P27: INTRODUCTION OF A PILOT VIRTUAL FRACTURE CLINIC: A TIME AND COST ANALYSIS

Introduction

The British Orthopaedic Association Standards for Trauma and Orthopaedics(BOAST) have produced guidelines advising that all patients be reviewed by an orthopaedic consultant within 72 hours of presentation. However, data from traditional fracture clinics rarely fulfil this criterion. Furthermore, data from the National Health Service(NHS) has determined that traditional fracture clinics have become unfit for purpose with low patient satisfaction rates, excessive waiting times and over 6.9 million missed appointments every year. Our aim is to test the feasibility of a virtual fracture clinic(VFC) with a view to reducing service costs and improving adherence to BOAST guidelines specified timeline for orthopaedic consultant review.

Method

A retrospective analysis of 103 patients referred to our pilot VFC from January 1st to 31st 2019 was carried out. We included shoulder dislocations, clavicle injuries, simple distal radius fractures, radial head fractures, metacarpal and metatarsal injuries, undisplaced fractures of the medial and lateral malleolus of the ankle and soft tissue injuries. The primary outcome measured time from presentation to review by an orthopaedic consultant. A cost analysis was also performed to estimate the overheads and potential savings associated with VFC introduction. Statistical analysis was done via SPSS.

Result

Following VFC establishment, time from ED presentation to review by orthopaedic consultant reduced from a mean of 229 hours to 72 hours(P=0.0001). Cost analysis demonstrated that the VFC created savings of €3170 per week, amounting to projected savings of €38,040.

Conclusion

VFC has the potential to improve clinical performance while delivering substantial financial savings.

Take-home message

Virtual fracture clinic improves patients review times bringing them in line with BOAST guidelines while providing significant reductions in overheads leading to potential savings of over 38,000 euro.

Seed layer technique for high quality epitaxial manganite films

We introduce an innovative approach to the simultaneous control of growth mode and magnetotransport properties of manganite thin films, based on an easy-to-implement film/substrate interface engineering. The deposition of a manganite seed layer and the optimization of the substrate temperature allows a persistent bi-dimensional epitaxy and robust ferromagnetic properties at the same time. Structural measurements confirm that in such interface-engineered films, the optimal properties are related to improved epitaxy. A new growth scenario is envisaged, compatible with a shift from heteroepitaxy towards pseudo-homoepitaxy. Relevant growth parameters such as formation energy, roughening temperature, strain profile and chemical states are derived.

Superficial Peroneal Nerve Incarceration in the Fibular Fracture Site of a Pronation External Rotation Type Ankle Fracture

Ankle fractures are common representing up to 10% of all fractures with an incidence that is rising. Both conservative treatment and operative management of ankle fractures can lead to excellent outcomes. Neurovascular injuries are uncommon but can be a source of significant morbidity and associated poor outcome. The superficial peroneal nerve (SPN) in the lateral approach and the sural nerve in the posterolateral approach are at risk of injury. We report an unexpected finding of a superficial peroneal nerve incarcerated in the fibular fracture site of pronation external rotation type/ Weber-C ankle fracture. To the best of our knowledge we believe this to be the first English language report of an incarcerated SPN at a fibular ankle fracture site.

Advancing medication infusion safety through the clinical integration of technology

Adverse drug events resulting from errors in prescribing or administering medications are preventable. Within a hospital system, numerous technologies are employed to address the common sources of medication error, including the use of electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. Infusion safety is inherently risky because of the high-risk medications administered and the lack of integration among the stand-alone systems in most institutions. Intravenous clinical integration (IVCI) is a technology that connects electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. It combines the safety features of an automatically programmed infusion pump (drug, concentration, infusion rate, and patient weight, all auto-programmed into the device) with software that provides visibility to real-time clinical infusion data. Our article describes the characteristics of IVCI at WellSpan Health and its impact on patient safety. The integrated infusion system has the capability of reducing medication errors, improving patient care, reducing in-facility costs, and supporting asset management. It can enhance continuous quality improvement efforts and efficiency of clinical work flow. After implementing IVCI, the institution realized a safer patient environment and a more streamlined work flow for pharmacy and nursing.

