Differences in Diabetes Control in Telemedicine vs. In-Person Only Visits in Ambulatory Care Setting

Importance: The COVID-19 pandemic has led to increased utilization of telemedicine. Patients with diabetes are a vulnerable population that require regular treatment and monitoring. Little is known about the impact visit modality on diabetes outcomes in an ambulatory setting. Objective: Compare proportions of patients with diabetes with uncontrolled diabetes among those with telemedicine versus in-person only ambulatory visits and examine differences by age, race, gender, ethnicity, and insurance. Design: A retrospective cohort study. Setting: The largest academic healthcare system in the state of Georgia with ambulatory clinics in urban, suburban and rural settings. Participants: Adults with diabetes scheduled for an ambulatory primary or specialty clinic visit between May 2020 and May 2021 were included. Patients were compared among three visit groups: those with all in-person visits, those with one telemedicine visit, and those with 2+ telemedicine visits. Demographics including age, race, ethnicity, gender, insurance status, and comorbidities were extracted from the electronic medical record. Main Outcomes and Measures: The primary clinical outcome was uncontrolled diabetes, defined as HbAlc ≥ 9.0%. Chi-square test was used to determine crude differences in uncontrolled diabetes between visit groups. Multivariable logistic regression was used to assess differences in uncontrolled diabetes between visit groups following risk adjustment. Results: A total of 18,148 ambulatory clinic visits for patients with diabetes were scheduled during the study period, and 11.6% had uncontrolled diabetes. There was no difference in proportion of patients with uncontrolled diabetes between all in-person visits (834 (11.6%)), one telemedicine visit (558 (11.8%)), or 2+ telemedicine visits (709 (11.4%)) (p = 0.80). Patients with 2+ telemedicine visits had significantly lower odds of uncontrolled diabetes compared to all in-person visits after adjusting for age, gender, race, ethnicity, insurance status, and comorbidities (OR: 0.88; 95% CI: 0.79 - 0.99, p = 0.03). Conclusions and Relevance: Telemedicine visits were associated with a lower odds of uncontrolled diabetes. Further work is warranted to explore the relationship between telemedicine visits, equitable access to care, and diabetes outcomes.

An interprofessional approach to reducing hospital-onset Clostridioides difficile infections

BACKGROUND

Clostridioides difficile is the most prevalent hospital-onset (HO) infection. There are significant financial and safety impacts associated with HO-C. difficile infections (HO-CDIs) for both patients and health care organizations. The incidence of HO-CDIs at our community hospital within an academic acute health care system was continuously above the national benchmark.

METHODS

In response to the high HO-CDI rates at our facility, an interprofessional team selected evidence-based interventions with the goal of reducing HO-CDI incidence rates. Interventions included: diagnostic stewardship, enhanced environmental cleaning, antimicrobial stewardship and education and accountability.

RESULTS

After one year, we achieved a 63% reduction in HO-CDI and have sustained a 77% reduction. The infection rate remained below national benchmark for HO-CDI for over 4 years at a rate of 2.80 per 10,000 patient days and a SIR of 0.43 in 2020.

DISCUSSION

Multiple evidence-based interventions were successfully implemented over several service lines over a 4-year period through the collaboration of an interprofessional team. The addition of an accountability processes further improved compliance with standards of practice.

CONCLUSIONS

Collaboration of an interprofessional team led to substantial and sustained reductions in HO-CDI.

Clinical characteristics and social determinants of health associated with 30-day hospital readmissions of patients with COVID-19

