmental interactions are the likely cause. Scattered intervention projects have been implemented and evaluated, and some show promise. The current health and social repercussions of the disease are considerable, and the long-term outlook remains guarded. A national Aboriginal diabetes strategy is urgently needed.

Pre-hospital emergency medical services: a population based study of pediatric utilization

OBJECTIVES

To examine emergency medical services (EMS) usage by children in one state.

METHODS

Dispatch of an EMS vehicle in response to a call in the US is referred to as a "run". Runs for Utah for 1991-92 were linked to corresponding hospital records. Abbreviated injury severity scores (AISs) were assigned using ICDMAP-90 software.

RESULTS

For the two year period there were at least 15 EMS runs per 100 children per year, with incomplete reporting from rural areas. EMS response and scene times were similar for all age groups, but interventions were less frequent for children under 5 years of age. When the principal AIS region of injury was the head, neck, or face, cervical immobilization was less frequent for children less than 5 years of age (54%) than for older children (76%) and immobilization was associated with improved outcome, using the crude measure of lower hospital charges. There was a similar association between splinting of upper extremity fractures and reduced hospital charges. Both associations did not appear to be due to differences in injury severity.

CONCLUSIONS

The majority of EMS use by children is for trauma. Children less than 5 years of age are less likely to have an EMS intervention than older children. Whether the lower frequency of interventions is due to the lack of properly sized equipment on the vehicle, or to other factors, is undetermined.

Distinctive emergency department usage for injury for workers' compensation cases in Utah in 1996

To compare emergency department services paid by worker's compensation (WC) with services paid by other payers, a state database of 72,747 emergency department visits for injured adults (ages 21 to 54) in 1996 in Utah was analyzed. WC visits accounted for 21.6% (15,704) of all adult injury visits. The mean emergency department charge for WC visits was $282, and the admission rate was 17 per 1000 visits. The mean charge for other payers was $334, and the admission rate was 43 per 1000 visits. Differences were also found between these groups for Injury Severity Scores and diagnoses. In summary, WC emergency department usage was associated with less severe injuries than was emergency department usage for other payers in Utah in 1996.

Radical transurethral resection and chemotherapy in the treatment of muscle-invasive bladder cancer: a long-term follow-up

OBJECTIVE

To evaluate the treatment of patients with muscle-invasive bladder cancer (T2-T4a) by radical transurethral resection (TUR) and cisplatin-methotrexate systemic chemotherapy.

PATIENTS AND METHODS

Fifty patients with transitional cell carcinoma (TCC) of the bladder (nine T2, 36 T3 and five T4a) were treated by 'complete' TUR of the bladder tumour followed by 2-6 cycles of cisplatin (70 mg/m2) and methotrexate (40 mg/m2) chemotherapy. The median (range) tumour size was 3 (1-7 cm). In six patients, attempted TUR at the dome of the bladder led to intraperitoneal perforation; the tumour was excised by partial cystectomy in these patients. The latest follow-up results from 57 patients treated by radical TUR and methotrexate alone, reported previously, are included.

RESULTS

At the first evaluation cystoscopy immediately after completing chemotherapy, 38 patients were tumour-free, eight had persistent muscle-invasive TCC and four had Ta, T1+CIS disease. With an overall median follow-up of 47 months, 10 additional patients relapsed with muscle-invasive carcinoma in the bladder after a median interval of 15.6 months; three patients developed Ta, T1 tumours, three Ta, T1 + CIS, and six CIS only. Six of the 10 recurrent invasive tumours were at the same site, but four were at a different site in the bladder. Although during follow-up 12 patients developed superficial recurrence that required endoscopic treatment, the bladder was preserved (free of muscle-invasive cancer) in 37 of 50 patients. In 30 of these 37, this was achieved with no need for salvage radiotherapy or cystectomy. Six patients died from metastatic TCC with no tumour in the bladder.

CONCLUSION

In this selected group of patients, muscle-invasive bladder cancer was controlled by TUR and systemic chemotherapy, preserving normal bladder function in 60% of patients without apparently comprising overall survival.

The application of a prognostic factor analysis for Ta.T1 bladder cancer in routine urological practice

OBJECTIVE

To assess the reproducibility of the prognostic factor findings of Parmar et al. [1], in a routine urological practice.

PATIENTS AND METHODS

The superficial tumour recurrence-free rate has been analysed for 232 newly diagnosed consecutive patients with Ta.T1 transitional cell carcinoma of the bladder. All patients were without carcinoma in situ or muscle invasion at the time of diagnosis.

RESULTS

Applying the prognostic factors recommended (number of tumours at diagnosis; tumour recurrence at first 3-month cystoscopy) patients with Ta.T1 bladder cancer may be divided into three distinct groups with significantly different chances of superficial bladder tumour recurrence.

CONCLUSION

Two simple clinical criteria provide a reliable guide to the likelihood of tumour recurrence in patients with Ta.T1 bladder cancer. The modification of follow-up cystoscopy schedules on this basis requires prospective study.

The persistence of bacille Calmette-Guérin in the bladder after intravesical treatment for bladder cancer

OBJECTIVE

To determine the incidence of bacille Calmette-Guérin (BCG) bacilli persisting in the urinary tract of patients treated previously with intravesical BCG for carcinoma in situ or multiple Ta.T1 transitional cell carcinoma.

