Advantages of Intraoperative Neuromonitoring Over Direct Visualization of the Recurrent Laryngeal Nerve During Thyroidectomy

BACKGROUND

The well-recognized risk of injury to the recurrent laryngeal nerve (RLN) during thyroidectomy has instigated various preventive measures. One such measure involves directly visualizing the RLN, but this is not always feasible in practice. A more recent approach involves using intraoperative neuromonitoring to identify and preserve the RLN. This study aims to evaluate the effectiveness of intraoperative neuromonitoring compared to single visualization of the RLN in averting nerve injury.

METHODS

We conducted a retrospective, observational, and descriptive study on a cohort of 218 patients. A Chi-square test was employed to determine the influence of intraoperative neuromonitoring on the incidence of nerve injury, with P < 0.05 considered statistically significant. We used Jamovi software version 2.3.18 to analyze the data.

RESULTS

Of the 218 patients, intraoperative neuromonitoring was used in 150 (68.8%) cases; none of which resulted in nerve injury. Conversely, 68 (31.2%) patients underwent surgery without the use of neuromonitoring, with two (2.9%) patients in this group experiencing nerve injury (p=0.037). In comparison, the risk of nerve injury was 0% in the group monitored intraoperatively and 2.94% in the group that did not undergo intraoperatively neuromonitoring. Further, the relative risk of complications was 0.66% in patients operated with neuromonitoring, while it was 5.88% in the group operated without neuromonitoring, thus demonstrating a clinically significant protective against vasculonervous complications.

CONCLUSION

The results advocate for the use of intraoperative neuromonitoring, whenever available, as it is a safe method for significantly decreasing the incidence of RLN injury during thyroidectomy compared with only visualization.

Anal Canal Duplication in a 25-Year-Old Female Patient

Anal canal duplication (ACD) is a congenital malformation that typically presents and is diagnosed early in life. It can be associated with other syndromes or congenital malformations. ACD is one of the rarest duplications of the gastrointestinal tract, with no more than 90 to 100 cases reported in the literature. It can be confused with more frequent pathologies such as perianal fistula, especially when it occurs in adulthood. We present the case of a 25-year-old female patient who presents with a second orifice above the native anal orifice. An arthroscopic examination was performed, an incidental diagnosis of ACD was made, and a complete excision of the duplicated anal canal was performed. The aim of the study is to expand the information on this rare pathology in order to take it into account as a differential diagnosis in patients with abscesses, recurrent fistulous tracts, or any other anorectal pathology.

Effect of the aniline fragment in Pt(II) and Pt(IV) complexes as anti-proliferative agents. Standard reduction potential as a more reliable parameter for Pt(IV) compounds than peak reduction potential

The problems of resistance and side effects associated with cisplatin and other chemotherapeutic drugs have boosted research aimed at finding new compounds with improved properties. The use of platinum(IV) prodrugs is one alternative, although there is some controversy regarding the predictive ability of the peak reduction potentials. In the work described here a series of fourteen chloride Pt(II) and Pt(IV) compounds was synthesised and fully characterised. The compounds contain different bidentate arylazole heterocyclic ligands. Their cytotoxic properties against human lung carcinoma (A549), human breast carcinoma (MCF7) and human colon carcinoma (HCT116 and HT29) cell lines were studied. A clear relationship between the type of ligand and the anti-proliferative properties was found, with the best results obtained for the Pt(II) compound that contains an aniline fragment, (13), thus evidencing a positive effect of the NH₂ group. Stability and aquation studies in DMSO, DMF and DMSO/water mixtures were carried out on the active complexes and an in-depth analysis of the two aquation processes, including DFT analysis, of 13 was undertaken. It was verified that DNA was the target and that cell death occurred by apoptosis in the case of 13. Furthermore, the cytotoxic derivatives did not exhibit haemolytic activity. The reduction of the Pt(IV) compounds whose Pt(II) congeners were active was studied by several techniques. It was concluded that the peak reduction potential was not useful to predict the ability for reduction. However, a correlation between the cytotoxic activity and the standard reduction potential was found.

[Functional and quality of life results after a total knee replacement per year and five years of follow-up]

INTRODUCTION

Classically the results of any joint replacement surgery are evaluated at a minimum of 5 years. This period could be considered excessive to evaluate the functional results of this procedure. The objective of this study is to compare functional and quality of life results to 1 and five years of follow-up following a total knee replacement (TKR).

MATERIAL AND METHODS

Prospective observational study. All patients visited one year after the implantation of TKR were included. All of these filled out the SF-36 questionnaire and the KSS valuation scale. Both were administered again at age five after surgery.

RESULTS

689 patients were initially included in the study (163 men [23.7%] and 526 women [76.3%]) with an average age of 72.2 years. At age 5,585 (84.9%) of these patients were re-analyzed. While the knee section of the KSS scale remained similar in these two periods, the function section of the KSS titration scale showed a slight worsening over time (p = 0.008). With respect to SF-36, the physical summation worsened at five years (p = 0.00) and the mental summation remained stable (n.s.) between the year and five years after surgery.

DISCUSSION

Five years after a TKR, the physical exam does not vary from the year of surgery. However, the subjective evaluation measured by the function-KSS section and the physical SF-36, worsen slightly during this period. This could be due to aging patients.

