Orthopaedic injuries due to electric scooter trauma presenting to a level 1 trauma centre before and after introduction of a scooter-sharing scheme

Background

Epidemiological data from various jurisdictions has shown that electric scooters are associated with significant trauma. The Victorian state government introduced a trial scooter sharing scheme on February 1, 2022 in inner city Melbourne. This is a descriptive study from the largest trauma centre in Victoria, geographically at the heart of the government sharing scheme, investigating the "scope of the problem" before and after introduction of the ride sharing scheme.

Methods

Retrospective case series. Insitutional orthopaedic department database was searched from 1 Jan 2021 to 30 June 2022 to identify all admissions, requiring orthopaedic management, associated with e-scooter trauma. Data collected included, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, injuries sustained, surgical procedures, discharge destination, and death.

Results

In the 12 months prior to, and five months since introduction of the ride share scheme, 43 patients sustaining e-scooter related injuries were identified. Eighteen patients (42%) presented in the five months since ride sharing was introduced and 25 patients in the preceding 12 months. 58% of patients were found to be intoxicated. Fourteen percent required an ICU admission. Forty-four percent of patients were polytrauma admissions. The median length of stay was two days, longest individual hospital stay was 69 days. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. The mean Injury Severity Score was 17.28.

Conclusion

Electric scooters are associated with a significant trauma burden. This data may be combined with other clinical services and could be used to inform policy makers.

COVID-19: Four Paediatric Cases in Malaysia

OBJECTIVE

This is a brief report of 4 paediatric cases of COVID-19 infection in Malaysia BACKGROUND: COVID-19, a coronavirus, first detected in Wuhan, China has now spread rapidly to over 60 countries and territories around the world, infecting more than 85000 individuals. As the case count amongst children is low, there is need to report COVID-19 in children to better understand the virus and the disease.

CASES

In Malaysia, until end of February 2020, there were four COVID-19 paediatric cases with ages ranging from 20 months to 11 years. All four cases were likely to have contracted the virus in China. The children had no symptoms or mild flu-like illness. The cases were managed symptomatically. None required antiviral therapy.

DISCUSSION

There were 2 major issues regarding the care of infected children. Firstly, the quarantine of an infected child with a parent who tested negative was an ethical dilemma. Secondly, oropharyngeal and nasal swabs in children were at risk of false negative results. These issues have implications for infection control. Consequently, there is a need for clearer guidelines for child quarantine and testing methods in the management of COVID-19 in children.

Nurses' knowledge, beliefs and practices regarding the screening and treatment of postpartum depression in maternal and child health clinics: A cross-sectional survey

BACKGROUND

Postpartum depression (PPD) affects 10-15% of women worldwide, and screening is recommended by clinical guidelines. In Malaysia, nurses in maternal and child health (MCH) clinics provide postpartum care.

AIM

To determine nurses' level of knowledge, beliefs and practices regarding PPD and factors associated with screening practices.

METHODS

A cross-sectional study using universal sampling was conducted on nurses from seven government MCH clinics in Malaysia. Data was collected from March until April 2016 through a self-reported questionnaire. Univariate and multivariate analyses were performed to identify factors associated with having ever performed PPD screening.

RESULTS

Of the 108 nurses, 55.6% scored above the median total knowledge score (17 out of 24 points). Despite a high proportion of nurses believing that they were responsible for PPD screening (72.2%), counselling depressed mothers (72.2%) and referring mothers for further treatment (87.0%), only 64.8% and 51.9% were confident in recognizing PPD and counselling depressed mothers, respectively. Only 25.9% had ever practiced PPD screening, which was associated with beliefs concerning screening taking too much time (adjusted odds ratio [AOR]=0.13, 95% confidence interval [CI]= 0.02-0.74, P=0.022) and that screening is their responsibility (AOR=14.12, 95%CI=1.65-120.75, P=0.016).

CONCLUSION

More than half of the nurses scored above the median total knowledge score and had positive beliefs towards PPD screening. However, PPD screening practices were poor, and this outcome was associated with their beliefs regarding time and responsibility.

The views and experiences of Malaysian primary care doctors in managing patients with chronic low back pain: a qualitative study

BACKGROUND

Chronic low back pain (CLBP) is a common and often difficult to treat condition in the primary care setting. Research involving in-depth exploration on the views and experiences faced by primary care doctors in managing patients with CLBP in Malaysia is limited.

OBJECTIVE

To explore the primary care practitioners' views and experiences in managing patients with CLBP.