COVID-19 readmissions are associated with increased patient mortality and healthcare system strain. This retrospective cohort study of PCR-confirmed COVID-19 positive adults (>18 years) hospitalized and readmitted within 30 days of discharge from index admission was performed at eight Atlanta hospitals from March to December 2020. The objective was to describe COVID-19 patient-level demographics and clinical characteristics, and community-level social determinants of health (SDoH) that contribute to 30-day readmissions. Demographics, comorbidities, COVID-19 treatment, and discharge disposition data were extracted from the index admission. ZIP codes were linked to a demographic/lifestyle database interpolating to community-level SDoH. Of 7155 patients with COVID-19, 463 (6.5%) had 30-day, unplanned, all-cause hospital readmissions. Statistically significant differences were not found in readmissions stratified by age, sex, race, or ethnicity. Patients with a high-risk Charlson Comorbidity Index had higher odds of readmission (OR 4.8 (95% CI: 2.1 to 11.0)). Remdesivir treatment and intensive care unit (ICU) care were associated with lower odds of readmission (OR 0.5 (95% CI: 0.4 to 0.8) and OR 0.5 (95% CI: 0.4 to 0.7), respectively). Patients residing in communities with larger average household size were less likely to be readmitted (OR 0.7 (95% CI: 0.5 to 0.9). In this cohort, patients who received remdesivir, were cared for in an ICU, and resided in ZIP codes with higher proportions of residents with increased social support had lower odds of readmission. These patient-level factors and community-level SDoH may be used to identify patients with COVID-19 who are at increased risk of readmission.

Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention

Objective

To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI).

Design

We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention.

Setting

An academic healthcare system with 4 hospitals.

Patients

All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients.

Intervention

Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing.

Results

Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01).

Conclusions

Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.

[Proton therapy for head and neck squamous cell carcinomas: From physics to clinic]

Intensity-modulated radiation therapy (IMRT) is presently the recommended technique for the treatment of locally advanced head and neck carcinomas. Proton therapy would allow to reduce the volume of irradiated normal tissue and, thus, to decrease the risk of late dysphagia, xerostomia, dysgeusia and hypothyroidism. An exhaustive research was performed with the search engine PubMed by focusing on the papers about the physical difficulties that slow down use of proton therapy for head and neck carcinomas. Range uncertainties in proton therapy (±3 %) paradoxically limit the use of the steep dose gradient in distality. Calibration uncertainties can be important in the treatment of head and neck cancer in the presence of materials of uncertain stoichiometric composition (such as with metal implants, dental filling, etc.) and complex heterogeneities. Dental management for example may be different with IMRT or proton therapy. Some uncertainties can be somewhat minimized at the time of optimization. Inter- and intrafractional variations and uncertainties in Hounsfield units/stopping power can be integrated in a robust optimization process. Additional changes in patient's anatomy (tumour shrinkage, changes in skin folds in the beam patch, large weight loss or gain) require rescanning. Dosimetric and small clinical studies comparing photon and proton therapy have well shown the interest of proton therapy for head and neck cancers. Intensity-modulated proton therapy is a promising treatment as it can reduce the substantial toxicity burden of patients with head and neck squamous cell carcinoma compared to IMRT. Robust optimization will allow to perform an optimal treatment and to use proton therapy in current clinical practice.

2162. Factors Affecting the Geographic Variability of Antibiotic-Resistant Healthcare-Associated Infections in the United States Using the CDC’s Antibiotic Resistance Patient Safety Atlas

Background

National surveillance is proposed to be part of a National Strategy to Combat Antibiotic Resistance (AR) in the United States; recent access of state-summary metrics around antibiotic use and antibiotic resistance allows an opportunity to evaluate variability in AR among healthcare-associated infections (HAIs) between U.S. states.

Methods

We utilized data from 2016 accessible in the CDCÕs AR Patient Safety Atlas to create state-level values for the no. of HAIs (CLABSI, CAUTI, SSI) by select AR reported to NHSN, prescribing rates of outpatient antibiotics by class, and percentage of hospitals having full antibiotic stewardship programs. Other available data included 2016 CDC’s Healthcare-Associated Infections Progress Report and U.S. Census Data. We correlated (Pearson’s partial correlation coefficients) the state prevalence (% testing resistant) for multidrug-resistant P. aeruginosa (MDR-PA), extended-spectrum cephalosporin-resistant E. coli (ESC-E. coli), and methicillin-resistant S. aureus (MRSA) from HAIs with potential predictors; multivariate logistic regression was used to assess independence.