Abstract OT2-04-04: Neoadjuvant HER2-targeted therapy +/- immunotherapy with pembrolizumab (neoHIP): An open label randomized phase 2 trial

Background: Immune checkpoint inhibition (ICI) is synergistic with HER2-directed therapy in pre-clinical models. Clinically, pembrolizumab (K)-mediated ICI plus HER2-directed therapy with trastuzumab (H) was safe and demonstrated modest activity in H-resistant HER2-positive (HER2+) metastatic breast cancer. Because ICI may confer more robust activity when administered earlier in the course of disease, HER2-directed therapy with ICI administered in the curative-intent, treatment-naive setting may allow for de-escalation of cytotoxic backbones; confer life-long, tumor-specific immunity; and ultimately, improve cure rates. Moreover, the synergy of H and K with paclitaxel (T) may overcome the need for dual HER2-blockade with H plus pertuzumab (P). In this randomized, multicenter, phase II, open-label trial, the efficacy and safety of neoadjuvant THP vs THP-K vs TH-K are being explored (NCT03747120). Methods: 174 patients (pts) ≥18years with previously untreated, clinical stage II-III, HER2+ breast cancer will be randomized 1:1:1 to one of 3 study arms, stratified by clinical nodal status (positive vs. negative) and hormone receptor status (positive vs. negative). In arm A, pts receive THP: T at 80 mg/m2 weekly for 12 weeks, H day 1 at 8 mg/Kg (loading dose) and then 6 mg/Kg every 3 weeks x 3 doses, P day 1 at 840 mg (loading dose) and then 420 mg/Kg every 3 weeks x 3 doses (THP). In arm B, pts receive THP plus K day 1 at 200mg (flat dose) and then every 3 weeks x 3 doses (THP-K). In arm C, pts receive TH-K. Definitive surgery is 3-6 weeks after the last dose of T. After surgery, pts are treated per the treating physician’s discretion including HER2-directed therapy, endocrine therapy and radiotherapy per local clinical standards. The primary endpoint is pathologic complete response (pCR) rate in the breast and axilla (ypT0/Tis ypN0). Secondary end points include pCR rate by ypT0ypN0 and ypT0/Tis, residual cancer burden index, event free survival, breast conserving surgery rate, safety and overall survival. Exploratory correlative studies will characterize potential immune biomarkers predictive of efficacy and/or toxicity.

Citation Format: Heather McArthur, Jorge Leal, David Page, Christina DiLauro Abaya, Reva Basho, Lindsey Ristow, Hannah Coleman, Stephen Shiao, Simon Knott, Monica Mita, Mourad Tighiouart, Alice Chung, Farnaz Dadmanesh, Philomena McAndrew, Scott Karlan, Sunil Verma, Armando Giuliano. Neoadjuvant HER2-targeted therapy +/- immunotherapy with pembrolizumab (neoHIP): An open label randomized phase 2 trial [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT2-04-04.

Abstract OT1-01-04: A randomized phase 2 study of peri-operative ipilimumab, nivolumab and cryoablation versus standard care in women with residual, early stage/resectable, triple negative breast cancer after standard-of-care neoadjuvant chemotherapy

Background: Local tumor destruction with cryoablation (cryo) induces inflammation and releases antigens that can activate tumor-specific immune responses. Pre-clinically, cryo with checkpoint inhibition augmented tumor-specific immune responses and prevented recurrence. Clinically, we established that peri-operative (peri-op) cryo with ipilimumab (ipi) +/- nivolumab (nivo) was not only safe in patients (pts) with operable, early stage breast cancer (ESBC) but also generated robust intra-tumoral and systemic immune responses. In this randomized phase 2 study, we evaluate the disease specific impact of peri-op ipi/nivo/cryo versus standard care in women with residual triple negative breast cancer (TNBC) after neoadjuvant chemotherapy (NAC), a subset at high risk of early relapse.

Methods: Eligible pts are ≥18y, with ER &lt;10%, PR &lt;10%, HER2 negative (per ASCO/CAP definition), ≥ 1.0 cm, residual operable disease after taxane-based NAC. Approximately 160 pts will be randomized to one of two arms: breast surgery (control arm) or ipi/nivo/cryo followed by breast surgery and adjuvant nivo (intervention arm). Pts in the intervention arm will undergo percutaneous, image-guided cryo with concurrent research core biopsy 7-10 days prior to surgery and will receive ipi (1mg/kg IV) with nivo (240mg IV) 1 to 5 days prior to cryo. After surgery, pts will receive 3 additional doses of nivo at 240mg IV Q2 weeks. Adjuvant capecitabine is recommended for all patients per local standard-of-care. Patients will be stratified by NAC platinum administration, NAC anthracycline administration, and clinical nodal status (positive versus negative). The primary endpoint is 3-year Event Free Survival (EFS). Secondary endpoints include Invasive Disease-Free Survival (IDFS), Distant Disease-Free Survival (DDFS), overall survival (OS) and safety. Exploratory correlative studies will be performed on tumor and serum to characterize the immunologic impact of the intervention and to explore predictors of efficacy and toxicity.

Citation Format: Heather McArthur, Elizabeth Comen, Yolanda Bryce, Stephen B Solomon, Jorge Leal, Micaela Rodine, Christina DiLauro Abaya, Sujita Patil, David Page, Larry Norton. A randomized phase 2 study of peri-operative ipilimumab, nivolumab and cryoablation versus standard care in women with residual, early stage/resectable, triple negative breast cancer after standard-of-care neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT1-01-04.