STUDY DESIGN

A qualitative approach was employed using focus group discussions (FGD) at an academic primary care clinic in Kuala Lumpur, Malaysia. Twenty-three primary care doctors were purposively selected. Data were collected through audio-recorded interviews, which were transcribed verbatim and checked for accuracy. Data saturation was reached by the third FGD. An additional FGD was included to ensure completeness. A thematic approach using the one sheet of paper (OSOP) method was used to analyse the data.

RESULTS

Participants view managing patients with CLBP as challenging. This is mainly due to the difficulty in balancing the doctors' expectations with the patients' perceived expectations during consultation. Barriers identified include lack of awareness and conflicting views regarding the usefulness of the local clinical practice guideline (CPG) in clinical practice. Other barriers include time constraints and perceived lack of support from multidisciplinary teams in managing these patients.

CONCLUSION

Managing patients with CLBP is still a challenge for Malaysian primary care doctors. Any intervention should target identified barriers to improve the management of patients with CLBP.

Are interventions to increase the uptake of screening for cardiovascular disease risk factors effective? A systematic review and meta-analysis

Background

Cardiovascular disease (CVD) is the leading cause of death globally. However, many individuals are unaware of their CVD risk factors. The objective of this systematic review is to determine the effectiveness of existing intervention strategies to increase uptake of CVD risk factors screening.

Methods

A systematic search was conducted through Pubmed, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials. Additional articles were located through cross-checking of the references list and bibliography citations of the included studies and previous review papers. We included intervention studies with controlled or baseline comparison groups that were conducted in primary care practices or the community, targeted at adult populations (randomized controlled trials, non-randomized trials with controlled groups and pre- and post-intervention studies). The interventions were targeted either at individuals, communities, health care professionals or the health-care system. The main outcome of interest was the relative risk (RR) of screening uptake rates due to the intervention.

Results

We included 21 studies in the meta-analysis. The risk of bias for randomization was low to medium in the randomized controlled trials, except for one, and high in the non-randomized trials. Two analyses were performed; optimistic (using the highest effect sizes) and pessimistic (using the lowest effect sizes). Overall, interventions were shown to increase the uptake of screening for CVD risk factors (RR 1.443; 95% CI 1.264 to 1.648 for pessimistic analysis and RR 1.680; 95% CI 1.420 to 1.988 for optimistic analysis). Effective interventions that increased screening participation included: use of physician reminders (RR ranged between 1.392; 95% CI 1.192 to 1.625, and 1.471; 95% CI 1.304 to 1.660), use of dedicated personnel (RR ranged between 1.510; 95% CI 1.014 to 2.247, and 2.536; 95% CI 1.297 to 4.960) and provision of financial incentives for screening (RR 1.462; 95% CI 1.068 to 2.000). Meta-regression analysis showed that the effect of CVD risk factors screening uptake was not associated with study design, types of population nor types of interventions.

Conclusions

Interventions using physician reminders, using dedicated personnel to deliver screening, and provision of financial incentives were found to be effective in increasing CVD risk factors screening uptake.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0579-8) contains supplementary material, which is available to authorized users.

Weight satisfaction, management strategies and health beliefs in knee osteoarthritis patients attending an outpatient clinic

BACKGROUND

Although weight control is important in managing knee osteoarthritis (OA), it is difficult to achieve. Understanding beliefs regarding weight management in people with knee OA may improve weight control.

AIMS

To examine differences in bodyweight satisfaction, weight management strategies and weight-related health-beliefs in obese, overweight and normal weight people with knee OA.

METHODS

The beliefs and attitudes to weight in 102 people with symptomatic knee OA were ascertained. Participants were classified as being obese, overweight or of normal weight.

RESULTS

Although obese and overweight participants were less satisfied with their bodyweight, they were more likely to want to lose weight and to report dieting compared with normal weight participants(P < 0.001 for all) and also more likely to report weight gain in the past 6 months (P < 0.001). While most participants rated food intake to be a main determinant of health, this belief was more common in normal weight participants (P = 0.04). When asked about their own weight gain, obese participants more frequently believed genetic and metabolic factors to be important than normal and overweight participants (P = 0.01). While 51 (53%) believed that increasing activity was more important than dietary change to avoid weight gain, this was more commonly believed by obese and overweight participants (P < 0.05).

CONCLUSIONS

Despite desiring and attempting to lose weight, obese people with symptomatic knee OA more commonly reported weight gain. Overweight and obese participants attributed weight gain to non-modifiable factors but believed physical activity is more important than dietary change in weight management. Thus, education regarding the importance of diet as compared with non-modifiable factors and physical activity may improve weight management in obese people with knee OA.

