Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards.

The 'Sepsis Six' bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016-2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full 'Sepsis Six' care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the 'Sepsis Six' bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1-26.9) with no difference between each year of study. 90-day survival for years 2017-2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.

Evaluation of an expectation and outcome measurement questionnaire in ankle fracture patients: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) Eurasia study.

BACKGROUND: The Trauma Expectation Factor Trauma Outcomes Measure (TEFTOM) questionnaire is a self-administered, patient-rated outcome measurement questionnaire designed to measure both 'expectation' and 'outcome' in orthopaedic trauma patients using two subsets of 10 items. We aimed to validate this instrument in a culturally diverse cohort of patients recruited from Asian and European regions. METHODS: A total of 193 adult patients with surgically treated AO Foundation/Orthopaedic Trauma Association types 43 and 44 ankle malleolar and distal tibia fractures were recruited with 158 followed up till 1 year. Expectations were assessed prior to surgery, at 2 weeks and after 6 months using the trauma expectation factor (TEF) score. Outcomes were evaluated at 2 weeks, 6 and 12 months using the trauma outcome measure (TOM), American Academy of Orthopaedic Surgeons (AAOS), foot and ankle outcome score (FAOS) and short form-36 (SF-36) questionnaires. Psychometric properties of TEFTOM were assessed. RESULTS: TEF and TOM demonstrated good internal consistency (Cronbach's α > 0.87) and reliability at all time points (intra-class correlation coefficients > 0.90). TOM showed strong correlations (R2 ≥ 0.60) with the AAOS foot and ankle score, all FAOS subscales, except 'symptoms' and SF-36 physical functioning, role physical, bodily pain, social functioning and the physical component summary at 6 and 12 months. Effect sizes for TOM were 2.30 and 0.74 from 2 weeks to 6 months and from 6 months to 12 months, respectively. The baseline patient TEF was predictive for the 1-year TOM score. CONCLUSIONS: TEFTOM demonstrated good psychometric properties in this cohort of patients with ankle fractures. The TEF 'expectation' score was predictive of the TOM 'outcome' score. We recommend researchers and clinicians to utilize TEFTOM when patient expectation measurement is concerned for orthopaedic trauma patients.

Patellar tendon or hamstring graft anterior cruciate ligament reconstructions in patients aged above 50 years.

BACKGROUND: The treatment of anterior cruciate ligament (ACL) injury consists of arthroscopic ACL reconstruction with patellar tendon or hamstring graft. Satisfactory results have been reported so far in the younger age group. Dilemma arises regarding the suitability of ACL reconstruction in patients aged 50 years and above. This retrospective analyses the outcome of ACL reconstruction in patients aged 50 years and above. MATERIALS AND METHODS: 55 patients aged 50 years and above presented to our institution with symptomatic ACL tear and were managed with arthroscopic reconstruction with patellar tendon/hamstring graft. 22 patients underwent ACL reconstruction with bone- patellar tendon-bone graft and the remaining 33 with a hamstring graft. Evaluation of functional outcome was performed using International Knee Documentation Committee (IKDC) and Lysholm scoring in the preoperative period, at the end of 1 year and at the final followup. Radiographic evaluation was performed using the Kellgren-Lawrence grading system. RESULTS: The mean preoperative IKDC score was 39.7 ± 3.3. At the end of 1-year following the operation, the mean IKDC score was 73.6 ± 4.9 and at the final followup was 67.8 ± 7.7. The mean preoperative Lysholm score was 40.4 ± 10.3. At the end of 1-year following the intervention, the mean Lysholm score was 89.7 ± 2.1 and at final followup was 85.3 ± 2.5. Overall, 14 out of 42 patients who underwent radiographic assessment showed progression of osteoarthritis changes at the final followup after the intervention. CONCLUSION: In our study, there was a statistically significant improvement in the IKDC and Lysholm scores following the intervention. There was a slight deterioration in the scores at the final followup but the overall rate of satisfaction was still high and most of the patients were able to do their routine chores and light exercises suitable for their age group. Around one-third of patients show progression of radiographic changes in the postoperative period and this requires long term evaluation.

Patellar clunk in total knee arthroplasty using modified Sigma posterior stabilized femoral component.

AIM: The purpose of this study was to evaluate the efficacy of the enhanced PS femoral component design released in 2008 by DePuy. The patellar clunk syndrome has been reported in a significant number of patients following total knee arthroplasty. Design modifications of the implant have been made to reduce the incidence of the patellar clunk, especially in the posterior substituted designs. METHODS: 130 total knee replacements performed using the enhanced PS femoral components were followed-up with clinical and radiographic evaluations. RESULTS: Patellar clunk was seen in 3 of the 130 knees (2%). This is much less than the incidence of patellar clunk reported until now. CONCLUSIONS: Removal of the sharp ridge in the intercondylar groove in the newer implant seems to have been effective in reducing the incidence of the patellar clunk. It also indicates that the sharp ridge was the most probable cause of the clunk.

Long-term in vitro stability assessment of polycarbonate urethane micro catheters: resistance to oxidation and stress cracking.