Impact of isolation precautions on quality of life: a meta-analysis

Impact of isolation precautions on psychological wellbeing of patients has yet to be fully quantified. To assess the impact of isolation precautions on patients' health-related quality of life and depression or anxiety scales and estimate per day cost of anxiety and depression. Literature pertaining to impact of isolation precautions was searched on EMBASE and PubMed databases and Google Scholar. A two-step independent screening of the articles was performed. Articles that compared isolated and non-isolated patients using different quality of life and psychological burden scales were included. A meta-analysis was conducted using the Hospital Anxiety and Depression Scales (HADS-A and HADS-D). Psychological burden measures from selected literature were presented in a graph as effect sizes. Per day cost of anxiety and depression was estimated using pooled mean difference from meta-analysis. Out of 106 articles, 94 were excluded due to inclusion criteria, leaving 12 for full text review. After review of full text of the articles, seven articles were shortlisted for empirical analysis and four out of these seven for meta-analysis. The pooled mean difference estimates for HADS-A was -1.4 (P=0.15) and that for HADS-D was -1.85 (P=0.09). In the empirical analysis of psychological burden scales, the effect in all studies except one was negative. Results from meta-analysis and empirical analysis of psychological burden implied that isolated patients are worse off in general. The implied estimated per day cost of anxiety and depression in terms of quality-adjusted life years (QALYs) is approximately US$10.

Physiotherapy rehabilitation for osteoporotic vertebral fracture-a randomised controlled trial and economic evaluation (PROVE trial)

The trial compared three physiotherapy approaches: manual or exercise therapy compared with a single session of physiotherapy education (SSPT) for people with osteoporotic vertebral fracture(s). At 1 year, there were no statistically significant differences between the groups meaning there is inadequate evidence to support manual or exercise therapy.

INTRODUCTION

To evaluate the clinical and cost-effectiveness of different physiotherapy approaches for people with osteoporotic vertebral fracture(s) (OVF).

METHODS

>Prospective, multicentre, adaptive, three-arm randomised controlled trial. Six hundred fifteen adults with back pain, osteoporosis, and at least 1 OVF participated.

INTERVENTIONS

7 individual physiotherapy sessions over 12 weeks focused on either manual therapy or home exercise compared with a single session of physiotherapy education (SSPT). The co-primary outcomes were quality of life and back muscle endurance measured by the QUALEFFO-41 and timed loaded standing (TLS) test at 12 months.

RESULTS

At 12 months, there were no statistically significant differences between groups. Mean QUALEFFO-41: - 1.3 (exercise), - 0.15 (manual), and - 1.2 (SSPT), a mean difference of - 0.2 (95% CI, - 3.2 to 1.6) for exercise and 1.3 (95% CI, - 1.8 to 2.9) for manual therapy. Mean TLS: 9.8 s (exercise), 13.6 s (manual), and 4.2 s (SSPT), a mean increase of 5.8 s (95% CI, - 4.8 to 20.5) for exercise and 9.7 s (95% CI, 0.1 to 24.9) for manual therapy. Exercise provided more quality-adjusted life years than SSPT but was more expensive. At 4 months, significant changes above SSPT occurred in endurance and balance in manual therapy, and in endurance for those ≤ 70 years, in balance, mobility, and walking in exercise.

CONCLUSIONS

Adherence was problematic. Benefits at 4 months did not persist and at 12 months, we found no significant differences between treatments. There is inadequate evidence a short physiotherapy intervention of either manual therapy or home exercise provides long-term benefits, but arguably short-term benefits are valuable.

TRIAL REGISTRATION

ISRCTN 49117867.

Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from "The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man"

OBJECTIVE

We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes.

DESIGN

Natural-experiment (April 2008-December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation.

SETTING

Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs).

PARTICIPANTS

Patients undergoing primary planned TKR aged ≥18 years.

INTERVENTION

ERAS implementation (April 2009-March 2011).

OUTCOMES

Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years).

RESULTS

486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased.

CONCLUSIONS

Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.

Predictors of mortality and length of stay in patients with hospital-acquired Clostridioides difficile infection: a population-based study in Alberta, Canada

In a population-based, five-year retrospective cohort study of 5304 adult patients with hospital-acquired Clostridioides difficile infection across Alberta (N=101 hospitals), 30-day all-cause and attributable mortality were 12.2% and 4.5%, respectively. Patients >75 years of age had the highest odds of attributable mortality (odds ratio (OR) 9.34, 95% confidence interval (CI) 2.92-29.83) and largest difference in mean length of stay (11.7 days, 95% CI 8.2-15.2). A novel finding was that elevated white blood cell count at admission was associated with reduced attributable mortality (OR 0.67, 95% CI 0.50-0.90) which deserves further study. Advancing age was incrementally and significantly associated with all outcomes.