Results

States prevalence of HAI AR varied and was explained in part by no. of skilled nursing facility bed days for MRSA (P = 0.002), % of population black for MRSA (P < 0.001) and ESC-E. coli (P < 0.001), % of population > 65 for ESC-E. coli (P < 0.001) and MDR-PA (P < 0.001), and no. of LTACHs for MDR-PA (P = 0.01). After adjusting for these, rates of outpatient fluoroquinolone (FQ) and cephalosporin prescribing (figure) were significant predictors of ESC-R E. coli HAIs (adjusted OR 1.02, P < 0.001 and 1.01, P < 0.001, respectively) and FQ rates for MRSA HAIs (aOR 1.01, P = 0.004); the MRSA correlation was slightly elevated in states with a higher population of African-Americans. Of note, % hospitals with inpatient stewardship did not explain geographic variability in any HAI AR studied.

Conclusion

Outpatient antibiotic prescribing rates can explain much of the state-to-state variability in studied HAI-related AR even after adjusting for differences in age and healthcare facility composition. Stewardship across the spectrum of healthcare delivery is likely needed to improve patient safety in acute care hospitals.

Disclosures

All authors: No reported disclosures.

Treatment of high risk prostate cancer with combined radiotherapy and hormonal treatment- results and identification of factors influencing outcome

PURPOSE

The aim of this work was to prospectively analyze the outcome of combined hormonal treatment and radical radiotherapy in high risk non metastatic prostate cancer patients (T1=4, N0-1, M0).

METHODS

Between April 2003 and December 2007 196 patients with high risk prostate cancer were treated with curative intent. The treatment consisted of 2-month neoadjuvant hormonal treatment (LHRH analog), radical radiotherapy (68-78 Gy, conformal technique) and an optional 2-year adjuvant hormonal treatment.

RESULTS

The median follow up time was 59 months. Fiveyear overall survival was 86% and 5-year biochemical disease free survival (DFS) 70%. Factors found to be statistically significant relative to outcomes were Gleason score (p=0.017), initial PSA value (p=0.039) and adjuvant hormonal treatment (p=0.035). There was no significant association between radiotherapy dose or volume and biochemical DFS (bDFS). Late genitourinary and gastrointestinal toxicity was acceptable.

CONCLUSION

Treatment combining hormonal therapy and radical radiotherapy can be recommended for this subgroup of prostate cancer patients. Adjuvant hormonal treatment should also be used.

Definitive radiochemotherapy with weekly cisplatin in patients with head and neck cancer; single institution outcome analysis

PURPOSE

The objective of this study was to evaluate the feasibility, toxicity and efficacy of definitive radiochemotherapy with weekly cisplatin in head and neck cancer in a single institutional setting.

METHODS

Previously untreated patients with stage II-IV head and neck cancer were included. Radiotherapy consisted of 70 Gy/7 weeks/35 fractions. All patients received concurrent cisplatin 40 mg/m(2) weekly.

RESULTS

Between 2/2002 and 8/2009, 148 consecutive patients (WHO ≤ 2, male to female ratio 6/1, median age 56 years) were treated. The mean follow-up was 40 months. Tumors of the oropharynx were the most frequent (46%) and stage IV predominated (80%). Eighty-nine percent of the patients had received the full radiation treatment as planned. Omission of weekly cisplatin occurred frequently, mainly because of hematological toxicity. Only 64% of the patients completed at least 5 cycles of chemotherapy. Grade 3/4 mucosal toxicity developed in 32% of the patients. The late toxicities were acceptable: 74% of the patients were able to eat solid food during the 1st post-treatment year, 4 patients were not able to swallow at all during the 1st post-treatment year, requiring thus permanent feeding tube. Five cases of osteoradionecrosis of the mandible were reported. Three-year overall survival, locoregional control, time to progression and disease free survival were 34, 60, 52 and 29%, respectively.

CONCLUSION

Definitive radiochemotherapy with weekly cisplatin was toxic, with high rate of morbidity and mortality in this patient population. Five weekly cycles of 40 mg/m(2) cisplatin seem to be the dose limit for most patients. Three-year survival was significantly reduced despite the promising high initial response and locoregional control.

