Systematic criteria for type and screen based on procedure's probability of erythrocyte transfusion.

BACKGROUND: At many hospitals, the type and screen decision is guided by the hospital's maximum surgical blood order schedule, a document that includes for each scheduled (elective) surgical procedure a recommendation of whether a preoperative type and screen be performed. There is substantial heterogeneity in the scientific literature for how that decision should be made. METHODS: Anesthesia information management system data were retrieved from the 160,207 scheduled noncardiac cases in adults of 1,253 procedures at a hospital. RESULTS: Neither assuming a Poisson distribution of mean erythrocyte units transfused, nor grouping rare procedures into larger groups based on their anesthesia Current Procedural Terminology code, was reliable. In contrast, procedures could be defined to have minimal estimated blood loss (less than 50 ml) based on low incidence of transfusion and low incidence of the hemoglobin being checked preoperatively. Among these procedures, when the lower 95% confidence limit for erythrocyte transfusion was less than 5%, type and screen was shown to be unnecessary. The method was useful based on including multiple differences from the hospital's maximum surgical blood order schedule and clinicians' test ordering (greater than or equal to 29% fewer type and screen). Results were the same with a Bayesian random effects model. CONCLUSIONS: We validated a method to determine procedures on the maximum surgical blood order schedule for which type and screen was not indicated using the estimated blood losses and incidences of transfusion.

Periprosthetic infection: are current treatment strategies adequate?

Two-staged resection arthroplasty with delayed reimplantation is currently the method of choice for treatment of an infected total hip arthroplasty. There is paucity of data regarding the risk factors for reinfection after reimplantation. The objective of this study was to determine the efficacy of two-stage resection arthroplasty for infected THA and to identify risk factors for reinfection. The outcome of this procedure was evaluated in 54 consecutive patients at our institution from January 1999 to August 2005. The mean follow-up time for patients who were successfully treated was 32 months (range: 24 to 76 months). Infection with methicillin-resistant organisms occurred in 33 patients (61%). Recurrent infection was diagnosed in 14 patients (26%) after the second stage reimplantation procedure at an average of 10.6 months. An elevated ASA, which is an indicator of advanced comorbid health status, and infection with methicillin-resistant organisms were risk factors for treatment failure. An additional 8% of the cohort developed early mechanical failure at a mean of 13.8 months. The increase in the number of resistant organisms and the rise in the number of patients with comorbid conditions have compromised the efficacy of two-stage exchange arthroplasty. Hence novel techniques for the treatment of periprosthetic infection are desperately needed.

The Tinel sign: a historical perspective.

The Tinel sign is one of the most well-known and widely used clinical diagnostic tools in medicine. Aside from Jules Tinel, after whom the sign is named, several authors have described the famous "tingling" sign seen in regenerating injured nerves. In fact, Tinel was not the first to present the sign to the scientific community. The clinical value and utility of the Tinel sign have remained in question since its introduction; many may misinterpret the sign as a prelude to complete functional recovery of injured nerves, when in fact it only signals the progress of nerve regeneration. Today the Tinel sign is widely associated with the diagnosis of carpal tunnel syndrome and in the evaluation of regenerating peripherally injured nerves. Knowledge of the history and misconceptions surrounding the sign provides clinicians today with a greater appreciation of current debates on the use of the Tinel sign.

Comparison of glucose monitoring methods during steady-state exercise in women.

Data from Continuous Glucose Monitoring (CGM) systems may help improve overall daily glycemia; however, the accuracy of CGM during exercise remains questionable. The objective of this single group experimental study was to compare CGM-estimated values to venous plasma glucose (VPG) and capillary plasma glucose (CPG) during steady-state exercise. Twelve recreationally active females without diabetes (aged 21.8 ± 2.4 years), from Central Washington University completed the study. CGM is used by individuals with diabetes, however the purpose of this study was to first validate the use of this device during exercise for anyone. Data were collected between November 2009 and April 2010. Participants performed two identical 45-min steady-state cycling trials (~60% P(max)) on non-consecutive days. Glucose concentrations (CGM-estimated, VPG, and CPG values) were measured every 5 min. Two carbohydrate gel supplements along with 360 mL of water were consumed 15 min into exercise. A product-moment correlation was used to assess the relationship and a Bland-Altman analysis determined error between the three glucose measurement methods. It was found that the CGM system overestimated mean VPG (mean absolute difference 17.4 mg/dL (0.97 mmol/L)) and mean CPG (mean absolute difference 15.5 mg/dL (0.86 mmol/L)). Bland-Altman analysis displayed wide limits of agreement (95% confidence interval) of 44.3 mg/dL (2.46 mmol/L) (VPG compared with CGM) and 41.2 mg/dL (2.29 mmol/L) (CPG compared with CGM). Results from the current study support that data from CGM did not meet accuracy standards from the 15197 International Organization for Standardization (ISO).

A cost/utility analysis of open reduction and internal fixation versus cast immobilization for acute nondisplaced mid-waist scaphoid fractures.

BACKGROUND: Open reduction and internal fixation and cast immobilization are both acceptable treatment options for nondisplaced waist fractures of the scaphoid. The authors conducted a cost/utility analysis to weigh open reduction and internal fixation against cast immobilization in the treatment of acute nondisplaced mid-waist scaphoid fractures. METHODS: The authors used a decision-analytic model to calculate the outcomes and costs of open reduction and internal fixation and cast immobilization, assuming the societal perspective. Utilities were assessed from 50 randomly selected medical students using the time trade-off method. Outcome probabilities taken from the literature were factored into the calculation of quality-adjusted life-years associated with each treatment. The authors estimated medical costs using Medicare reimbursement rates, and costs of lost productivity were estimated by average wages obtained from the U.S. Bureau of Labor Statistics. RESULTS: Open reduction and internal fixation offers greater quality-adjusted life-years compared with casting, with an increase ranging from 0.21 quality-adjusted life-years for the 25- to 34-year age group to 0.04 quality-adjusted life-years for the > or =65-year age group. Open reduction and internal fixation is less costly than casting ($7940 versus $13,851 per patient) because of a longer period of lost productivity with casting. Open reduction and internal fixation is therefore the dominant strategy. When considering only direct costs, the incremental cost/utility ratio for open reduction and internal fixation ranges from $5438 per quality-adjusted life-year for the 25- to 34-year age group to $11,420 for the 55- to 64-year age group, and $29,850 for the > or =65-year age group. CONCLUSIONS: Compared with casting, open reduction and internal fixation is cost saving from the societal perspective ($5911 less per patient). When considering only direct costs, open reduction and internal fixation is cost-effective relative to other widely accepted interventions.