Role of Seroalbumin in the Cytotoxicity of cis-Dichloro Pt(II) Complexes with (N^N)-Donor Ligands Bearing Functionalized Tails

Given the potent anticancer properties of cis-diamminedichloroplatinum(II) and knowing its mode of action, we synthesized four new cis-[PtCl₂(N^N)] organoplatinum complexes, two with N-substituted pbi ligands (pbiR = 1-R-2-(2-pyridyl)benzimidazole) (namely, 1 and 2) and two more with 4,4'-disubstituted bpy ligands (bpy = 2,2'-bipyridine) (namely, 3 and 4). We explored their cytotoxicity and ability to bind to deoxyguanosine monophosphate (dGMP), DNA, and albumin models. By ¹H NMR and UV-vis spectroscopies, circular dichroism, agarose gel electrophoresis, differential scanning calorimetry measurements, and density functional theory calculations, we verified that only 3 can form aquacomplex species after dimethyl sulfoxide solvation; surprisingly, 1, 2, and 3 can bind covalently to DNA, whereas 4 can form a noncovalent complex. Interestingly, only complexes 1 and 4 exhibit good cytotoxicity against human ovarian carcinoma (HeLa) cell line, whereas 2 and 3 are inactive. Although lung carcinoma (A549) cells are more resistant to the four platinum complexes than HeLa cells, when the protein concentration in the extracellular media is lower, the cytotoxicity becomes substantially enhanced. By native electrophoresis of bovine seroalbumin (BSA) and inductively coupled plasma mass spectrometry uptake studies we bear out, on one hand, that 2 and 3 can interact strongly with BSA and its cellular uptake is negligible and, on the other hand, that 1 and 4 can interact with BSA only weakly, its cellular uptake being higher by several orders. These results point up the important role of the protein binding features on their biological activity and cellular uptake of cis-"PtCl₂" derivatives. Our results are valuable in the future rational design of new platinum complexes with improved biological properties, as they expose the importance not only of their DNA binding abilities but also of additional factors such as protein binding.

Healthcare and wider societal implications of stillbirth: a population-based cost-of-illness study

Objective

To extend previous work and estimate health and social care costs, litigation costs, funeral‐related costs, and productivity losses associated with stillbirth in the UK.

Design

A population‐based cost‐of‐illness study using a synthesis of secondary data.

Setting

The National Health Service (NHS) and wider society in the UK.

Population

Stillbirths occurring within a 12‐month period and subsequent events occurring over the following 2 years.

Methods

Costs were estimated using published data on events, resource use, and unit costs.

Main outcome measures

Mean health and social care costs, litigation costs, funeral‐related costs, and productivity costs for 2 years, reported for a single stillbirth and at a national level.

Results

Mean health and social care costs per stillbirth were £4191. Additionally, funeral‐related costs were £559, and workplace absence (parents and healthcare professionals) was estimated to cost £3829 per stillbirth. For the UK, the annual health and social care costs were estimated at £13.6 million, and total productivity losses amounted to £706.1 million (98% of this cost was attributable to the loss of the life of the baby). The figures for total productivity losses were sensitive to the perspective adopted about the loss of life of the baby.

Conclusion

This work expands the current intelligence on the costs of stillbirth beyond the health service to costs for parents and society, and yet these additional findings must still be regarded as conservative estimates of the true economic costs.

Tweetable abstract

The costs of stillbirth are significant, affecting the health service, parents, professionals, and society.

Plain Language Summary

The costs of stillbirth are significant, affecting the health service, parents, professionals, and society.

Costs of fragility hip fractures globally: a systematic review and meta-regression analysis

Purpose This study was conducted in order to systematically review the costs of hip fractures globally and identify drivers of differences in costs. Methods A systematic review was conducted to identify studies reporting patient level fragility hip fracture costs between 1990 and 2015. We extracted data on the participants and costs from these studies. Cost data concerning the index hospitalisation were pooled, and a meta-regression was used to examine its potential drivers. We also pooled data on the first-year costs following hip fracture and considered healthcare, social care as well as other cost categories if reported by studies. Results One hundred and thirteen studies reported costs of hip fracture based on patient level data. Patients developing complications as well as patients enrolled in intervention arms of comparative studies were found to have significantly higher costs compared to the controls. The pooled estimate of the cost for the index hospitalisation was $10,075. Health and social care costs at 12 months were $43,669 with inpatient costs being their major driver. Meta-regression analysis identified age, gender and geographic region as being significantly associated with the differences in costs for the index hospitalisation. Conclusion Hip fracture poses a significant economic burden and variation exists in their costs across different regions. We found that there was a considerable variation across studies in terms of study design, methodology, follow-up period, costs considered and results reported that highlights the need for more standardisation in this area of research.

Perceptions of risks for diabetes-related complications in Type 2 diabetes populations: a systematic review

AIM

In Type 2 diabetes, there is no clear understanding of how people perceive their risk of experiencing diabetes-related complications. To address this issue, we undertook an evidence-based synthesis of how people with Type 2 diabetes perceive their risk of complications.

METHODS

We performed a systematic search of nine electronic databases for peer-reviewed articles published on or before 1 March 2016. Data from 18 studies reporting lay perceptions of risks for complications in Type 2 diabetes populations were included. Publication year ranged between 2002 and 2014.

RESULTS

Methods used to assess risk perceptions were heterogeneous, ranging from questionnaires measuring the accuracy of perceived risks to semi-structured and focus group interviews. We found evidence of low risk awareness in most dimensions of risk perceptions measured and the existence of optimistic bias.