PATIENTS AND METHODS

One-hundred and twenty-five patients were treated at the Freeman Hospital, Newcastle upon Tyne, UK over an 8-year period, 90 of whom submitted early morning urine samples for culture for acid-fast bacilli at varying intervals following BCG treatment. The records of all patients were reviewed to determine the incidence of caseating granulomata containing acid-fast bacilli together with the incidence of toxicity and the outcome of treatment.

RESULTS

Five patients were found to have persisting acid-fast mycobacteria in their urine or bladder up to 16.5 months after completing intravesical instillations of BCG. In one patient this probably accounted for bladder symptoms that required palliative cystectomy. In four patients the 'infection' was not severe. Two patients were treated with antituberculous chemotherapy without complication. Three years after intravesical BCG therapy 36 of 69 patients (52%) had remained tumour free.

CONCLUSION

BCG organisms can persist in the urinary tract for at least 16.5 months after the completion of intravesical BCG instillation therapy.

Clinical consequences of antiphospholipid antibodies: an historic cohort study

OBJECTIVE

To determine the risk of antiphospholipid antibody-related disorders in women with elevated levels of these antibodies.

METHODS

We used an historic cohort study design. Surveys of medical and obstetric histories for the interval from initial antibody testing to the time of patient interview were used to calculate age-adjusted rates for the development of medical disorders associated with antiphospholipid antibodies. The cohort included 130 women with lupus anticoagulant, medium to high levels of immunoglobulin G anticardiolipin antibodies, or both.

RESULTS

The median interval of study was 3.2 years (range 0.7-9.5, mean 3.7). Sixty-three subjects (48%) developed at least one new disorder during the study interval. The age-adjusted rates (per 1000 patient-years; +/- standard error) for the development of the disorders studied were as follows: thrombosis (156.8 +/- 30.0), cerebrovascular accident (93.8 +/- 25.1), amaurosis fugax (57.1 +/- 23.2), transient ischemic attack (170.4 +/- 27.6), systemic lupus erythematosus (9.8 +/- 3.8), and autoimmune thrombocytopenia (56.0 +/- 22.2). Of the 34 thrombotic events that occurred during the study interval, eight were associated with pregnancy and eight occurred while the patients were taking anticoagulant medications.

CONCLUSIONS

Our subjects developed complications associated with antiphospholipid antibodies at a substantial rate, and almost half suffered at least one new event during the study interval. The high rate of thrombosis in individuals with antiphospholipid antibodies, especially associated with pregnancy, underscores the need to evaluate long-term anticoagulation in these patients.

Revision of the Physical Activity Readiness Questionnaire (PAR-Q)

The original Physical Activity Readiness Questionnaire (PAR-Q) offers a safe preliminary screening of candidates for exercise testing and prescription, but it screens out what seems an excessive proportion of apparently healthy older adults. To reduce unnecessary exclusions, an expert committee established by Fitness Canada has now revised the questionnaire wording. The present study compares responses to the original and the revised PAR-Q questionnaire in 399 men and women attending 40 accredited fitness testing centres across Canada. The number of subjects screened out by the revised test decreased significantly (p < .05), from 68 to 48 of the 399 subjects. The change reflects in part the inclusion of individuals who had made an erroneous positive response to the original question regarding high blood pressure. There is no simple gold standard to provide an objective evaluation of the sensitivity and specificity of either questionnaire format, but the revised wording has apparently had the intended effect of reducing positive responses, particularly to the question regarding an elevation of blood pressure.

Sudden death in the late hospital phase of acute myocardial infarction

Forty-seven patients died suddenly during the late hospital phase of acute myocardial infarction. Risk factors associated with late in-hospital sudden death included prior cardiovascular disease, circulatory failure while in the coronary care unit, and certain arrhythmias and conduction disturbances while in the coronary care unit. These were associated with a twofold to sixfold increase in late in-hospital phase sudden death. The most prevalent risk factor occured in 62% of the sudden-death patients; the highest incidence of sudden death with a single risk factor was 2.6%, and the greatest relative risk was 6.0. Relative risks were uniformly greater for males than females. Multiple factors were associated with a greater risk than single factors. These risk factors characterize the group of sudden-death patients as a whole but do not allow precise identification of individual patients at high risk.

Effect of hypertension on myocardial rupture after acute myocardial infarction

Fifty-three of 4,369 patients with acute myocardial infarction died of myocardial rupture. The incidence of rupture varied directly, among men, with the systolic blood pressure on admission to the coronary care unit (CCU), and the highest systolic pressure while in the CCU. Rupture occurred in 0.3% of the men with systolic pressures on admission to the CCU between 110-129 mm Hg, increasing to 2.0% of men with pressures between 170-189 mm Hg. Similarly, 0.3% of the men with a highest systolic pressure less than 150 mm Hg had a rupture, while 1.6% of those with pressures between 170-189 mm Hg ruptured. Diastolic blood pressure, past history of hypertension, and sustained hypertension after infarction were not related to the occurrence of rupture. Eighteen of the 53 patients who sustained rupture had systolic hypertension (greater than or equal to 150 mm Hg) sometime during the 24 hours before rupture, and 14 had diastolic hypertension (greater than or equal to 95 mm Hg). Hypertension appears to be one of several variables interacting to influence the occurrence of myocardial rupture.