Imaging and electrodiagnostic work-up of acute adult brachial plexus injuries

Imaging and electrodiagnostic studies form an essential part of the evaluation of the patient with traumatic brachial plexopathy, enabling clarification of surgical options, prognostication of outcome and formulation of postoperative management. The primary objective of imaging is to identify pre-ganglionic injury indicative of nerve root avulsion. The presence of one or more nerve root avulsion injuries is a critical factor in surgical decision-making and the prognosis of surgical reconstruction. CT myelography is the current imaging modality of choice for this purpose. Initial electrodiagnostic (EDX) testing is ideally performed no sooner than 4 weeks following injury unless otherwise clinically indicated. Follow-up testing can be helpful at approximately 6 week intervals. The sensory nerve amplitudes are the most important component of nerve conduction testing in distinguishing between pre- and post-ganglionic injuries. Electromyographic studies will also assist in the determination of a pre- from post-ganglionic injury, the level of plexus involvement and identify potential donor nerves that may be suitable for use as transfers.

Dissociation and implantation of Exeter femoral instrumentation during total hip arthroplasty

Proprietary femoral plug introducers are routinely used to insert intramedullary plugs during total hip arthroplasty. The cement restrictor pin from an Exeter intramedullary plug introducer may become detached during insertion of the cement restrictor plug, or during sponge packing of the femur. We suggest some precautions that should be taken to prevent this from occurring and advise that the patient is unlikely to experience any long-term adverse reactions to the presence of the restrictor pin in the intramedullary canal.;

The usefulness of computed tomography following open reduction and internal fixation of acetabular fractures

PURPOSE

To investigate the role of a supplemental imaging modality in postoperative assessment of acetabular fractures following open reduction and internal fixation.

METHODS

Postoperative axial computed tomographic (CT) scans were compared with plain radiographs of 20 patients with regard to their sensitivity for detecting articular fracture reduction in terms of gap displacement and step deformity or offset. Three observers independently reviewed the plain radiographs and CT scans at 2 separate time points and categorised the outcome as either anatomical or non-anatomical. The inter-observer reliability and intra-observer reproducibility of these measurements was expressed as a kappa statistic. The radiological result was correlated with the clinical outcome measures using the Merle D'Aubigne scale, the Harris Hip Score, and the SF-36 score.

RESULTS

Plain radiography was less effective in the detection of postoperative articular displacement (mean, 75.1% sensitive). The inter-observer and intra-observer agreement between reviewers was good to excellent in detecting reduction quality between the 2 modalities. Patient management was not altered by the findings of the CT scans.

CONCLUSIONS

Although postoperative CT scanning of acetabular fractures in selective cases may be useful, issues such as higher cost, less effective allocation of resources, and excessive radiation doses do not support its routine use.

In-cement technique for revision hip arthroplasty

The in-cement technique for revision hip arthroplasty involves retaining the original cement-bone interface. This has been proven to be a biomechanically stronger method than recementing after complete removal of the original cement mantle.

This study reviewed a series of 54 consecutive revision hip arthroplasty procedures, using the in-cement technique, between November 1999 and November 2003. Clinical and radiological follow-up included functional assessment.

There were 54 procedures performed in 51 patients, whose mean age at surgery was 70.3 years (45 to 85). A total of 42 were available at a mean follow-up of 29.2 months (6 to 51). There was no radiological evidence of loosening. Functional assessments were available for 40 patients who had a mean Harris hip score of 85.2 (51.9 to 98.5), a mean Oxford hip score of 19.6 (12 to 41), a mean UCLA activity profile score of 5.9 (3 to 8) and a mean SF-36 score of 78.0 (31.6 to 100).

The in-cement technique provides consistent, high functional outcomes and should be considered in appropriately selected cases.

The use of uncemented extensively porous-coated femoral components in the management of Vancouver B2 and B3 periprosthetic femoral fractures

We assessed the outcome of patients with Vancouver type B2 and B3 periprosthetic fractures treated with femoral revision using an uncemented extensively porous-coated implant. A retrospective clinical and radiographic assessment of 22 patients with a mean follow-up of 33.7 months was performed. The mean time from the index procedure to fracture was 10.8 years. There were 17 patients with a satisfactory result. Complications in four patients included subsidence in two, deep sepsis in one, and delayed union in one. Concomitant acetabular revision was required in 19 patients. Uncemented extensively porous-coated femoral stems incorporate distally allowing stable fixation. We found good early survival rates and a low incidence of nonunion using this implant.

