Prosthetic Joint Infections and Cost Analysis?

Prosthetic joint infection is a devastating complication of arthroplasty surgery that can lead to debilitating morbidity for the patient and significant expense for the healthcare system. With the continual rise of arthroplasty cases worldwide every year, the revision load for infection is becoming a greater financial burden on healthcare budgets. Prevention of infection has to be the key to reducing this burden. For treatment, it is critical for us to collect quality data that can guide future management strategies to minimise healthcare costs and morbidity / mortality for patients. There has been a management shift in many countries to a less expensive 1-stage strategy and in selective cases to the use of debridement, antibiotics and implant retention. These appear very attractive options on many levels, not least cost. However, with a consensus on the definition of joint infection only clarified in 2011, there is still the need for high quality cost analysis data to be collected on how the use of these different methods could impact the healthcare expenditure of countries around the world. With a projected spend on revision for infection at US$1.62 billion in the US alone, this data is vital and urgently needed.

Performance of patients with a "frozen pelvis" in an in vitro fertilization program.

It is now possible to identify and study the performance of different subgroups of patients in in vitro fertilization (IVF) programs. Patients with severe pelvic adhesions due to pelvic inflammatory disease (PID) or endometriosis were classed as having a frozen pelvis if less than or equal to 20% of total ovarian surface was visible and if the rest of the ovary was bound down with significant adhesions. IVF offers the only hope of pregnancy for these patients. Fifty-one treatment cycles in 23 such patients were matched against 51 cycles in 48 patients with adhesion-free ovaries. The study group had a significantly higher number of cancelled oocyte retrievals because of poor estradiol (E2) response. They also had a significantly lower rate of E2 rise and a lower peak value of E2 before and after the administration of human chorionic gonadotropin. These patients took longer to respond to a hyperstimulation regime, and when a response occurred they formed fewer follicles, as measured with the use of ultrasound. Lower numbers of oocytes were obtained from this group, but the fertilization rate of oocytes was the same for both groups. One pregnancy occurred in the study group and 11 in the control group. It is possible that disruption of ovarian blood supply or mechanical factors due to the pressure of significant adhesions prevent a good follicular response in patients with a frozen pelvis.

Vaginal delivery following caesarean section.

A retrospective analysis was made of 456 patients who had previously undergone Caesarean section and who were considered suitable for a trial of labour. Sixty percent of patients had a vaginal delivery. Patients with obstructed labour or failure to progress as the indication for primary Caesarean section were significantly more likely to require a repeat operation but 44% of these patients still achieved a vaginal delivery. Patients who had had a vaginal delivery prior to, or subsequent to, the Caesarean section had a low incidence of repeat Caesarean section. X-ray pelvimetry was of limited value in predicting outcome. Intravenous oxytocin was used in 17% of patients. No uterine rupture occurred and no fetal mortality resulted directly due to the trial of labour. Trial of labour following Caesarean section is a safe procedure when conducted in an appropriate hospital setting.

Dysfunctional uterine bleeding in women over 40 years of age.

Two hundred patients aged 40 years or more who were discharged from hospital with a diagnosis of dysfunctional uterine bleeding were followed up for 6 years. Ninety-three patients eventually underwent hysterectomy and in 64% a pathological abnormality was noted in the uterus. The length of the uterine cavity and the presence of painful and/or heavy periods were the best predictors of outcome. Response to hormonal therapy was poor.

Pain with amniocentesis and transabdominal CVS.

Fifty consecutive patients undergoing transabdominal chorionic villus sampling (CVS) and 52 undergoing amniocentesis completed a questionnaire following the procedure to determine the amount of pain they experienced. Mild pain, discomfort only or no pain was reported by 96% undergoing amniocentesis and 90% with CVS. Moderate or severe pain was reported after completion of the CVS by 8% and following amniocentesis by 2%. Both procedures were well tolerated.

Transabdominal chorionic villus sampling.