Hyperfractionated accelerated radiotherapy with concomitant integrated boost of 70-75 Gy in 5 weeks for advanced head and neck cancer. A phase I dose escalation study

BACKGROUND AND PURPOSE

The present study was performed to evaluate the feasibility of a new, 5-week regimen of 70-75 Gy hyperfractionated accelerated radiotherapy with concomitant integrated boost (HARTCIB) for locally advanced, inoperable head and neck cancer.

METHODS AND MATERIALS

A total of 39 patients with very advanced, stage IV nonmetastatic head and neck squamous cell carcinoma (median gross tumor volume 72 ml) were included in this phase I dose escalation study. A total of 50 fractions intensity-modulated radiotherapy (IMRT) were administered twice daily over 5 weeks. Prescribed total dose/dose per fraction for planning target volume (PTV(tumor)) were 70 Gy in 1.4 Gy fractions, 72.5 Gy in 1.45 Gy fractions, and 75 Gy in 1.5 Gy fractions for 10, 13, and 16 patients, respectively. Uninvolved lymphatic nodes (PTV(uninvolved)) were irradiated with 55 Gy in 1.1 Gy fractions using the concomitant integrated boost.

RESULTS

Acute toxicity was evaluated according to the RTOG/EORTC scale; the incidence of grade 3 mucositis was 51% in the oral cavity/pharynx and 0% in skin and the recovery time was ≤ 9 weeks for all patients. Late toxicity was evaluated in patients in complete remission according to the RTOG/EORTC scale. No grade 3/4 late toxicity was observed. The 1-year locoregional progression-free survival was 50% and overall survival was 55%.

CONCLUSION

HARTCIB (75 Gy in 5 weeks) is feasible for patients deemed unsuitable for chemoradiation. Acute toxicity was lower than predicted from radiobiological models; duration of dysphagia and confluent mucositis were particularly short. Better conformity of radiotherapy allows the use of more intensive altered fractionation schedules compared with older studies. These results suggest that further dose escalation might be possible when highly conformal techniques (e.g., stereotactic radiotherapy) are used.

[Total hip replacement from a MIS-AL approach (comparison with a standard anterolateral approach)]

PURPOSE OF THE STUDY

Minimally invasive surgery (MIS) techniques have recently become a powerful and effective marketing instruments that are often perceived by the patient as the criterion of the surgeon's and institution's standard. In addition to studies reporting the benefits of minimally invasive procedures, some authors have recently found no such benefits or even pointed out some disadvantages. In this paper we present our own view of this issue. Our definition of minimally invasive surgery: a minimally invasive procedure is such that an optimally placed incision using anatomical intervals without damage to muscle insertions allows us to gain a good view of the operating field and to safely perform the planned surgery. Because of this optimal approach it is possible to make skin incisions shorter.

MATERIAL

Between April 21, 2005, and December 28, 2006, the first 40 MIS hip procedures were performed at the Department of Orthopaedic Surgery of the ILF Bulovka. Forty patients who, in the same period, were operated on from an anterolateral standard approach and who met the same indication criteria, including age, comprised a control group. In both groups all routinely used types of implants were included.

METHODS

For objective assessment of potential differences between surgical outcomes of the two techniques, the following para- meters were recorded: operating time, peri-operative blood loss, pre- and post-operative Hb levels, Hb level on the first post- operative morning, amount of blood drained away with a Redon drain, number of anodyne applications (indirect evaluation of post-operative pain) and length of hospital stay. The parameters were compared for the cemented and the uncemented implants separately. The results were evaluated using the paired t-test, with the significance level set at a value of p<0.05.

RESULTS

A comparison of the MIS-AL results with those of the standard total hip replacement procedure did not show any significant differences, not even during further follow-up; by the end of 2008 no implant failure or necessity of revision arthro- plasty was reported.

DISCUSSION

So far the only indisputable fact is that all the benefits of minimally invasive techniques described until now are merely related to time, as they facilitate a faster rate of soft tissue repair; therefore, these techniques only shorten recovery and thus speed up return of the operated hip to full function.