Social support and maladaptive coping as predictors of the change in physical health symptoms among persons living with HIV/AIDS

This study examined social support and maladaptive coping as predictors of HIV-related health symptoms. Sixty-five men and women living with HIV/AIDS completed baseline measures assessing coping strategies, social support, and HIV-related health symptoms. The sample was primarily low-income and diverse with respect to gender, ethnicity, and sexual orientation. Three, 6, and 12 months after completing baseline assessments, physical health symptoms associated with HIV disease were assessed. After controlling for demographic characteristics, CD4 T-cell count, and baseline HIV-related health symptoms, individuals reporting lower increase in HIV-related health symptoms used less venting (expressing emotional distress) as a strategy for coping with HIV. However, when satisfaction with social support was added to the model, the use of this coping strategy was no longer significant, and individuals reporting more satisfying social support were more likely to report lower increase in their HIV-related health symptoms, suggesting that social support is a robust predictor of health outcomes over time independent of coping style and baseline medical status. These findings provide further evidence that social support can buffer deleterious health outcomes among individuals with a chronic illness. Future research needs to examine mediating pathways that can explain this relationship.

Screening of lower back pain, low back pain clinic. The clinical experience

Acute low back pain is a common complaint with high prevalence in society. Orthopaedic and specialist spinal services may be overwhelmed by large numbers of patients with low back pain who do not require investigation or surgical intervention. This phenomenon has led to the establishment of back pain screening clinics as a system of triage for those with acute low back pain. In March 2001, a back pain screening clinic was established in the Adelaide and Meath Hospitals incorporating the National Children's hospital. Six hundred and sixty-five patients were seen in the first year of this clinic. Of these, only ninety-six required referral to the orthopaedic spinal clinic. Just twenty-nine of these patients required surgical intervention. The introduction of this service resulted in a reduction in the waiting periods for the specialised spine clinic. We conclude that back pain screening clinics result in a clinical and economical improvement in the care of those suffering from acute low back pain. This is achieved by the systematic and efficient assessment, treatment and referral of patients afflicted with acute low back pain.

Acute stress reactions to recent life events among women and men living with HIV/AIDS

OBJECTIVE

This study examined the prevalence of acute stress reactions to recent life events among persons living with HIV/AIDS. A second aim was to investigate the relationship of acute stress reactions among HIV-infected men and women to posttraumatic stress disorder (PTSD) symptoms to previous traumatic life events.

METHOD

Participants included 64 HIV-seropositive persons (33 men and 31 women) drawn from a larger study examining the effects of group therapy on quality of life and health behavior. These individuals were assessed at baseline on demographic and medical status characteristics and (PTSD) symptoms andthen randomly assigned to either receive group therapy plus education or education alone. Three months later they were assessed for acute stress reactions to recent life events.

RESULTS

Nearly a third (31.3 percent) of the participants reported levels of acute stress reactions to recent life events that met all symptom criteria for the diagnosis of acute stress disorder. However, only 9.4 percent of the respondents described a recent stressful life event that was threatening to the life or physical integrity of themselves or others. Acute stress reactions to recent life events were significantly and positively related to experiencing PTSD symptoms to prior traumatic life events. Acute stress did not differ significantly by gender, AIDS status, or whether or not participants had received 12 weeks of group therapy.

CONCLUSIONS

A subset of individuals with HIV/AIDS experience high levels of acute stress reactivity to life events considered non-traumatic. HIV-infected individuals who react strongly to ongoing life stressors are more likely to have developed PTSD symptoms in response to previous traumatic life events.

Usefulness of functional outcome questionnaires in primary screening of spinal disease

Back pain screening clinics are established to clinically screen patients with back pain for organic lumbar pathology. The aim of this study is to assess the relationship between clinical signs of organic pathology and the level of disability as measured by functional outcome scores. Sixty-nine patients who were found to have clinical signs of organic pathology and 69 age- and sex-matched patients from 512 patients who were found to have no signs of organic pathology in the same time period in the back pain screening clinic were selected. The Oswestry Disability, Short Form-36, and visual analogue (pain) scores between the two groups were statistically analyzed. We found a significant increase in the level of disability in the group with organic pathology; however, the variation in the scores makes them unspecific for use in screening of acute spinal pathology. We also found a strong relationship between psychologic disability and length of symptoms.

