The service impact of failed locking plate fixation of distal tibial fractures: a service and financial evaluation at a major trauma centre.

INTRODUCTION: The surgical treatment of distal tibial fractures is challenging and controversial. Recently, locking plate fixation has become popular, but the outcomes of this treatment are mixed with complication rates as high as 50 % in the published literature. There are no reports specifically relating to the financial and resource costs of failed treatment in the literature. METHOD: Retrospective service analysis of patients who had undergone locking plate fixation of a distal third tibial fracture between 2008 and 2011 with at least 12 months follow-up. Rates of readmission, reoperation, bony union and infection were ascertained. The financial and resource (hospital stay and number of outpatient appointments) implications of failed treatment were calculated. RESULTS: Forty-two patients were identified. There were 31 type A fractures, one type B fracture and 10 type C fractures. Three injuries were open. Twenty patients were treated with minimally invasive percutaneous osteosynthesis (MIPO). The readmission and reoperation rates were 26 % (n = 11) and 19 % (n = 8), respectively. A total of 89 % of readmissions were due to infection. All patients had received appropriate antibiotic regimens. The average costs of successful and failed treatment were £ 5538 and £ 18,335, respectively. The average time to union was 24.5 weeks. The rate of non-union was 21 % (n = 9). The rate of infection was 28 % (n = 12), with all patients with open fracture incurring an infection. Tourniquet time had no effect on the incidence of complications. Smokers were more likely to incur a complication (p < 0.05), and non-union was lower in the MIPO group (p < 0.05). The length and total cost of inpatient care were significantly lower in the MIPO group (p < 0.05). MIPO patients were five times less likely to incur readmission or reoperation. Failed treatment was three times more expensive and four times longer than successful treatment. CONCLUSION: The study identified a large burden to the service following failure of locking plate treatment of these fractures, but the outcomes were similar to series published in the literature. Readmission rates were high following these injuries, and failed treatment was costly and had a significant impact on hospital resources. The implementation of major trauma networks and centralised subspecialised units should improve quality and value for money.

Consensus on managing open ankle fractures in the frail patient.

Aims: Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods: A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results: In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion: A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing.

Exercise-associated rhythm disturbances in poorly performing Thoroughbreds: risk factors and association with racing performance.

BACKGROUND: Exercise-associated cardiac rhythm disturbances are common, but there is a lack of evidence-based criteria on which to distinguish clinically relevant rhythm disturbances from those that are not. OBJECTIVES: To describe and characterise rhythm disturbances during clinical exercise testing; to explore potential risk factors for these rhythm disturbances and to determine whether they influenced future racing. STUDY DESIGN: Retrospective cohort using a convenience sample. METHODS: Medical records were reviewed from two clinical services to identify horses with poor performance and/or respiratory noise with both exercise endoscopy and electrocardiography results. Respiratory and ECG findings recorded by the attending clinicians were described, and for polymorphic ventricular rhythms (n = 12), a consensus team agreed the final rhythm characterisation. Several statistical models analysing risk factors were built and racing records were reviewed to compare horses with and without rhythm disturbance. RESULTS: Of 245 racehorses, 87 (35.5%) had no ectopic/re-entrant rhythms, 110 (44.9%) had isolated premature depolarisations during sinus rhythm and 48 (19.6%) horses had complex tachydysrrythmias. Rhythm disturbances were detected during warm-up in 20 horses (8.2%); during gallop in 61 horses (24.9%) and during recovery in 124 horses (50.6%). Most complex rhythm events occurred during recovery, but there was one horse with a single couplet during gallop and another with a triplet during gallop. Fifteen horses (one with frequent isolated premature depolarisations and 14 complex rhythms) were considered by clinicians to be potentially contributing to poor performance. Treadmill exercise tests, the presence of exercise-associated upper respiratory tract obstructions and National Hunt racehorses were associated with rhythm disturbances. The proportion of horses racing again after diagnosis (82%) was similar in all groups and univariable analysis revealed no significant associations between subsequent racing and the presence of any ectopic/re-entrant rhythm, or the various sub-groups based on phase of exercise in which this was detected. MAIN LIMITATIONS: Reliance on retrospective data collection from medical records with no control group. Exercise ECGs were collected using only 1 or 2 leads. Variables examined as risk factors could be considered to be inter-related and our sub-groups were small. CONCLUSIONS: This study confirms a high prevalence of cardiac rhythm disturbances, including complex ectopic/re-entrant rhythms, in poorly performing racehorses. Detection of rhythm disturbances may vary with exercise test conditions and exercise-associated upper respiratory tract obstructions increase the risk of rhythm disturbances.