CONCLUSIONS

Based on comparison of the standard anterolateral and minimally invasive techniques it can be concluded that the MIS- AL approach is effective even without the use of special instrumentation. However, the results of this study failed to give unambiguous support to its advantage over the classical technique.

Immunological response in the mouse melanoma model after local hyperthermia

Our study was aimed to characterize the phenotype and functional endpoints of local microwave hyperthermia (LHT, 42 degrees C) on tumor infiltrating and spleen leukocytes. The effectiveness of LHT applied into the tumor of B16F10 melanoma-bearing C57/BL6 mice was compared with anesthetized and non-treated animals. Subpopulations of leukocytes were analyzed using the flow cytometry, and the cytotoxic activity of splenocytes against syngeneic B16F10 melanoma and NK-sensitive YAC-1 tumor cell lines was evaluated in (51)Cr-release assay. Similarly, the in vitro modification of the heat treatment was performed using healthy and melanoma-bearing splenocytes. We found a 40 % increase of activated monocytes (CD11b+CD69+) infiltration into the tumor microenvironment. In the spleen of experimental animals, the numbers of cytotoxic T lymphocytes (CTLs-CD3+CD8+) and NK cell (CD49b+NK1.1+) raised by 22 % and 14 %, respectively, while the NK1.1+ monocytes decreases by 37 %. This was accompanied by an enhancement of cytotoxic effector function against B16F10 and YAC-1 targets in both in vivo and in vitro conditions. These results demonstrate that LHT induces better killing of syngeneic melanoma targets. Furthermore, LHT evokes the homing of activated monocytes into the tumor microenvironment and increases the counts of NK cells and CTL in the spleen.

[Scapholunate instability of the wrist following distal radius fracture]

PURPOSE OF THE STUDY

Scapholunate (SL) ligament disruption frequently occurs together with distal radius fractures. If it is not diagnosed and treated, instability develops and will eventually be manifested as arthritic lesions known as scapholunate advanced collapse (SLAC) of the wrist. The aim of this study was to record the occurrence of SL ligament disruption in the patients treated conservatively for displaced fractures of the distal radius and to find out which fracture types are most often associated with injury to the SL ligament.

MATERIAL AND METHODS

A total of 75 patients treated conservatively for distal radius fractures in 1997-98 were included in the study. The group comprised 41 women and 34 men, with fractures of the right upper limb in 44 and fractures of the left upper limb in 31 patients. They all were at active age, i. e., between 18 and 60 years, and came for a check-up 3 years after injury. They were examined for radiographic findings of SL instability and signs of SLAC development. Radiographs obtained after injury and images taken after reduction and then after bone union were retrospectively evaluated to look for signs of SL instability. The initial fractures were categorized on the AO classification and, for each fracture type, the percent of patients with co-existent SL instability was assessed.

RESULTS

In the group of 75 patients examined at 3 years after injury, 16 (27 %) wrists showed radiographic signs of instability, with SLAC development in 13 patients and no arthritic lesions in three. All patients with SL instability reported pain, restricted range of motion in the wrist or reduced grip strength. The distribution of instability in relation to AO fracture type, expressed as percent, was as follows: SL instability associated with type A2 fracture was found in 38 %, with type A3 fracture in 17 %, and with type B in 25 % of the patients. SL instability was associated with type C1, type C2 and type C3 in 21 %, 27 % and 8 % of the patients, respectively. In radiographs taken after reduction, signs of damage to the SL ligament were apparent in 56 % of these patients. Radiographic findings at 6 weeks after injury showed signs of SL instability in as many as 81 % of the patients.

DISCUSSION

Our results show that SL instability is found in association with type A2 and type A3 fractures, in which trauma force is "used" to break the distal radius and subsequently, due to carpal supination, to disrupt the SL ligament. In type B1 fractures, SL disruption results from an avulsion fracture of the radial styloid process due to ulnar deviation of the wrist. The retrospective evaluation of radiographs revealed that, immediately after reduction, signs of SL instability were obvious in 56 % of the cases. At that stage the condition could have been treated by K-wire transfixation and reattachment of the SL ligament. At 6 weeks, radiographic evidence of SL ligament disruption was found in 81 % of the patients. Even at that stage repair would have been possible by either reattachment or reconstruction of the ligament. It is apparent from these results that the evaluation of radiographic findings after reduction and during follow-up should also focus on other changes in the wrist in addition to signs of bone union.

