Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital.

OBJECTIVE: Healthcare faces the continual challenge of improving outcome while aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway. DESIGN: Discrete event simulation was used to model and analyse cost and resource utilisation with an activity-based costing approach. Data for a full comparison before the process change was unavailable so we used a modelling approach, comparing a virtual fracture clinic (VFC) with a simulated traditional fracture clinic (TFC). SETTING: The orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study. OUTCOME MEASURES: Our study focused exclusively on patients with non-operative trauma attending emergency department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries are presented in association with activity costs from the models. RESULTS: Patients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face (f2f) attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p≤0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI 21.74 to 23.92) per patient compared with £36.81 (95% CI 35.65 to 37.97) for the TFC pathway. CONCLUSIONS: Our results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional f2f clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings.

Satisfaction and functional outcome with "self-care" for the management of fifth metacarpal fractures.

BACKGROUND: Fifth metacarpal fractures are common and comprise a significant proportion of traditional orthopaedic fracture clinic workload. We reviewed the functional outcome and the satisfaction of patients managed with a new protocol that promoted "self-care" and resulted in the discharge of most of these patients from the emergency department with no further follow-up. METHODS: A retrospective study was performed of patients discharged with a fifth metacarpal fracture between April 2012 to October 2012. A postal questionnaire was sent to each patient, followed by a telephone call. Patient-reported outcome measures (EQ-5D, QuickDASH) and patient satisfaction were assessed. Of the 167 patients eligible for the study, 5 were excluded. Of the remaining 162, 64 were uncontactable or declined to participate. The mean follow-up time was 21.6 months (SD 1.9, range 18.1 to 24.7). RESULTS: The median EQ-5D health index score was 0.87 (IQR 0.74 to 1.00), and the median QuickDASH score was 2.3 (IQR 0 to 6.8). Seventy-nine (80.6 %) patients were satisfied with the outcome of their injury, while 83 (84.9 %) reported being satisfied with the process. There was no difference between those with a fracture or those without a fracture in EQ-5D (p = 0.307) or QuickDASH (p = 0.820). CONCLUSION: Fifth metacarpal fractures can be managed effectively through an Emergency Department protocol without any formal orthopaedic follow-up. This pathway lead to excellent patient-reported outcome measures and patient satisfaction. This protocol has reduced unnecessary hospital attendances for patients and increased the time available for clinicians to deal with more challenging injuries.

Functional outcome and satisfaction with a "self-care" protocol for the management of mallet finger injuries: a case-series.

BACKGROUND: Mallet finger injuries are usually successfully treated non-operatively with a splint. Most patients are reviewed at least twice in a clinic after the initial presentation in A&E. A new protocol promoting "self-care" was introduced at our institution. Patients were provided with structured verbal and written information, and given access to a telephone helpline. METHODS: A prospective electronic patient record was used to identify all patients who presented to the emergency department with a mallet finger with a minimum six month follow-up. A satisfaction and patient reported outcome measure was administered via a postal questionnaire. The response rate was 36/47 (77%). RESULTS: The median QuickDASH score was 2.3 (IQR 0 to 4.6). All patients were satisfied with the treatment plan provided. Nine used the helpline and all were satisfied with information given. Although 13 patients reported some extensor lag, or bump, they had no functional limitation. Seven patients were reviewed by the general practitioner or other clinicians during their treatment period for issues such a skin care, splint size changes or sickness certification. Five were subsequently reviewed at the end of their treatment period in a clinic at their request, or their general practitioner, but did not require further surgical intervention. CONCLUSIONS: Self-care for mallet finger injuries, with adequate patient information and telephone back-up, leads to acceptable functional results and satisfaction. LEVEL OF EVIDENCE: III.

A new "virtual" patient pathway for the management of radial head and neck fractures.

BACKGROUND: Minimally displaced radial head and neck fractures are common and the outcome with conservative treatment is generally excellent. A new protocol was introduced to manage patients with these suspected fractures at a major urban hospital. Simple, undisplaced fractures without other associated injuries or instability were discharged with structured advice but no further face-to-face review. Patients with more complex injuries were reviewed at a "virtual clinic." The aim of this study was to examine the outcome of this process in terms of patient flow, satisfaction, reattendance, and reintervention. METHODS: The 202 eligible patients, who presented during a 1-year period from October 2011 to October 2012, were identified retrospectively from a prospectively collected administrative database. Mason type III and IV fractures were excluded. A questionnaire was administered by mail or phone call to assess satisfaction with the process, information received, and function. RESULTS: Twenty (10%) patients required face-to-face review in a clinic, whereas 182 (90%) were managed with direct discharge; 155 patients responded to the survey (77%). The overall satisfaction rate was 96% in the suspected fracture group and 87% in the definite fracture group (P = .08). Satisfaction with the information provided was 95%. Two (1%) required late surgical intervention. CONCLUSION: In this study, patients with suspected Mason I or II fractures were managed with limited face-to-face follow-up with high satisfaction rates. The reintervention rate was extremely low. This process has significant benefits to patients, who have fewer hospital visits, and to orthopaedic departments, which have more time to devote to complex cases.