Associations among echocardiography, cardiac biomarkers, insulin metabolism, morphology, and inflammation in cats with asymptomatic hypertrophic cardiomyopathy.

BACKGROUND: Insulin, insulin-like growth factor-1 (IGF-1), and inflammation possibly are involved in cats with asymptomatic hypertrophic cardiomyopathy (aHCM). OBJECTIVES: To evaluate echocardiography, morphology, cardiac and inflammatory markers, insulin and IGF-1 in cats with aHCM. ANIMALS: Fifty-one client-owned cats with aHCM. METHODS: Observational descriptive study. Variables (body weight [BW], body condition score [BCS], echocardiography, and serum concentrations of N-terminal pro-B-type natriuretic peptide [NT-proBNP], ultra-sensitive troponin-I [c-TnI], serum amyloid A [SAA], insulin, glucose and IGF-1) were evaluated for significant increases above echocardiography cutoff values and laboratory reference ranges, associations and effect of left atrial (LA) remodeling and generalized hypertrophy. RESULTS: Cats with aHCM had BCS ≥6/9 (P = .01) and insulin (P < .001), NT-proBNP (P = .001) and cTn-I (P < .001) above laboratory reference ranges. Associations were present between NT-proBNP and maximum end-diastolic interventricular septum thickness (IVSd; ρ = .32; P = .05), maximum end-diastolic left ventricular free wall thickness;(ρ = .41; P = .01), LA/Aorta (ρ = .52; P = .001) and LA diameter (LA-max; ρ = .32; P = .05); c-TnI and LA/Aorta (ρ = .49; P = .003) and LA-max (ρ = .28; P = .05); and SAA and number of IVSd regions ≥6 mm thickness (ρ = .28; P = .05). Body weight and BCS were associated with IGF-1 (r = 0.44; P = .001), and insulin (ρ = .33; P = .02), glucose (ρ = .29; P = .04) and IGF-1 (ρ = .32; P = .02), respectively. Concentrations of NT-proBNP (P = .02) and c-TnI (P = .01), and SAA (P = .02), were higher in cats with LA remodeling, and generalized hypertrophy, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE: Results suggest potential implications of insulin, IGF-1, and inflammation in cats with aHCM, but it remains to be confirmed whether these findings represent a physiological process or a part of the pathogenesis and development of disease.

Exploring semantic deep learning for building reliable and reusable one health knowledge from PubMed systematic reviews and veterinary clinical notes.

BACKGROUND: Deep Learning opens up opportunities for routinely scanning large bodies of biomedical literature and clinical narratives to represent the meaning of biomedical and clinical terms. However, the validation and integration of this knowledge on a scale requires cross checking with ground truths (i.e. evidence-based resources) that are unavailable in an actionable or computable form. In this paper we explore how to turn information about diagnoses, prognoses, therapies and other clinical concepts into computable knowledge using free-text data about human and animal health. We used a Semantic Deep Learning approach that combines the Semantic Web technologies and Deep Learning to acquire and validate knowledge about 11 well-known medical conditions mined from two sets of unstructured free-text data: 300 K PubMed Systematic Review articles (the PMSB dataset) and 2.5 M veterinary clinical notes (the VetCN dataset). For each target condition we obtained 20 related clinical concepts using two deep learning methods applied separately on the two datasets, resulting in 880 term pairs (target term, candidate term). Each concept, represented by an n-gram, is mapped to UMLS using MetaMap; we also developed a bespoke method for mapping short forms (e.g. abbreviations and acronyms). Existing ontologies were used to formally represent associations. We also create ontological modules and illustrate how the extracted knowledge can be queried. The evaluation was performed using the content within BMJ Best Practice. RESULTS: MetaMap achieves an F measure of 88% (precision 85%, recall 91%) when applied directly to the total of 613 unique candidate terms for the 880 term pairs. When the processing of short forms is included, MetaMap achieves an F measure of 94% (precision 92%, recall 96%). Validation of the term pairs with BMJ Best Practice yields precision between 98 and 99%. CONCLUSIONS: The Semantic Deep Learning approach can transform neural embeddings built from unstructured free-text data into reliable and reusable One Health knowledge using ontologies and content from BMJ Best Practice.