Pneumoperitoneum or Chilaiditi's sign

Chilaiditi's sign describes the incidental radiographic finding of the bowel positioned between the right diaphragm and the liver. This is often misdiagnosed as pneumoperitoneum or free air under the diaphragm, which may lead to unnecessary investigations or surgical procedures. Here, we report two incidental chest radiograph findings of air under the diaphragm in patients who were being screened for pulmonary tuberculosis. This case series highlights the importance of awareness of the diagnosis of Chilaiditi's sign to avoid unnecessary hospital referrals.

Tuberculosis in Malaysia: predictors of treatment outcomes in a national registry

OBJECTIVES

To determine treatment outcomes and associated predictors of all patients registered in 2012 with the Malaysian National Tuberculosis (TB) Surveillance Registry.

METHODS

Sociodemographic and clinical data were analysed. Unfavourable outcomes included treatment failure, transferred out and lost to follow-up, treatment defaulters, those not evaluated and all-cause mortality.

RESULTS

In total, 21 582 patients were registered. The mean age was 42.36 ± 17.77 years, and 14.2% were non-Malaysians. The majority were new cases (93.6%). One fifth (21.5%) had unfavourable outcomes; of these, 46% died, 49% transferred out or defaulted and 1% failed treatment. Predictors of unfavourable outcomes were older age, male sex, foreign citizenship, lower education, no bacille Calmette-Guérin (BCG) vaccination scar, treatment in tertiary settings, smoking, previous anti-tuberculosis treatment, human immunodeficiency virus infection, not receiving directly observed treatment, advanced chest radiography findings, multidrug-resistant TB (MDR-TB) and extra-pulmonary TB. For all-cause mortality, predictors were similar except for rural dwelling and nationality (higher mortality among locals). Absence of BCG scar, previous treatment for TB and MDR-TB were not found to be predictors of all-cause mortality. Indigenous populations in East Malaysia had lower rates of unfavourable treatment outcomes.

CONCLUSIONS

One fifth of TB patients had unfavourable outcomes. Intervention strategies should target those at increased risk of unfavourable outcomes and all-cause mortality.

Trampoline related injuries in adults

INTRODUCTION

Trampoline-related injuries in adults are uncommon. Participation in trampolining is increasing following its admission as a sport in the Olympics and the opening of local recreational trampoline centres. The aim of this study was to assess the number and outcomes of adult trampoline-related orthopaedic injuries presenting to four trauma hospitals in Victoria.

METHODS

A cohort study was performed for the period 2007-2013. Adult patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who had sustained a trampolining related injury were included in this study. Descriptive analyses were used to describe the patient population, the injuries sustained and their in-hospital and 6-month outcomes.

RESULTS

There was an increase in trampolining injuries from 2007 (n=3) to 2012 (n=14) and 2013 (n=18). Overall, fifty patients with a median age of 25 (range 16-66) were identified. Thirty-five patients (70%) had lower limb injuries, 20 patients (40%) had spinal injuries and one patient had an upper limb injury. Thirty-nine patients (78%) required surgery. Fractures of the tibia (n=13), ankle fractures (n=12) and cervical spine injuries (n=7) were the most common injuries; all of which required surgery. Complications included death, spinal cord injuries, compartment syndrome and open fractures. At 6 months post injury, more than half (52%) of the patients had not achieved a good recovery, 32% had some form of persistent disability, 14% did not get back to work and overall physical health for the cohort was well below population norms for the SF-12.

CONCLUSION

Adult trampoline-related injuries have increased in the last few years in this cohort identified through VOTOR. Lower limb and spinal injuries are most prevalent. Public awareness and education are important to reduce the risk for people participating in this activity.

Depression, anxiety and stress among patients with diabetes in primary care: A cross-sectional study

BACKGROUND

The incidence of diabetes mellitus is ever increasing. Individuals with diabetes mellitus may have concurrent mental health disorders and are shown to have poorer disease outcomes. The objectives of this study were to determine the prevalence of depression, anxiety and stress (DAS) in diabetes patients aged 20 years or more in the primary care setting.

METHODS

This was a cross-sectional study involving the use of self-administered questionnaire conducted in eight primary care private and government clinics in Pulau Pinang and Melaka, Malaysia. The validated DASS-21 questionnaire was used as a screening tool for the symptoms of DAS. Prior permission was obtained from the patients and, clearance from ethical committee was obtained before the start of the study. Data analysis was done using SPSS statistical software.

RESULTS

A total of 320 patients with diabetes from eight centres were enrolled via convenience sampling. Sample size was calculated using the Kish's formula. The prevalence of DAS among patients with diabetes from our study was 26.6%, 40% and 19.4%, respectively. Depression was found to be significantly associated with marital status and family history of DAS; anxiety was significantly associated with monthly household income, presence of co-morbidities and family history of DAS; and stress was significantly associated with occupation and family history of DAS.