Total elbow replacement: outcome of 1,146 arthroplasties from the Scottish Arthroplasty Project.

BACKGROUND AND PURPOSE: Total elbow replacement (TER) is used in the treatment of inflammatory arthropathy, osteoarthritis, and posttraumatic arthrosis, or as the primary management for distal humeral fractures. We determined the annual incidence of TER over an 18-year period. We also examined the effect of surgeon volume on implant survivorship and the rate of systemic and joint-specific complications. METHODOLOGY: We examined a national arthroplasty register and used linkage with national hospital episode statistics, and population and mortality data to determine the incidence of complications and implant survivorship. RESULTS: There were 1,146 primary TER procedures (incidence: 1.4 per 10(5) population per year). The peak incidence was seen in the eighth decade and TER was most often performed in females (F:M ratio = 2.9:1). The primary indications for surgery were inflammatory arthropathy (79%), osteoarthritis (9%), and trauma (12%). The incidence of TER fell over the period (r = -0.49; p = 0.037). This may be due to a fall in the number of procedures performed for inflammatory arthropathy (p < 0.001). The overall 10-year survivorship was 90%. Implant survival was better if the surgeon performed more than 10 cases per year. INTERPRETATION: The prevalence of TER has fallen over 18 years, and implant survival rates are better in surgeons who perform more than 10 cases per year. A strong argument can be made for a managed clinic network for total elbow arthroplasty.

C-Banding/DAPI and in situ hybridization reflect karyotype structure and sex chromosome differentiation in Humulus japonicus Siebold & Zucc.

Japanese hop (Humulus japonicus Siebold & Zucc.) was karyotyped by chromosome measurements, fluorescence in situ hybridization with rDNA and telomeric probes, and C-banding/DAPI. The karyotype of this species consists of sex chromosomes (XX in female and XY1Y2 in male plants) and 14 autosomes difficult to distinguish by morphology. The chromosome complement also shows a rather monotonous terminal distribution of telomeric repeats, with the exception of a pair of autosomes possessing an additional cluster of telomeric sequences located within the shorter arm. Using C-banding/DAPI staining and 5S and 45S rDNA probes we constructed a fluorescent karyotype that can be used to distinguish all autosome pairs of this species except for the 2 largest autosome pairs, lacking rDNA signals and having similar size and DAPI-banding patterns. Sex chromosomes of H. japonicus display a unique banding pattern and different DAPI fluorescence intensity. The X chromosome possesses only one brightly stained AT-rich terminal segment, the Y1 has 2 such segments, and the Y2 is completely devoid of DAPI signal. After C-banding/DAPI, both Y chromosomes can be easily distinguished from the rest of the chromosome complement by the increased fluorescence of their arms. We discuss the utility of these methods for studying karyotype and sex chromosome evolution in hops.

Organochlorines, lead, and mercury in Akwesasne Mohawk youth.

Most humans have detectable body burdens of polychlorinated biphenyls (PCBs), hexachlorobenzene (HCB), and p,p'-dichlorophenyldichloroethylene p,p'-DDE), a metabolite of p,p'-dichlorodiphenyltrichloroethane (DDT). Native American communities may be at increased risk of exposure through subsistence-based diets and greater physical contact with contaminated soil and water. In this article we describe the levels of toxicants (PCBs, p,p'-DDE, HCB, mirex, lead, and mercury) among youth 10-17 years old (n = 271) of the Akwesasne Mohawk Nation. Ultratrace, congener-specific PCB analysis of human serum quantitated 83 PCB congeners (plus 18 as pairs/triplets), in addition to p,p'-DDE, HCB, and mirex, and included all major Aroclor-derived congeners typically present in human samples. Twenty congeners (in 16 chromatographic peaks) were detected in 50% or more of the individuals sampled [geometric mean (GM) of the sum of these congeners = 0.66 ppb]. Thirteen congeners (in 10 peaks) were detected in 75% or more of the samples (GM = 0.51 ppb). Of the 20 congeners detected in 50% or more of the samples, 17 had five or more chlorine substitutions. International Union for Pure and Applied Chemistry congeners 118, 101(+90), and 153 were detected in nearly all participants (GM = 0.06 ppb, 0.05 ppb, 0.09 ppb, respectively). p,p'-DDE and HCB were detected in 100% and 98% of the samples (GM: p,p'-DDE = 0.37 ppb; HCB = 0.03 ppb). Mirex was detected in approximately 46% of the samples (GM = 0.02 ppb). No cases of elevated lead level were observed. One participant had a mercury level marginally higher than the U.S. Environmental Protection Agency's current level of concern (0.50 microg/dL). Although differences in analytic methods and participant ages limit comparability, toxicant levels from the Mohawk youth are lower than those associated with severe food contamination (Yusho and Yu-cheng) but similar to other chronically exposed groups.