CONCLUSIONS

Perceptions were generally biased and varied according to the dimension of risk measured, the subpopulation concerned and the type of complications considered. Future work is needed to identify the best practical ways of correcting for biased risk perceptions so as to encourage self-care behaviours and treatment adherence.

Cost-effectiveness of a pragmatic structured education intervention for the prevention of type 2 diabetes: economic evaluation of data from the Let's Prevent Diabetes cluster-randomised controlled trial

OBJECTIVES

Prevention of type 2 diabetes mellitus (TD2M) is a priority for healthcare systems. We estimated the cost-effectiveness compared with standard care of a structured education programme (Let's Prevent) targeting lifestyle and behaviour change to prevent progression to T2DM in people with prediabetes.

DESIGN

Cost-effectiveness analysis alongside randomised controlled trial.

SETTING

44 general practices in Leicestershire, England.

PARTICIPANTS

880 participants with prediabetes randomised to receive either standard care or a 6-hour group structured education programme with follow-up sessions in a primary care setting.

MAIN OUTCOME MEASURE

Incremental cost utility from the UK National Health Service (NHS) perspective. Quality of life and resource use measured from baseline and during the 36 months follow-up using the EuroQoL EQ-5D and 15D instruments and an economic questionnaire. Outcomes measured using quality-adjusted life years (QALYs) and healthcare costs calculated in 2012-2013 prices.

RESULTS

After accounting for clustering and missing data, the intervention group was found to have a net gain of 0.046 (95% CI -0.0171 to 0.109) QALYs over 3 years, adjusted for baseline utility, at an additional cost of £168 (95% CI -395 to 732) per patient compared with the standard care group. The incremental cost-effectiveness ratio is £3643/QALY with an 86% probability of being cost-effective at a willingness to pay threshold of £20 000/QALY.

CONCLUSIONS

The education programme had higher costs and higher quality of life compared with the standard care group. The Let's Prevent programme is very likely to be cost-effective at a willingness to pay threshold of £20 000/QALY gained.

TRIAL REGISTRATION NUMBER

ISRCTN80605705.

The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs

Delayed discharges represent an inefficient use of acute hospital beds. Social isolation and referral to a public-funded rehabilitation unit were significant predictors of delayed discharges while admission from an institution was a protective factor for older hip fracture patients. Preventing delays could save between 11.2 and 30.7 % of total hospital costs for this patient group.

INTRODUCTION

Delayed discharges of older patients from acute care hospitals are a major challenge for administrative, humanitarian, and economic reasons. At the same time, older people are particularly vulnerable to social isolation which has a detrimental effect on their health and well-being with cost implications for health and social care services. The purpose of the present study was to determine the impact and costs of social isolation on delayed hospital discharge.

METHODS

A prospective study of 278 consecutive patients aged 75 or older with hip fracture admitted, as an emergency, to the Orthopaedics Department of Hospital Universitário de Santa Maria, Portugal, was conducted. A logistic regression model was used to examine the impact of relevant covariates on delayed discharges, and a negative binomial regression model was used to examine the main drivers of days of delayed discharges. Costs of delayed discharges were estimated using unit costs from national databases.

RESULTS

Mean age at admission was 85.5 years and mean length of stay was 13.1 days per patient. Sixty-two (22.3 %) patients had delayed discharges, resulting in 419 bed days lost (11.5 % of the total length of stay). Being isolated or at a high risk of social isolation, measured with the Lubben social network scale, was significantly associated with delayed discharges (odds ratio (OR) 3.5) as was being referred to a public-funded rehabilitation unit (OR 7.6). These two variables also increased the number of days of delayed discharges (2.6 and 4.9 extra days, respectively, holding all else constant). Patients who were admitted from an institution were less likely to have delayed discharges (OR 0.2) with 5.5 fewer days of delay. Total costs of delayed discharges were between 11.2 and 30.7 % of total costs (€2352 and €9317 per patient with delayed discharge) conditional on whether waiting costs for placement in public-funded rehabilitation unit were included.

CONCLUSION

High risk of social isolation, social isolation and referral to public-funded rehabilitation units increase delays in patients' discharges from acute care hospitals.

Impact of hip fracture on hospital care costs: a population-based study

Using a large cohort of hip fracture patients, we estimated hospital costs to be £14,163 and £2139 in the first and second year following fracture, respectively. Second hip and non-hip fractures were major cost drivers. There is a strong economic incentive to identify cost-effective approaches for hip fracture prevention.

INTRODUCTION

The purpose of this study was to estimate hospital costs of hip fracture up to 2 years post-fracture and compare costs before and after the index fracture.

METHODS

A cohort of patients aged over 60 years admitted with a hip fracture in a UK region between 2003 and 2013 were identified from hospital records and followed until death or administrative censoring. All hospital records were valued using 2012/2013 unit costs, and non-parametric censoring methods were used to adjust for censoring when estimating average annual costs. A generalised linear model examined the main predictors of hospital costs.

RESULTS

A cohort of 33,152 patients with a hip fracture was identified (mean age 83 years (SD 8.2). The mean censor-adjusted 1- and 2-year hospital costs after index hip fracture were £14,163 (95 % confidence interval (CI) £14,008 to £14,317) and £16,302 (95 % CI £16,097 to £16,515), respectively. Index admission accounted for 61 % (£8613; 95 % CI £8565 to £8661) of total 1-year hospital costs which were £10,964 higher compared to the year pre-event (p < 0.001). The main predictors of 1-year hospital costs were second hip fracture, other non-hip fragility fractures requiring hospitalisation and hip fracture-related complications. Total UK annual hospital costs associated with incident hip fractures were estimated at £1.1 billion.