CONCLUSION

The prevalence of DAS was higher in patients with diabetes compared with the general community. We recommend to routinely screen all patients with diabetes using the DASS-21 questionnaire because it is easy to perform and inexpensive.

Weight change following knee and hip joint arthroplasty-a six-month prospective study of adults with osteoarthritis

Background

Inconsistent findings of weight change following total knee (TKA) and hip (THA) arthroplasty may largely be attributable to heterogeneous cohorts and varied definitions of weight loss. This study examined weight change following TKA and THA for osteoarthritis (OA).

Methods

64 participants with hip or knee OA were recruited from orthopaedic joint arthroplasty waiting lists at a single major Australian public hospital between March and October 2011. The Short Form (SF) 12 survey was used to assess baseline physical and mental functioning. 49 participants completed 6 month follow-up (20 from the THA group and 29 from the TKA group).

Results

The majority of subjects lost weight (>0 kg) 6 months following THA (70 %) and TKA (58.6 %). When at least a 5 % reduction in total body weight was used to define clinically significant weight loss, the proportion of people with weight loss was 37.9 % for TKA and 25 % for THA. Greater weight loss occurred 6 months following TKA compared with THA (7.2 % versus 3.7 % of body weight; p = 0.04). Worse pre-operative physical functioning (SF-12) was associated with greater weight loss following TKA (β = 0.22 kg, 95 % CI 0.02-0.42 kg; p = 0.04).

Conclusion

Most people lost weight (>0 kg) 6 months following TKA and THA and a considerable proportion of people achieved ≥5 % loss of body weight. The magnitude of weight loss was greater following TKA than THA, with worse pre-operative function being a predictor of more weight loss. Further attention to weight management is required to assist a greater number of people to achieve a larger magnitude of weight loss following knee and hip joint arthroplasty.

Incidence of acute kidney injury following total joint arthroplasty: a retrospective review by RIFLE criteria

Background

Total joint arthroplasty (TJA) is a common procedure with demand for arthroplasties expected to increase exponentially. Incidence of acute kidney injury (AKI) following TJA is reportedly low, with most studies finding an incidence of <2%, increasing to 9% when emergency orthopaedic patients are included.

Methods

Retrospective medical record review of consecutive primary, elective TJA procedures was undertaken at a large tertiary hospital (Alfred). Demographic, peri-operative and post-operative data were recorded. Factors associated with AKI (based on RIFLE criteria) were determined using multiple logistic regression.

Results

Between January 2011 and June 2013, 425 patients underwent TJA; 252 total knee replacements (TKR) and 173 total hip replacements (THR). Sixty-seven patients (14.8%) developed AKI, including 51 TKR. Factors associated with AKI (adjusting for known confounders) include increasing body mass index [adjusted odds ratio (AOR) 1.14; 95% CI: 1.07, 1.21], older age (AOR 1.07; 95% CI 1.02, 1.13) and lower pre-operative glomerular filtration rate (AOR 0.97; 95% CI 0.96, 0.99) and taking angiotensin-converting enzyme inhibitors (AOR 2.70; 95% CI 1.12, 6.48) and angiotensin-II receptor blockers (AOR 2.64; 95% CI 1.18, 5.93). In most patients, AKI resolved by discharge, however, only 62% of patients had renal function tests after discharge.

Conclusions

This study showed a rate of AKI of nearly 15% in our TJA population, substantially higher than previously reported. Given that AKI and long-term complications are associated, prospective research is needed to further understand the associated factors and predict those at risk of AKI. There may be opportunities to maximize the pre-operative medical management and mitigate risk.

Evidence-based guideline for the written radiology report: methods, recommendations and implementation challenges

The written radiology report is the dominant method by which radiologists communicate the results of diagnostic and interventional imaging procedures. It has an important impact on decisions about further investigation and management. Its form and content can be influential in reducing harm to patients and mitigating risk for practitioners but varies markedly with little standardisation in practice. Until now, the Royal Australian and New Zealand College of Radiologists has not had a guideline for the written report. International guidelines on this subject are not evidence based and lack description of development methods. The current guideline seeks to improve the quality of the written report by providing evidence-based recommendations for good practice. The following attributes of the report are addressed by recommendations: Content Clinical information available to the radiologist at the time the report was created Technical details of the procedure Examination quality and limitations Findings (both normal and abnormal) Comparison with previous studies Pathophysiological diagnosis Differential diagnoses Clinical correlation and/or answer to the clinical question Recommendations, particularly for further imaging and other investigations Conclusion/opinion/impression Format Length Format Language Confidence and certainty Clarity Readability Accuracy Communication of discrepancies between an original verbal or written report and the final report Proofreading/editing of own and trainee reports.