Cost analysis of primary total hip replacement

Arthritis of the hip is a cause of significant morbidity to the sufferer, for which total hip replacement is firmly established as an effective treatment. In order to assess the cost utility and benefit of total hip replacement, we compared the costs incurred to the health benefit accrued as measured by improvement in pre to post operative Harris hip scores, WOMAC osteoarthritis indices and SF 36 scores. Our calculations suggested the average unit cost of a total hip replacement at Cappagh National Orthopaedic Hospital, in 1999, to be in the region of 6,500 pounds. Cost utility was calculated as cost per QALY. Cost benefit was expressed as cost per 10 point increments in Harris hip scores, WOMAC and SF 36 scores. We conclude that total hip replacement is a worthwhile and efficient investment of health resources.

Outcomes following quadriceps tendon ruptures

Complete rupture of the quadriceps femoris tendon is a well-described injury. There is a scarcity of literature relating to the outcome of patients with this injury after surgery. We undertook a retrospective analysis of patients who had surgical repair of their ruptured quadriceps tendon at our institution over a seven year period-totalling 27 patients. Males were more commonly affected with a M:F ratio of 8:1. The peak incidence was in the sixth decade of life. The non-dominant limb was twice as likely to be affected. Assessment consisted of completion of a functional knee questionnaire, clinical examination and isokinetic testing on a Biodex dynanometer. Symptomatic outcome following surgical repair was excellent with a mean symptom score generated of 22.7 out of a maximum of 25. 18/19 patients returned to their premorbid level of activity on average 18.1 weeks following injury. There was no difference in quadriceps girth comparing affected and unaffected limbs. Less than 5 degrees deficit in range of motion existed between affected and unaffected limbs. Approximately two-thirds of patients were the same or better when comparing peak torque/body weight, average power, maximum average peak torque and total work/body weight in affected and unaffected limbs.

A survey of primary care physicians' perceptions and needs regarding the precepting of medical students in their offices

OBJECTIVE

To assess the interest, perceptions, and needs of primary care physicians with regard to office-based precepting of medical students.

DESIGN

Random survey.

SETTING

The New England region of the United States (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut).

PARTICIPANTS

Family physicians, general internists and paediatricians.

MAIN OUTCOME MEASURES

These included: (1) practice and preceptor demographics; (2) Likert scale agreement or disagreement with various positive and negative perceptions about precepting students; rating (from unimportant to necessary) of potential benefits from medical schools associated with the support of precepting in the office setting, and (3) comparisons among physician groups to determine differences in perceptions and needs.

RESULTS

There is a high level of interest in precepting regardless of primary care specialty, practice structure, payment mechanism, or precepting experience. Negative impacts included decreased productivity and increased length of the day by a median of 60 minutes. Positive impacts included keeping one's own knowledge up-to-date and enhanced enjoyment of practice. Benefits such as academic appointments, continuing medical education credits, faculty development, computer linkages for clinical information and medical library access are rated highly. Monetary payment, whether as a modest honorarium or as compensation for lost time/income, was felt to be important by half of our sample.

CONCLUSION

A significant interest in precepting medical students on a regular basis is expressed by primary care physicians in the ambulatory medicine setting. The results of this survey can be used by medical schools to address negative perceptions and to develop appropriate benefits packages to recruit and retain these primary care preceptors.

Transcultural therapy. 2: Mental health and learning disabilities

The first article in this two-part series (Vol 7(15): 901-6) examined the issues surrounding healthcare provision in the context of the UK as a multicultural society in relation to mental health and learning disabilities. This second article considers the development of psychotherapy, theory and skills of working in terms of its impact and influence upon the education and practice of community mental health nurses and community nurses in learning disability within the UK. The major schools of influence in psychology will be examined in relation to their limitations for practice with clients from various cultures. In addition, three multicultural models of counselling which address cultural diversity will be appraised. Finally, the need for educational systems and service providers to foster and develop positive cultural attitudes among nurse practitioners will be emphasized. Both individual practitioners and employment organizations will need to be much more responsive and committed to developing multicultural services as we approach the millennium.