Micro catheter tubes were prepared from poly (carbonate urethane) (PCU, Bionate) and poly (ether urethane) (PEU, Pellethane) and their stability was investigated in vitro under applied strain. The tubes were stretched to an elongation of 200% or 300% and exposed to hydrogen peroxide/cobalt chloride (H(2)O(2)/CoCl(2)) solution for specific periods of time (up to 10 months). The samples were observed for surface degradation via scanning electron microscopy, the bulk erosion via the weight difference, and the changes in molecular weight using gel permeation chromatography. The 200% and 300% strained Pellethane tubes kept in H(2)O(2)/CoCl(2) solution for 1 month showed substantial cracking of the surface layer with pitting and have degraded completely within 45 to 60 days (from scanning electron microscopy). Bionate tubes treated in similar conditions for a 10-month period exhibited minute surface erosion in the depth of 0.25-1 microm and showed no evidence of major cracking or pitting. The gel permeation chromatography analysis of 300% strained catheters indicated that the degradation of Bionate tubes was negligible. The 10-month samples had shown approximately 18% reduction in their number average molecular weight (M(n)) and about 8% reduction in weight average molecular weight (M(w)). The Pellethane studied in similar conditions had indicated approximately 72% reduction in M(n) and about approximately 50% reduction in M(w) for 1 month. Overall, the Bionate underwent less degradation and the degradated surface layer was much thinner than Pellethane. These in vitro results are valuable in designing the in vivo studies for using Bionate tube as a long-term implant.

The development of porous alginate/elastin/PEG composite matrix for cardiovascular engineering.

The development of suitable three-dimensional matrices for the maintenance of cellular viability and differentiation is critical for applications in tissue engineering and cell biology. To this end, gel matrices of different proportions of alginate/elastin/polyethylene glycol (Alg/Ela/PEG) were prepared and examined. The composite matrix membranes were evaluated for their porous scaffold using SEM, enzymatic degradation and water content. An equal blend of Alg/Ela with a ratio of Alg/Ela: PEG (7:3) was selected for fabricating Alg/Ela/PEG scaffolds for this study. The Alg/Ela/PEG membranes fabricated at 20 degrees C and - 20 degrees C had a mean surface pore size of 35-45 microm. However, their ultrastructures had shown bigger pore structures (60-75 microm) compared to their surface. It is interesting to note that the membranes of Alg/Ela/PEG prepared at 20 degrees C had larger ultrastructural pores than that of membranes prepared at -20 degrees C. Further, the SEM studies revealed that in the absence of PEG the composite membranes of Alg/Ela formed with less porous structures. The water content of membranes prepared at 20 degrees C was higher with Alg/Ela/PEG (61.6 +/- 4.8%), compared to Alg/Ela (49.9 +/- 0.3%). The enzymatic degradation and water content studies also revealed that the membranes fabricated at - 20 degrees C had high water uptake and low enzymatic degradation, as that of the membranes prepared at 20 degreees C. In other words the larger pore structured membranes had less water content and high degradation profile. This study proposes that this novel composite matrix produces a hierarchical structure that is useful for generating tissue scaffolds for repairing the failing cardiac muscles. However, more detailed investigations with cytocompatibility studies are needed to find applications.

Changes in cisplatin delivery due to surface-coated poly (lactic acid)-poly(epsilon-caprolactone) microspheres.

Smooth muscle cell proliferation plays a major role in the genesis of restenosis after angioplasty or vascular injury. Local delivery of agents capable of modulating vascular responses, have the potential to prevent restenosis. However, the development of injectable microspheres for sustained drug delivery to the arterial wall is a major challenge. We demonstrated the possibility of entrapping an antiproliferative agent, cisplatin, in a series of surface coated biodegradable microspheres composed of poly(lactic acid)poly(caprolactone) blends, with a mean diameter of 2-10 pm. The microspheres were surface coated with poly ethylene glycol (PEG), chitosan (Chit), or alginate (Alg). A solution of cisplatin and a 50:50 blend of polylactic acid (PLA)-polycaprolactone (PCL) dissolved in acetone-dichloromethane mixture was poured into an aqueous solution of PEG (or polyvinyl alcohol or Chit or Alg) with stirring using a high speed homogenizer, for the formation of microspheres. Cisplatin recovery in microspheres ranged from 25-45% depending on the emulsification system used for the preparations. Scanning electron microscopy revealed that the PLA-PCL microspheres were spherical in shape and had a smooth surface texture. The amount of drug release was much higher initially (20-30%), this was followed by a constant slow-release profile for a 30-day period of study. It has been found that drug release depends on the amount of entrapped drug, on the presence of extra cisplatin in the dispensing phase, and on the polymer coatings. This PEG or Alg-coated PLA/PCL microsphere formulation may have potential for the targeted delivery of antiproliferative agents to treat restenosis.

Delivery of LMW heparin via surface coated chitosan/peg-alginate microspheres prevents thrombosis.

Heparin remains the gold-standard inhibitor of the process involved in the vascular response to injury. Continued anticoagulation is achieved by subcutaneous administration of low-molecular-weight heparin (LMW Hep) or with an orally active anticoagulant such as warfarin. An oral heparin would avoid the inconvenience of subcutaneous injections and adverse events associated with warfarin. A mild chitosan/PEG/calcium alginate microencapsulation process, as applied to encapsulation of biological macromolecules such as heparin and LMW Hep was investigated. Heparin and LMW Hep entrapped alginate beads were further surface/enteric coated with chitosan and cellulose acetate phthalate (CAP) via carbodiimide (EDC) functionalities. It was observed that approximately 70% of the content is being released into Tris-HCl buffer, pH 7.4 within the initial 6 hours and no significant release of LMW Hep was observed from enteric coated microspheres (12%) during treatment with 0.1 M HCl, pH 1.0 for 4 hours. But acid treated capsules had released almost all the entrapped LMW Hep into Tris-HCl, pH 7.4 media within 6 hours. From scanning electron microscopic and swelling studies, it appeared that the surface coatings (via chitosan and CAP) had modified the alginate microspheres and subsequently the drug release. The released heparin and LMW Hep had shown their anticoagulant functions. These results established the feasibility of modifying the formulation in order to obtain the desired controlled release of bioactive agent (LMW Hep), for a convenient pH dependent delivery system.