Nutritional status and short-term outcome of hip arthroplasty

PURPOSE

To review nutritional status and outcome of 90 patients who underwent total hip arthroplasty (THA) or hemiarthroplasty.

METHODS

Records of 51 women and 39 men aged 26 to 96 (median, 71) years who underwent elective THA (n=48) for osteoarthritis, or trauma-related THA (n=10) or hemiarthroplasty (n=32) for subcapital femoral neck fractures using an uncemented femoral stem were retrospectively reviewed. Patient demographics and intra- and post-operative complications were recorded. Patient co-morbidities were assessed according to the Charlson grading system. Nutritional status was assessed using haematological markers of serum albumin (ALB) level and total lymphocyte count (TLC). Samples were taken on the day of the operation and within 24 hours of operation. Suboptimal nutrition was defined as a serum ALB level of <3.5 g/dl and a TLC of <1.50 cells/mm.

RESULTS

86% of trauma patients and 30% of elective patients were malnourished preoperatively (p<0.001). Preoperatively, more males than females had suboptimal ALB levels (28% vs. 8%, p=0.033) and TLC (82% vs. 31%, p<0.001). Age was inversely proportional to preoperative ALB and TLC values; patients older than 75 years had significantly lower values. Of those staying >7 days in hospital, 67% were aged >75 years as opposed to 31% were aged ≤ 75 years (p=0.001). Male gender, old age, and presentation with trauma were risk factors for suboptimal nutritional parameters (p<0.001 for all). Patients with suboptimal ALB and TLC values had a significantly longer stay in hospital (p=0.032 and p=0.021, respectively).

CONCLUSION

The rate of malnourishment was significantly higher in patients having trauma-related surgery than in those having elective surgery. Malnourished patients are at greater risk of prolonged hospital stay. Preoperative nutritional assessment may be useful in predicting patients at high surgical risk.

Health resource utilisation costs in acute patients with persistent midline cervical tenderness following road trauma

INTRODUCTION

The costs associated with patients discharged with isolated clinician-elicited persistent midline tenderness and negative computed tomography (CT) findings have not been reported. Our aim was to determine the association of acute and post-acute patient and injury characteristics with health resource costs in such patients following road trauma.

METHODS

In a prospective cohort study, road trauma patients presenting with isolated persistent midline cervical tenderness and negative CT, who underwent additional acute imaging with MRI, were recruited. Patients were reviewed in the outpatient spine clinic following discharge, and were followed up at 6 and 12 months post-trauma. Multivariate linear regression was used to assess the association of injury mechanism, clinical assessment, socioeconomic factors and outcome findings with health resource costs generated in the acute hospital and post-acute periods.

RESULTS

There were 64 patients recruited, of whom 24 (38%) had cervical spine injury detected on MRI. Of these, 2 patients were managed operatively, 6 were treated in cervical collars and 16 had the cervical spine cleared and were discharged. At 12 months, there were 25 patients (44%) with residual neck pain, and 22 (39%) with neck-related disability. The mean total cost was AUD $10,153 (SD=10,791) and the median was $4015 (IQR: 3044-6709). Transient neurologic deficit, which fully resolved early in the emergency department, was independently associated with higher marginal mean acute costs (represented in the analysis by the β coefficient) by $3521 (95% CI: 50-6880). Low education standard (β coefficient: $5988, 95% CI: 822-13,317), neck pain at 6 months (β coefficient: $4017, 95% CI: 426-9254) and history of transient neurologic deficit (β coefficient: $8471, 95% CI: 1766-18,334) were associated with increased post-acute costs.

CONCLUSION

In a homogeneous group of road trauma patients with non fracture-related persistent midline cervical tenderness, health resource costs varied considerably. As long term morbidity is common in this population, a history of resolved neurologic deficit may require greater intervention to mitigate costs. Additionally, adequate communication between acute and community care providers is essential in order to expedite the recovery process through early return to normal daily activities.

Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

INTRODUCTION

Bed rest with elevation of the affected limb is commonly prescribed postoperatively following ankle fracture fixation although there is no evidence that this is necessary.

AIM

The aim of this prospective, randomised study was to investigate the effects of early mobilisation following surgical fixation of an ankle fracture on wound healing and length of stay (LOS).

METHOD

A total of 104 patients underwent primary internal fixation of an ankle fracture at The Alfred hospital, Melbourne between July 2008 and January 2010.

INTERVENTION

The strategy included either early mobilisation group (first day post surgery) or control group (bed rest with elevation until day 2 post surgery).