CONCLUSIONS

Hospital costs following hip fracture are high and mostly occur in the first year after the index hip fracture. Experiencing a second hip fracture after the index fracture accounted for much of the increase in costs. There is a strong economic incentive to prioritise research funds towards identifying the best approaches to prevent both index and subsequent hip fractures.

Topical and intravenous tranexamic acid reduce blood loss compared to routine hemostasis in total knee arthroplasty: a multicenter, randomized, controlled trial

INTRODUCTION

Tranexamic acid (TXA) is becoming widely used in orthopedic surgery to reduce blood loss and transfusion requirements, but consensus is lacking regarding the optimal route and dose of administration. The aim of this study was to compare the efficacy and safety of topical and intravenous routes of TXA with routine hemostasis in patients undergoing primary total knee arthroplasty (TKA).

MATERIALS AND METHODS

We performed a randomized, multicenter, parallel, open-label clinical trial in adult patients undergoing primary TKA. Patients were divided into three groups of 50 patients each: Group 1 received 1 g topical TXA, Group 2 received 2 g intravenous TXA, and Group 3 (control group) had routine hemostasis. The primary outcome was total blood loss. Secondary outcomes were hidden blood loss, blood collected in drains, transfusion rate, number of blood units transfused, adverse events, and mortality.

RESULTS

One hundred and fifty patients were included. Total blood loss was 1021.57 (481.09) mL in Group 1, 817.54 (324.82) mL in Group 2 and 1415.72 (595.11) mL in Group 3 (control group). Differences in total blood loss between the TXA groups and the control group were clinically and statistically significant (p < 0.001). In an exploratory analysis differences between the two TXA groups were not statistically significant (p = 0.073) Seventeen patients were transfused. Transfusion requirements were significantly higher in Group 3 (p = 0.005). No significant differences were found between groups regarding adverse events.

CONCLUSION

We found that 1 g of topical TXA and 2 g of intravenous TXA were both safe strategies and more effective than routine hemostasis to reduce blood loss and transfusion requirements after primary TKA.

LEVEL OF EVIDENCE

I.

The impact of diabetes-related complications on healthcare costs: new results from the UKPDS (UKPDS 84)

AIMS

To estimate the immediate and long-term inpatient and non-inpatient costs for Type 2 diabetes-related complications.

METHODS

The costs of all consultations, visits, admissions and procedures associated with diabetes-related complications during UK Prospective Diabetes Study post-trial monitoring in the period 1997-2007 were estimated using hospitalization records for 2791 patients in England and resource use questionnaires that were administered to 3589 patients across the UK.

RESULTS

The estimated (95% CI) inpatient care costs (in 2012 pounds sterling) in the event year for the example of a 60-year-old man were: non-fatal ischaemic heart disease £9767 (£7038-£12 696); amputation £9546 (£6416-£13 463); non-fatal stroke £6805 (£3856-£10 278); non-fatal myocardial infarction £6379 (£4290-£8339); fatal stroke £3954 (£2012-£6428); fatal ischaemic heart disease £3766 (£746-£5512); heart failure £3191 (£1678-4903); fatal myocardial infarction £1521 (£647-£2670); and blindness in one eye £1355 (£415-£2655). In subsequent years, estimated (95% CI) costs ranged from £1792 (£1060-£2943) for amputations to £453 (£315-£691) for blindness in one eye. Costs of non-inpatient healthcare in the event year were: amputation £2699 (£1409-£4126); blindness in one eye £1790 (£878-£3056); non-fatal stroke £1019 (£770-£1499); nonfatal myocardial infarction £1963 (£794-£1157); heart failure £979 (£708-£1344); non-fatal ischaemic heart disease £864 (£718-£1014); and cataract extraction £700 (£619-£780). In each subsequent year, non-inpatient costs ranged from £1611 (£1193-£2116) for amputations to £654 (£572-£799) for ischaemic heart disease.

CONCLUSIONS

Diabetic complications are associated with substantial immediate and long-term healthcare costs. Our comprehensive new estimates of these costs, derived from detailed recent UK Prospective Diabetes Study post-trial data, should aid researchers and health policy analyses.

UKPDS outcomes model 2: a new version of a model to simulate lifetime health outcomes of patients with type 2 diabetes mellitus using data from the 30 year United Kingdom Prospective Diabetes Study: UKPDS 82

AIMS/HYPOTHESIS

The aim of this project was to build a new version of the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS-OM1), a patient-level simulation tool for predicting lifetime health outcomes of people with type 2 diabetes mellitus.

METHODS

Data from 5,102 UKPDS patients from the 20 year trial and the 4,031 survivors entering the 10 year post-trial monitoring period were used to derive parametric proportional hazards models predicting absolute risk of diabetes complications and death. We re-estimated the seven original event equations and estimated new equations for diabetic ulcer and some second events. The additional data permitted inclusion of new risk factor predictors such as estimated GFR. We also developed four new equations for all-cause mortality. Internal validation of model predictions of cumulative incidence of all events and death was carried out and a contemporary patient-level dataset was used to compare 10 year predictions from the original and the new models.