[Diagnostic pitfalls in stereotactic biopsy]. / Trudnosci diagnostyczne w ocenie materialu z biopsji stereotaktycznej.

Between October 1998-August 2000, 65 patients were diagnosed, and underwent stereotactic biopsy of brain lesions. Procedures were performed with the Riechert-Mundinger stereotactic device. The diagnosis was made intra-operatively, by examination of cytological smears. The initial diagnosis was confirmed after H&E, and selective stains, as well as immunohistochemical examinations of paraffin specimens. The method applied makes possible to obtain a reliable, and precise morphological diagnosis in the majority of cases, so that a proper treatment method could be introduced.

[Extramedullary erythropoiesis in cerebellar hemangioblastomas]. / Pozaszpikowa erytropoeza w naczyniakach plodowych mózdzku.

Three patients operated on for cerebellar haemangioblastoma are reported. Rarely observed extramedullary erythropoiesis was found in tumour tissue. One patient had erythrocytosis (solid form of the tumour), the remaining patients with cystic tumour had normal erythrocyte count.

[Application of alteplase in prevention of cerebral vasospasm and its sequelae in patients after aneurysmal subarachnoid hemorrhage from ruptured cerebral aneurysm]. / Zastosowanie rekombinowanego tkankowego aktywatora plazminogenu w profilaktyce skurczu naczyniowego oraz jego nastepstw u chorych po krwotoku podpajeczynówkowym z peknietego tetniaka mózgu.

15 patients after SAH from ruptured cerebral aneurysm were operated on within 72 hours after SAH. During the operation after clipping of aneurysm 10 mg of rtPA was administered into basal cisterns, Control group consisted of patients who did not receive rtPA. All the patients on the basis of CT scan were classified to III grade according to Fisher's classification. Control CT scan revealed dissolution of most clots in basal cisterns. In comparison with control group the patients who received rtPA rarely experienced radiological signs of vasospasm and delayed neurological deficit.

[Aneurysm of the anterior communicating artery as a possible late complication of internal carotid artery ligation]. / Tetniak tetnicy laczacej przedniej jako mozliwe pózne powiklanie podwiazania tetnicy szyjnej wewntrznej.

A case of a 55-year-old woman with anterior communicating artery aneurysm has been described. The aneurysm led to subarachnoid haemorrhage 8 years after ligation of the right internal carotid artery in order to turn off an aneurysm of this artery. Angiography showed the existence of collateral circulation through the arterial circle of the brain with haemodynamic disturbances, confirmed by Doppler ultrasonography. According to the views found in the literature these disturbances are considered the probable factor of initiation of the described aneurysm.

Gene sequence of recA+ and construction of recA mutants of Vibrio cholerae.

The recA+ gene of Vibrio cholerae O1 has been cloned, its nucleotide sequence determined and the product characterized. A deletion mutation was constructed in the recA gene and mutants showed the typical sensitivity to UV and to DNA-damaging agents, as well as an inability to mediate homologous DNA recombination. The chromosomal recA deletion mutants in V. cholerae do not show altered virulence in the infant mouse cholera model and are thus ideal strains for use in complementation studies.

[A case of chondroma of the cerebello-pontine angle and clivus]. / Przypadek chrzestniaka kata mostowo-mózdzkowego i stoku.

A 42-year old woman with a rare intracranial tumour-chondroma of the cerebello-pontine angle and clivus is presented. Clinical signs of the disease appeared when the tumour attained a huge size. Despite grave postoperative course the prognosis in our patient was good.

[Subacute epidural hematoma]. / Podostry krwiak nadtwardówkowy.

Eleven patients are reported who had subacute epidural haematoma diagnosed by CT 48 hours after craniocerebral trauma. These haematomas, most frequently, were located outside the temporal region. In some cases capsule of the haematoma could be recognized. The indication to surgical treatment was increasing intensity of intracranial pressure and development or persistence of the signs of focal CNS injury. Effective conservative treatment was given to patients with good general condition in whom CT showed no shifting of midline structures over 5 mm, and the fissure of the fracture was not lying transversely to the course of middle meningeal artery branches.