OUTCOME MEASURES

Data collected included demographic, injury type and surgical procedure. Outcome data included inpatient LOS, wound condition at 10-14 days, opioid use and re-admission rate.

RESULTS

Groups were comparable at baseline. Wound breakdown rate was 2.9% (3 patients in the control group). Median LOS of the early mobilisation group was 55 h compared with 71 h in the control group (p<0.0001). Opioid use for the control group was an average of 90 mg morphine equivalent in the first 24 h post surgery compared with 67 mg morphine equivalent for the early mobilisation group (p=0.32).

CONCLUSION

This study indicates that early mobilisation following surgical fixation of an ankle fracture results in a shorter hospital stay without evidence of an increased risk of re-admission or wound complication.

Enzymatic profiling of clinical and environmental isolates of Burkholderia pseudomallei

Melioidosis has been recognized as an important cause of sepsis in the tropics. The disease caused by an environmental saprophyte Burkholderia pseudomallei, affects mostly adults with underlying immunocompromised conditions. In this study, the enzymatic profiles of 91 clinical and 9 environmental isolates of B. pseudomallei were evaluated using the APIZYM system, in addition to assessment of protease, phospholipase C and sialidase activities using agar plate methods and other assays. The activity of 10 enzymes - alkaline phosphatase, esterase, esterase lipase, lipase, leucine arylamidase, valine arylamidase, cystine arylamidase, acid phosphatase, naphthol-AS-BI-phosphohydrolase and N-acetyl-β-glucosaminidase were detected in >75% of the clinical isolates. The majority of B. pseudomallei isolates in this study exhibited protease and phospholipase activities. No sialidase activity was detected. Five Burkholderia thailandensis isolates had similar APIZYM profiles as B. pseudomallei clinical isolates except for the lower detection rate for N-acetyl-β-glucosaminidase. The subtle differences in the number of enzymes secreted and the levels of enzymatic activities of phenotypically identical clinical and environmental strains of B. pseudomallei give weight to the fact that the causative agent of melioidodis originates from the environment.

Effectiveness of a colour coded HbA1c graphical record in improving diabetes control in people with type 2 diabetes: a randomized control trial

We conducted a six-month randomized-controlled-trial to evaluate the effectiveness of a colour-coded HbA1c-graphical record in improving HbA1c level among type 2 diabetes patients. There was an improvement in the mean HbA1c knowledge score but the usage of the colour-coded HbA1c-graphical record did not produce reduction in the HbA1c level.

Cervical spine magnetic resonance imaging in alert, neurologically intact trauma patients with persistent midline tenderness and negative computed tomography results

STUDY OBJECTIVE

We aim to determine the prevalence and factors associated with cervical discoligamentous injuries detected on magnetic resonance imaging (MRI) in acute, alert, neurologically intact trauma patients with computed tomography (CT) imaging negative for acute injury and persistent midline cervical spine tenderness. We present the cross-sectional analysis of baseline information collected as a component of a prospective observational study.

METHODS

Alert, neurologically intact trauma patients presenting to a Level I trauma center with CT negative for acute injury, who underwent MRI for investigation of persistent midline cervical tenderness, were prospectively recruited. Deidentified images were assessed, and injuries were identified and graded. Outcome measures included the presence and extent of MRI-detected injury of the cervical ligaments, intervertebral discs, spinal cord and associated soft tissues.

RESULTS

There were 178 patients recruited during a 2-year period to January 2009. Of these, 78 patients (44%) had acute cervical injury detected on MRI. There were 48 single-column injuries, 15 two-column injuries, and 5 three-column injuries. Of the remaining 10 patients, 6 had isolated posterior muscle edema, 2 had alar ligamentous edema, 1 had epidural hematoma, and 1 had atlanto-occipital edema. The injuries to 38 patients (21%) were managed clinically; 33 patients were treated in cervical collars for 2 to 12 weeks, and 5 patients (2.8%) underwent operative management, 1 of whom had delayed instability. Ordinal logistic regression revealed that factors associated with a higher number of spinal columns injured included advanced CT-detected cervical spondylosis (odds ratio [OR] 11.6; 95% confidence interval [CI] 3.9 to 34.3), minor isolated thoracolumbar fractures (OR 5.4; 95% CI 1.5 to 19.7), and multidirectional cervical spine forces (OR 2.5; 95% CI 1.2 to 5.2).

CONCLUSION

In patients with cervical midline tenderness and negative acute CT findings, we found that a subset of patients had MRI-detected cervical discoligamentous injuries and that advanced cervical spine degeneration evident on CT, minor thoracolumbar fracture, and multidirectional cervical spine forces were associated with increased injury extent. However, a larger study is required to validate which variables may reliably predict clinically important injury in such patients, thereby indicating the need for further radiographic assessment.