The first 100 patients undergoing first trimester transabdominal chorionic villus sampling (placental biopsy) in our hospital are reviewed. At the time of follow up 24 patients had delivered, 68 pregnancies were at 24 weeks or more and progressing normally, 7 pregnancies were terminated and there was only 1 spontaneous miscarriage. The advantages of the transabdominal approach are discussed.

Ultrasound-guided fetal intravascular transfusions for severe erythroblastosis, 1984-1993.

The results of the first 10 years' experience in ultrasound-guided fetal intravascular transfusions at the Royal Women's Hospital were reviewed. Since the first transfusion, a variety of techniques have been employed in 78 fetuses, all with severe erythroblastosis. A total of 288 intrauterine transfusions have been attempted with an overall survival rate of 75.6% (59 of 78). The overall survival rate for delivered fetuses improved from 64.3% (18 of 28) in 1984-1987, to 82.0% (41 of 50) in 1988-1993. There was a total of 33 hydropic fetuses, of whom 20 (60.6%) survived, significantly fewer compared with 86.7% (39 of 45) of the nonhydropic fetuses (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.09 to 0.70, p < .01). Fetuses who were sicker at the time of transfusion, as reflected by larger haemoglobin deficits, had lower survival rates, as did those requiring transfusions at earlier gestational ages. When these variables were allowed for, the survival rate significantly improved over time (OR 6.3, 95% CI 1.3 to 30.4, p < 0.05), probably reflecting the increased skill of the ultrasonologists, but the presence of hydrops per se was no longer important. Variations of the technique employed, such as exchange or intraperitoneal transfusion, or different sites for transfusion, were not significantly related to survival.

Transabdominal chorion villus sampling: a safe and reliable procedure.

A complete follow-up of the first 578 patients undergoing transabdominal chorion villus sampling (TACVS) in our combined practices was undertaken to determine the pregnancy loss rate. Factors contributing to losses and the problems incurred in achieving a clinically relevant result were also examined. It was found that increasing experience led to fewer procedural difficulties but that there persisted a higher problem rate in those women with a retroverted uterus. In 98.1% of patients an adequate volume of tissue was obtained and in 95.5% a clinically relevant result was achieved. This second figure rose to 96.3% in the latter part of the study. There was a total fetal loss rate of 2%, with only 0.5% (3 patients) having a missed abortion within 4 weeks of the procedure. It is concluded that TACVS is a reliable procedure with a high level of safety.

Correlation between nuchal thickness and abnormal karyotype in first trimester fetuses.

OBJECTIVE: To evaluate the accuracy of ultrasound measurement of nuchal thickness in first trimester fetuses for predicting fetal karyotype. DESIGN: A prospective study of the nuchal thickness of fetuses measured during an ultrasound examination in all women undergoing first trimester chorionic villus sampling (CVS). SETTING: Two major public hospitals and two associated private practices between 7 September 1993 and 6 September 1994. PARTICIPANTS: Pregnant women with various indications for CVS (in 82% because of maternal age). RESULTS: 1306 women underwent CVS, including 11 with twin pregnancies: 1317 fetuses were tested. Karyotype results were obtained for 1312 fetuses: 41 (3.1%) had an abnormal karyotype, and 20 of these (49%) had a nuchal thickness measurement of 3 mm or more, compared with 44 (3.5%) of the 1271 fetuses with a normal karyotype. Of the 21 fetuses shown to have trisomy 21, 12 would have been detected if a nuchal thickness of 3 mm or more had been used as an indicator, giving a sensitivity of 57%. Nuchal thickness measurements of 1 or 2 mm excluded trisomy 21 with a negative predictive value of 99.3%. Fetuses with moderate nuchal thickening, normal karyotype and no other problems noted on the initial ultrasound scan had neonatal outcomes similar to those in the general obstetric population. CONCLUSION: Nuchal thickening in the first trimester (10 weeks on) of pregnancy in a high risk population is a powerful indicator of increased risk of aneuploidy.