Transcultural therapy. 1: Mental health and learning disabilities

In this article, the first of two parts, the issues surrounding healthcare provision are discussed in the context of the UK as a multicultural society. Concerns relating to nurse education and training are identified in regard to the implications for practice surrounding diagnosis across cultures, classification of illness, and the status and influence of psychological assessments within the field of mental health and learning disability. Finally, the concept of empowerment is critically reviewed, emphasizing that service providers need to collaborate with communities. Community mental health and learning disability nurses are required to make dynamic alliances with communities, through the individual, and so redirect the power relationship to the community and subsequently respond to the demands for cultural diversity sensitively from within healthcare provision and services.

Chronic debilitating fatigue in Irish general practice: a survey of general practitioners' experience

BACKGROUND

Doctors are called upon to treat chronic debilitating fatigue without the help of a protocol of care.

AIMS

To estimate the incidence of chronic debilitating fatigue in Irish general practice, to obtain information on management strategy and outcome, to explore the attitudes of practitioners (GPs) towards the concept of a chronic fatigue syndrome (CFS), and to recruit practitioners to a prospective study of chronic fatigue in primary care.

METHOD

A total of 200 names were selected from the database of the Irish College of General Practitioners (ICGP); 164 of these were eligible for the study.

RESULTS

Altogether, 118 questionnaires were returned (72%). Ninety-two (78%) responders identified cases of chronic fatigue, giving an estimated 2.1 cases per practice and an incidence of 1 per 1000 population. All social classes were represented, with a male to female ratio of 1:2. Eleven disparate approaches to treatment were advocated. Many (38%) were dissatisfied with the quality of care delivered, and 45% seldom or hardly ever referred cases for specialist opinion. The majority (58%) accepted CFS as a distinct entity, 34% were undecided, and 8% rejected it. Forty-two (35%) GPs volunteered for a prospective study.

CONCLUSION

Chronic fatigue is found in Irish general practice among patients of both sexes and all social classes. Doctors differ considerably in their management of patients and are dissatisfied with the quality of care they deliver. Many cases are not referred for specialist opinion. A prospective database is required to accurately assess the scale of this public health problem and to develop a protocol of care.

Teaching nursing research using two-way video technology

Schools of nursing are meeting the needs of students by instituting distance education courses that use two-way video technology. This article describes the structural features of the classroom that are changed and provides strategies that can be effective for teaching nursing research. These strategies are related to: teaching and demonstrating use of statistical formulas; selecting and teaching use of software for data analysis; teaching about research design, sampling, and data collection procedures; and critiquing empirical articles.

Effects of phenytoin, phenobarbital, and ascorbic acid on misonidazole elimination

The kinetics of an oral dose (1.0 gm/m2) of the 2-nitroimidazole radiosensitizer misonidazole were studied in three groups of six healthy subjects before and after a 1-wk course of phenytoin, phenobarbital, or ascorbic acid. Phenytoin and phenobarbital decreased mean misonidazole half-life by 27% and 23% and the decrease was associated with the respective increases in mean clearance of 42% and 31%. The area under the plasma concentration-time curve for the metabolite O-desmethylmisonidazole increased correspondingly. Volume of distribution of misonidazole was unchanged. After treatment with ascorbic acid there was a very small increase in the mean clearance of misonidazole, but there was no significant change in other kinetic parameters. Induction by phenytoin and phenobarbital of the oxidative metabolism of misonidazole is the most likely mechanism responsible. Deliberate induction of a patient's metabolism may help to reduce the neurotoxicity associated with the use of the drug. The efficacy of the radiosensitizing action of the drug is unlikely to be compromised under these conditions since peak plasma concentrations of misonidazole were not affected by treatment with either phenytoin or phenobarbital. The potentiation of the cytotoxic effects of misonidazole by ascorbic acid is unlikely to be related to a direct effect on the oxidative metabolism of misonidazole.

The synthesis of 2-Acetamido-2-deoxy-5-thio-D-glucopyranose and its derivatives

Syntheses of the title compounds are described (see Scheme 1). They proceed via the intermediate (11) designed to facilitate the synthesis of other thiopyranose analogues of amino sugars, particularly those of biochemical significance.