Cardiovascular risk scores do not account for the effect of treatment: a review

Objective

To compare the strengths and limitations of cardiovascular risk scores available for clinicians in assessing the global (absolute) risk of cardiovascular disease.

Design

Review of cardiovascular risk scores.

Data sources

Medline (1966 to May 2009) using a mixture of MeSH terms and free text for the keywords ‘cardiovascular’, ‘risk prediction’ and ‘cohort studies’.

Eligibility criteria for selecting studies

A study was eligible if it fulfilled the following criteria: (1) it was a cohort study of adults in the general population with no prior history of cardiovascular disease and not restricted by a disease condition; (2) the primary objective was the development of a cardiovascular risk score/equation that predicted an individual's absolute cardiovascular risk in 5–10 years; (3) the score could be used by a clinician to calculate the risk for an individual patient.

Results

21 risk scores from 18 papers were identified from 3536 papers. Cohort size ranged from 4372 participants (SHS) to 1591209 records (QRISK2). More than half of the cardiovascular risk scores (11) were from studies with recruitment starting after 1980. Definitions and methods for measuring risk predictors and outcomes varied widely between scores. Fourteen cardiovascular risk scores reported data on prior treatment, but this was mainly limited to antihypertensive treatment. Only two studies reported prior use of lipid-lowering agents. None reported on prior use of platelet inhibitors or data on treatment drop-ins.

Conclusions

The use of risk-factor-modifying drugs—for example, statins—and disease-modifying medication—for example, platelet inhibitors—was not accounted for. In addition, none of the risk scores addressed the effect of treatment drop-ins—that is, treatment started during the study period. Ideally, a risk score should be derived from a population free from treatment. The lack of accounting for treatment effect and the wide variation in study characteristics, predictors and outcomes causes difficulties in the use of cardiovascular risk scores for clinical treatment decision.

A synthetic haemoglobin-based oxygen carrier and the reversal of cardiac hypoxia secondary to severe anaemia following trauma

We report a case of compassionate use of a haemoglobin-based oxygen carrier in a severely injured Jehovah's Witness patient, for whom survival was considered unlikely. Severe anaemia and cardiac hypoxia were reversed after slow infusion of this agent. No vasoactive side effects were associated with the treatment, possibly due to the slow infusion, and the patient survived.

Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion

STUDY DESIGN

The correlation between magnetic resonance imaging and discography of the cervical spine in degenerative disc disease was studied. In addition, the results of cervical discectomy and fusion were evaluated.

OBJECTIVES

To compare the value of cervical magnetic resonance imaging versus discography in selecting the level for discectomy and fusion and to evaluate the surgical outcome.

SUMMARY OF BACKGROUND DATA

The value of magnetic resonance imaging and discography in patients with cervical discogenic pain is less clear. Also, the status of a hypointense signal (dark) cervical disc and/or a small herniated disc on magnetic resonance imaging has not been determined.

METHODS

The magnetic resonance imaging studies and discography followed by computed tomography in 55 patients with cervical discogenic pain were evaluated. Surgical planning was based on the complete information of clinical symptoms, magnetic resonance imaging, and discography as well as computed tomography discography. Anterior cervical discectomy and keystone fusion was performed. Postoperative pain relief was assessed by the patients, and the follow-up radiographs were viewed by an independent reviewer. The overall surgical outcome was evaluated using Odom's criteria.

RESULTS

There were 161 disc levels that successfully underwent cervical discography with 79 positive levels. A positive discography result was found in 63% of dark (hypointense signal) discs and 45% of speckled discs. Fifty-nine percent of small herniated discs and 59% of torn discs had a positive discography, respectively. There were 100 abnormal cervical discs on magnetic resonance imaging. Magnetic resonance imaging had a false-positive rate of 51% and a false-negative rate of 27%. Successful cervical fusion was achieved in 95% of patients, and the overall satisfactory result was 76%.

CONCLUSIONS

Magnetic resonance imaging can identify most of the painful discs but still has relatively high false-negative and false-positive rates. There is a high chance that hypointense signal and small herniated discs are the pain generators, but they are not always symptomatic. Discography can save the levels from being unnecessarily fused. The combination of clinical symptoms, magnetic resonance imaging, and discography provides the most information for decision making and can improve the management of cervical discogenic pain.