CONCLUSIONS

Fractures of the distal radius are no longer frequent only in elderly women, as has recently been common, but they are found more and more often in active young persons. Because their bones are healthier, soft tissues are affected more frequently. Injury to the SL joint results in the development of arthritic lesions which may rapidly progress in active patients. SLAC development can be prevented by early diagnosis of soft tissue lesions on X-ray images, because these are usually apparent after reduction or at follow-up. If doubts arise, arthroscopy or another examination should be done, even though these may not be sufficiently reliable.

[Consequennce of nontreatment scapholunate instability of the wrist]

Authors evaluate the results of patients with acute rupture of the scapholunate (SL) ligament, demonstrated by arthroscopy, in this study. One group of patients was treated with reinsertion of SL ligament by the help of Mitek anchor. In the other group there were patients with diagnosed total rupture of SL ligament which rejected the reinsertion of the ligament. Authors evaluate results of both groups 24 months after the injury. On the basis of clinical and X-ray results, even after such short time, reasonably worse results for the group without performed reinsertion were determined. Even X-ray documented arthrotic changes of scapholunate advanced collapse (SLAC) type were present.

Symptomatic osteoradionecrosis of pelvic bones in patients with gynecological malignancies-result of a long-term follow-up

The aim of this study was to assess the incidence and risk factors of pelvic fractures as a result of radiation therapy in women with gynecological cancer. We retrospectively reviewed 3530 female patients treated at our institute between 1980 and 1998 with megavoltage radiation with or without brachytherapy for cancer in the pelvic area. Eligible were patients with vulvar, vaginal, cervical, endometrial, and fallopian tube cancer. Median follow-up was 88 months (range 0-240). Emphasis was put on treatment-related and patient-related risk factors. Of the eligible 3155 patients, 15 developed symptomatic bone fracture caused by osteoradionecrosis, which makes an overall incidence of 0.44% The diagnosis was based on anamnesis, clinical course, and X-ray or computed tomography images. Median time of onset was 44 months (range 6-197). All patients had pain as the first symptom. The only independent predictive factor for developing osteoradionecrosis seemed to be preexistent osteoporosis. Other risk factors that are related to osteoporosis include higher age, postmenopausal status, or steroid treatment. We did not find any significant treatment-related predictive factor for pelvic osteoradionecrosis. Patients with osteoporosis are probably at the highest risk for developing osteoradionecrotic fractures after pelvic radiotherapy. More studies are needed to find out other endogenous predictive factors.

[Our experience with repair of the scapholunate ligament using the MITEK bone anchor]

PURPOSE OF THE STUDY

A complete rupture of the scapholunate (SL) interosseal ligament results in palmar flexion of the scaphoid and dorsiflexion of the lunate that leads to disintegration of the carpal circle and the development of scapholunate dissociation with dorsal intercalary segment instability. If the injury is not treated properly or early, the abnormal position of the scaphoid and lunate results in degenerative changes of the wrist shown by X-ray and referred to as scapholunate advanced collapse (SLAC). The aim of this study was to evaluate the results of our method used for reconstruction of the SL ligament by means of MITEK bone anchors in acute injury.

MATERIAL AND METHODS

The group included 17 patients, 12 male and 5 female, aged 18 to 49 years, with complete SL ligament ruptures. The dominant hand was affected in 10 patients. After the diagnosis had been confirmed, we performed reconstructive surgery involving re-attachment of the SL ligament to the scaphoid by means of the MITEK Mini G2 anchor. The patients were examined by X-rays at 3, 6, 12 and 24 months after the operation to assess the SL angle, capitolunate (CL) angle, SL distance and signs of SLAC. Hand function and pain were evaluated on the basis of the Wrightington Hospital Wrist Scoring (WHWS) system.