RESULTS

Model equations were based on a median 17.6 years of follow-up and up to 89,760 patient-years of data, providing double the number of events, greater precision and a larger number of significant covariates. The new model, UKPDS-OM2, is internally valid over 25 years and predicts event rates for complications, which are lower than those from the existing model.

CONCLUSIONS/INTERPRETATION

The new UKPDS-OM2 has significant advantages over the existing model, as it captures more outcomes, is based on longer follow-up data, and more comprehensively captures the progression of diabetes. Its use will permit detailed and reliable lifetime simulations of key health outcomes in people with type 2 diabetes mellitus.

Regional differences in the frequency of the c.985A>G ACADM mutation: findings from a meta-regression of genotyping and screening studies

Several countries include medium-chain acyl-CoA dehydrogenase (MCAD) deficiency, a rare autosomal recessive disease, in their newborn screening programmes despite prevalence uncertainty. We estimated the frequency of its most common mutation, c.985A>G, tested for regional differences and compared screening and genotype frequencies. We identified 43 studies reporting the frequency of c.985A>G over 10 million individuals, and pooled frequency data using a novel Bayesian approach. We found significant variation in the frequency of the mutation across regions supporting a reported founder effect. The proportion of c.985A>G homozygotes was highest in Western Europe with 4.1 (95%CI: 2.8-5.6) per 100,000 individuals, then the New World (3.2, 95%CI: 2.0-4.7), Southern (1.2, 95%CI: 0.6-2.0) and Eastern European regions (0.9, 95%CI: 0.5-1.7). No cases with the mutation were identified in Asian and Middle Eastern regions. Significant differences were found in some countries between the genotype and screening allele frequency of c.985A>G. Our predictions could inform the frequency of the mutation by region and our approach could apply to other genetic conditions.

UK research expenditure on dementia, heart disease, stroke and cancer: are levels of spending related to disease burden?

BACKGROUND AND PURPOSE

A UK government review recommended that the impact of disease on the population and economy should be assessed to inform health research priorities. This study aims to quantify UK governmental and charity research funding for dementia, cancer, coronary heart disease (CHD) and stroke in 2007/08 and assess whether the levels of research expenditure are aligned with disease and economic burden.

METHODS

We identified UK governmental agencies and charities providing health research funding and determined their levels of funding for dementia, cancer, CHD and stroke. Research funding levels were compared to the number of cases, disability-adjusted life years (DALYs) and economic burden. Economic costs were estimated using data on morbidity, mortality, health and social care use, private costs and other related indicators.

RESULTS

Research funding to the four diseases was £833 million, of which £590 million (71%) was devoted to cancer, £169 million (20%) to CHD, £50 million (6%) to dementia and £23 million (4%) to stroke. Cancer received £482 in research funding per 1000 DALYs lost, CHD received £266, dementia received £166, with stroke receiving £71. In terms of economic burden, for every £1 million of health and social care costs attributable to each disease, cancer received £129 269 in research funding, CHD received £73 153, stroke received £8745 and dementia received £4882.

CONCLUSIONS

Most health research funding in the UK is currently directed towards cancer. When compared to their burden, our analysis suggests that research spending on dementia and stroke is severely underfunded in comparison with cancer and CHD.

Risk equations to predict life expectancy of people with Type 2 diabetes mellitus following major complications: a study from Western Australia

AIMS

  To develop a model for predicting life expectancy following major diabetes-related complications and to summarize these results by age and gender in the form of a simple table.

METHODS

  Equations for forecasting mortality were derived using an observational cohort of 12,792 patients who had one of the following complications of diabetes: myocardial infarction, stroke, heart failure, amputation or renal failure, recorded in administrative health and mortality data from the state of Western Australia between 1990 and 1999. Logistic regression was used to estimate mortality within the first month post-event and a Gompertz proportional hazards model was used to estimate survival over the patients' remaining lifetime. After examining the internal validity over a 5-year period, these equations were used to estimate remaining life expectancy by age and sex following specific complications.

RESULTS

  Of the complications examined, renal failure had most impact on life expectancy at all ages, followed by heart failure; the best prognosis was following stroke, myocardial infarction and amputation. For a 60-year-old male, life expectancy immediately post-event ranged from 10.1 years (95% CI 9.4-10.8 years) for stroke to 4.3 years (95% CI 3.1-6.1 years) for renal failure. Life expectancies for women at 60 and 70 years of age were significantly lower than men following myocardial infarction and significantly higher than men following heart failure and amputation at 70 and 80 years of age.

CONCLUSION

  The model allows estimation of both survival probability and life expectancy post-event for men and women of any age. The summary table may provide a useful and simple reference for clinicians and diabetes specialists.

[Vitamin A deficiency and nutritional status in patients with Down's syndrome]

INTRODUCTION

Vitamin A deficiency (VAD) is a worldwide public health problem. Epidemiological studies of VAD prevalence have been conducted in individuals with chromosome load and genetic potential compared with the general population; however, there are few studies in patients with Down's syndrome (DS). The objective of this study was to determine the prevalence of VAD and analyse nutritional status in patients with DS.