DNA fingerprinting of methicillin-resistant Staphylococcus aureus by pulsed-field gel electrophoresis (PFGE): comparison of strains from 2 Malaysian hospitals

AIM OF STUDY

To determine and compare the pulsed-field gel electrophoresis (PFGE) patterns of endemic MRSA strains in 2 major Malaysian hospitals and to compare the PFGE patterns with antibiotypes of the strains studied.

METHODS

Fifty-six MRSA strains selected randomly between September 1997 and July 1998 from Hospital Queen Elizabeth (HQE) and Hospital Umum Sarawak (HUS) were tested for antimicrobial resistance and DNA fingerprinting was carried out by pulsed-field gel electrophoresis (PFGE) technique.

RESULTS

Seven PFGE types were recognised (A, B, C, D, E and F). All 7 PFGE types were observed in HQE while only 2 PFGE types (B, C) were noted in HUS strains. There is a predominance of a single PFGE pattern (type B) in both hospitals, as seen in 46% of HQE strains and 89% of HUS strains. Subtype B2 was the commonest subtype in HQE while subtype B1 predominated in HUS. Strains resistant to fusidic acid and rifampicin exhibited PFGE type F that is unique to HQE. All strains were resistant to penicillin, erythromycin, cotrimoxazole, tetracycline and gentamicin. Strains with the same antibiotic susceptibility pattern can be different PFGE types.

CONCLUSION

Molecular typing of the MRSA by PFGE is a useful tool in the study of endemic strains present in an institution. Strains in HQE were found to be more heterogeneous than HUS strains. Common PFGE types can also be seen in both hospitals suggesting that some of the strains was genetically related and has propagated within and between the 2 hospitals. Our findings also indicate that the relationship between antibiotic susceptibility and PFGE patterns was not close and antibiograms should not be relied upon for typing strains in epidemiological studies. By knowing the DNA fingerprints of the isolates endemic in each hospital, the spread of MRSA with a particular PFGE type can be monitored within and between hospitals.

Thoracic and lumbar deformity: rationale for selecting the appropriate fusion technique (Anterior, posterior, and 360 degree)

The rationale of anterior versus posterior, or combined fusion is discussed with regards to different clinical diagnoses and situations. Factors involved in the decision-making process include stability, magnitude of deformity, rigidity of deformity, neurologic considerations, bone quality, and medical/metabolic factors. Careful preoperative assessment and planning are required as well as consideration for the patient's overall well being.

Cervical deformity: rationale for selecting the appropriate fusion technique (anterior, posterior, and 360 degree)

This article examines cervical deformities and their treatments, such as iatrogenic deformities, posttraumatic deformities, ankylosing spondylitis, rheumatoid arthritis, degenerative subaxial spondylolisthesis, myopathy, infectious spondylitis, and tumors. Congenital scoliosis and kyphosis and torticollis and rotatory atlanto-axial subluxation also are discussed.

Benign anterior knee cyst in early childhood

BACKGROUND

Anterolateral knee cysts are not uncommon in the first 7 years of life, but have not been described in the literature.

METHODS

Four patients presenting with an asymptomatic lump on the anterolateral joint line were reviewed.

RESULTS

The lump remains asymptomatic.

CONCLUSIONS

Anterolateral knee cysts of childhood are benign and do not require treatment. Their cause is conjectural.

An unusual cause of stress fracture of the first rib

An unusual case of stress fracture of the first rib that occurred in a young male as a result of the constant loading due to carrying a heavy schoolbag is reported. This case demonstrates the difficulty in diagnosis and highlights the need for awareness of this condition, thus avoiding invasive investigation.

A comparative study of two types of latex surgical gloves in elective orthopaedic surgery

Glove perforation during surgery represents a potential risk of infection for the surgeon. The authors postulated that thicker latex gloves may offer greater protection. The perforation rates for the Ansell Gammex glove and the thicker Baxter Triflex gloves were compared in single- and double-glove usage and no difference was found between the two brands, in either usage. The authors recommend double-gloving for all orthopaedic operations with regular glove changes during major procedures.

The use of taped skin closure in orthopaedic wounds

The cosmetic result, cost effectiveness, and complication rate of three different types of skin closure: staples, tapes, and interrupted nylon were compared. In 68 wounds, skin closure was randomized to staples, tapes, or interrupted 3/0 nylon sutures. All wounds were closed subcutaneously with interrupted undyed 2/0 dexon. For 3 months, 59 wounds were followed and assessed by an independent observer at 1 and 3 months postoperatively in the outpatient department. In three different skin closures, the cosmetic result was superior for tapes because the wound line itself was finer and there were no dot scars. Tapes were the most cost-effective because they are the cheapest although they were not as quick to apply as staples. There was no difference in complication rate. Tapes also afforded the greatest patient comfort.