RESULTS

The average preoperative value of the SL angle was 79 degrees and was corrected to 38 degrees by surgery. By subsequent physical therapy for 12 months, an SL angle of 51 degrees was achieved and increased to 52 degrees during the following year. The CL angle, showing a preoperative average value of 34 degrees, was corrected by surgery to 6 degrees, further increased to 9 degrees by exercising and then remained unchanged. The average SL distance of 5.25 mm preoperatively was reduced to 2.75 mm by surgery with no further change. At 24 months of follow-up, the results of pain evaluation were excellent, good and satisfactory in 41 %, 47 % and 12 % of the patients, respectively, with no poor outcome indicating restriction of the patient's daily activities. Functioning of the hand was excellent in 47 %, good also in 47 % and satisfactory in 6 % of the patients. The range of motion was excellent, good and satisfactory in 24 %, 64 % and 12 % of the patients, respectively. No stiff wrist was recorded after reconstruction of the SL ligament by our method. The hand grip was evaluated as excellent in 47 %, good in 35 % and satisfactory in 18 % of the patients.

DISCUSSION

The results show that by reconstruction of the SL ligament with the use of MITEK anchors, radiographic values of the SL and CL angles and SL distance can reach the normal levels within 24 months of the operation. As assessed by the WHWS system, excellent and good results were achieved in 88 % of the wrists treated. Similarly, at 24 months of followup, excellent or good functional outcomes were reported by 94 % of the patients, and excellent or good results in relation to the range of motion and hand grip were experienced by 88 % and 82 % of the patients, respectively.

CONCLUSIONS

When treating complete SL ligament ruptures within 4 weeks of injury, stabilization with Kirschner's wires, re-attachment of the SL ligament and suture of the articular capsule are adequate procedures leading to the best results. The ligament reconstruction with MITEK anchors, as presented here, is a relatively simple method giving good results. For treatment of chronic instability it is necessary to use other surgical procedures that, however, will reduce wrist mobility to a greater extent.

[Forefoot surgery under regional anesthesia]

PURPOSE OF THE STUDY

The aim of this study is to present the method of lower limb peripheral nerve block for forefoot surgery and, in comparison with other methods, to evaluate the results in terms of postoperative analgesia and postoperative complications.

MATERIAL

Our group included 164 patients, 13 men and 151 women in the age range from 16 to 79 years, who underwent surgery for forefoot deformities during the years 1998-99. Of these, 77 (46 %) were operated on under general anesthesia, 54 (33 %) under infiltration anesthesia and 33 (21 %) under peripheral nerve block.

METHODS

When peripheral nerve block was used, the anesthetic Marcain was administered about 1 hour before surgery at the following sites: along the deep branch of the peroneal nerve on the dorsal side of the foot, along the tibial nerve behind the inner ankle, and along the sural nerve in the outer ankle region. After surgery, the duration of requirement for analgesia in all three types of anesthesia was recorded. Complications associated with wound healing were also recorded. Subjective satisfaction of the patients was evaluated as a separate issue.

RESULTS

No intraoperative complications were found in the patients operated on under peripheral nerve block. In three patients, regional anesthesia was not sufficient and had to be completed with topical anesthetics administered during the operation. The patients treated under regional anesthesia asked for analgesics after an average of 9.5 hours; those operated on under infiltration and general anesthesia required analgesics at an average of 2.5 hours (range, 2 to 4 hours) and within 30 min of waking up, respectively. Complications associated with wound healing were recorded in 5 %, 11 % and 6 % of the patients treated under general, infiltration and regional anesthesia, respectively. Of the 33 patients operated on under regional anesthesia, 28 would prefer this anesthesia for any other similar surgery and five would rather have general anesthesia.