METHODS

A prospective and cross-sectional study was performed, with 50 karyotypically normal (KN) individuals (10.4+/-3.7 years old) and 38 randomly selected patients with DS (8.2+/-4.1 years old). Serum retinol was determined by HPLC using the Bieri method, with an international reference standard to define VAD (serum retinol <20 microg/dL). The data were analysed using the SAS/STAT statistical program.

RESULTS

The prevalence of VAD was 18.4% in individuals with DS and 4% in KN individuals (OR: 5.42; 95% CI=0.93-40.64; p=0.02). Children with DS between two and six years old shown a significativily lower serum retinol (p=<0.05).The patients with DS also showed a significant decrease in height and weight compared to KN (p=<0.001).

CONCLUSIONS

The prevalence of VAD detected in patients with DS could be considered a public health problem. Also, the chromosome 21 trisomy represent a risk factor associated with VAD.

The use of Magallanic peat as non-conventional sorbent for EDTA removal from wastewater

Kraft mills are responsible for large volumes discharges of highly polluted effluents. Application of new bleaching processes (i.e. total chlorine-free (TCF) process) is already a feasible option to reduce environmental impacts. The current trend in the increase in the production of TCF pulp will proportionally increase the consumption of chelating agents. The most commonly used chelants, ethylenediaminetetraacetic acid (EDTA) and diethylenetriaminepentaacetic acid (DPTA) are supposed to be relatively persistent substances, poorly degradable in biological treatment facilities and are subsequently considered as environmentally critical compounds. Adsorption could be used as a treatment technique to remove recalcitrant compounds from wastewaters. However, in most cases, sorbent and regeneration costs can make the whole process not economically feasible. The goal of this study was to evaluate the use of Magallanic peat as non-conventional sorbent for EDTA removal from wastewater. Adsorption studies were carried out considering a 2(3) factorial design. pH, temperature and sorbent/sorbate (S/S) relationship effects were evaluated in EDTA adsorption onto Magallanic peat. In addition, adsorption isotherm constants were determined according to the Langmuir and Freundlich models. The results showed that the optimal conditions for EDTA adsorption onto Magallanic peat were 20 degrees C, acid pH (4.0) and a low sorbent/sorbate ratio (0.1/100). At these conditions Magallanic peat showed an adsorption capacity for EDTA (Cs(sat)) of 128.2mg/g, comparable and even better than activated carbon (Cs(sat) 56.5mg/g). EDTA adsorption data at 60 degrees C obtained are not shown due to Magallanic peat degradation phenomena.

Validity of electronic surveillance systems: a systematic review

Electronic surveillance that utilises information held in databases is more efficient than conventional infection surveillance methods. Validity is not well-defined, however. We systematically reviewed studies comparing the utility of electronic and conventional surveillance methods. Publications were identified using Medline (1980-2007) and bibliographic review. The sensitivity and specificity of electronic compared with conventional surveillance was reported. Twenty-four studies were included. Six studies reported that nosocomial infections could be detected utilising microbiology data alone with good overall sensitivity (range: 63-91%) and excellent specificity (range: 87 to >99%). Two studies used three laboratory-based algorithms for the detection of infection outbreaks yielding variable utility measures (sensitivity, range: 43-91%; specificity, range: 67-86%). Seven studies using only administrative data including discharge coding (International Classification of Diseases, 9th edn, Clinical Modification) and pharmacy data claimed databases had good sensitivity (range: 59-96%) and excellent specificity (range: 95 to >99%) in detecting nosocomial infections. Six studies combined both laboratory and administrative data for a range of infections, and overall had higher sensitivity (range: 71-94%) but lower specificity (range: 47 to >99%) than with use of either alone. Three studies evaluated community-acquired infections with variable results. Electronic surveillance has moderate to excellent utility compared with conventional methods for nosocomial infections. Future studies are needed to refine electronic algorithms further, especially with community-onset infections.

Bipolar disorders and affective temperaments: a national family study testing the "endophenotype" and "subaffective" theses using the TEMPS-A Buenos Aires

BACKGROUND

The purpose of this study is to examine the prevalence of affective temperaments between clinically unaffected relatives of bipolar patients and secondarily to investigate the impact of these "subaffective" forms on their quality of life (QoL).

METHODS

The study was performed in seven sites across Argentina. We administered the scales TEMPS-A and Quality of Life Index to a sample of 114 non-ill first degree relatives of bipolar disorder patients ("cases") and 115 comparison subjects without family history of affective illness ("controls"). We used The Mood Disorder Questionnaire to rule out clinical bipolarity.

RESULTS

Mean scores on all TEMPS-A subscales were significantly higher in cases, except for hyperthymia. The prevalence of affective temperaments, according to Argentinean cut-off points, was also higher, with statistical significance for cyclothymic and anxious temperaments. Regarding QoL, we found no significant differences between both groups, except for interpersonal functioning, which was better in controls. A detailed subanalysis showed significant effects of QoL domains for all temperaments, except for the hyperthymic.

LIMITATIONS

We used self-report measures. A larger sample size would have provided us greater statistical power for certain analyses.

CONCLUSIONS

Our findings support the concept of a spectrum of subthreshold affective traits or temperaments - especially for the cyclothymic and anxious - in bipolar pedigrees. We further demonstrated that, except for the hyperthymic, quality of life was affected by these temperaments in "clinically well" relatives. Overall, our data are compatible with the "endophenotype" and "subaffective" theses for affective temperaments.