DISCUSSION

Regional anesthesia is associated with fewer complications of wound healing than topical anesthesia, which is apparently due to a lower degree of ischemia produced in the treated limb by peripheral nerve block. Healing after regional anesthesia is only a little worse than after general anesthesia, but with the absence of risks related to general anesthesia. Patients operated on under general anesthesia feel pain immediately after surgery, those receiving infiltration anesthesia ask for painkillers at an average of 2.5 hours and, with well-introduced regional anesthesia, patients are free from pain for 9.5 hour on the average. The duration of postoperative pain absence is also related to the anesthetic used. The use of 1 % Mesocain results in a fast onset of anesthesia but its effect is shorter, while 0.5 % Marcain has a slower onset but a longer effect.

CONCLUSIONS

Regional anesthesia for forefoot surgery, if the anesthetic is well administered, is one of the options associated with minimal risks. It apparently reduces complications of wound healing, when compared with infiltration anesthesia. It can be used in situations where general anesthesia would put the patient at risk. It also has a pronounced analgesic effect that persists well after surgery and provides better postoperative comfort for the patient. Key words: lower limb, peripheral nerve block, forefoot surgery.

[Determination of heavy metals in infusion solutions using modern polarography methods]

The pharmacopoeial method of determination of heavy metals based on the formation of coloured sulphides, in comparison with instrumental methods, has relatively little sensitivity and does not provide selective determination of the individual ions. In order to determine some heavy metals in water for injection and infusion solutions, the authors employed the method of differential pulse polarography (DPP) and differential pulse anodic solvent voltammetry (DPASV) on the hanging mercury dropping (HMDE) with the use of the fast scan method (FSDPP). DPASV method proved to be particularly suitable; without any larger analytical problems the sensitivity of determination up to 8.10(-10) mol.1(-1) for copper, lead, cadmium and zinc ions was achieved. Bismuth and tin ions are also polarographically active, as well as nickel and chromium ions with the use of SPP. The medium of pH 4 achieved by adding potassium hydrogen-phthalate proved to be good. When there was an interfering effect of the access of chloride ions for copper determination, a strongly acid medium of hydrochloric acid 1 mol.1(-1) was used; an interfering effect of decomposition products of sugars on zinc determination was eliminated by performance at pH 7. Potentials of the peaks of the individual metals in various media are shown in Table I, the found values in Table II.

[Mercurimetric determination of cephalosporin antibiotics]

The conditions for a potenciometric estimation of cefuroxime, cefsulodin, cefotaxime and ceftriaxon with mercury(II) perchlorate after the previous reaction of the antibiotics with hydroxylamine were established. The mercurimetric determination was well reproducible with the relative error of the mean ranging up to 1% and the results are identical with the spectrometric and microbiological determination. There is no need to use a standard. With this technique only the content of effective antibiotic with an intact beta-lactam ring can be estimated. The method did not provide objective results for cefoperazone and cefoxitin. The direct determination of cephalosporin degradation products was verified for cefalexin, cefalothin, cefuroxime, cefsulodin and ceftriaxon.

[Conditions for the mercurimetric determination of the drug content of penicillins]

Mercurimetric determination of penicillins includes direct titration with a solution of mercury (II) perchlorate in the medium of pyridine solvent or acetate buffer, which determines the content of decomposition products, and titration after alkaline hydrolysis, which indicates the total amount of penicillin. The determination which is indicated potentiometrically with continuous addition of the titrant, provides real and reproducible results in the titration rate of 0.6 ml/min with the initial concentration of penicillin 170 mg/30 ml and temperature 25 degrees C. Benzathine and procaine salts of benzylpenicillin and benzathine salt of phenoxymethylpenicillin were dissolved in dimethylformamide (DMF) before the titration in acetate buffer. Titrations of ampicillin, amoxycillin and azlocillin were performed in the mixture of acetate buffer and formamide which ensured real results. Hydrolysis of the lactam ring of azlocillin, mezlocillin, ticarcillin and piperacillin is quantitative in 10 min of action of NaOH (1 mol/l) which was confirmed by comparing with the enzymatic cleavage. Relative standard deviation for all penicillins was less than 1%. The accuracy of the method for the determination of penicillins was proved by comparing with the microbiological and iodometric determination. The mercurimetric determination of penicillins and their decomposition products in acetate buffer was applied to injections, tablets, capsules and dry sirup.