Frequency of outpatient antibiotic prescription on discharge to hospice care.

The use of antibiotics is common in hospice care despite limited evidence that it improves symptoms or quality of life. Patients receiving antibiotics upon discharge from a hospital may be more likely to continue use following transition to hospice care despite a shift in the goals of care. We quantified the frequency and characteristics for receiving a prescription for antibiotics on discharge from acute care to hospice care. This was a cross-sectional study among adult inpatients (≥18 years old) discharged to hospice care from Oregon Health & Science University (OHSU) from 1 January 2010 to 31 December 2012. Data were collected from an electronic data repository and from the Department of Care Management. Among 62,792 discharges, 845 (1.3%) patients were discharged directly to hospice care (60.0% home and 40.0% inpatient). Most patients discharged to hospice were >65 years old (50.9%) and male (54.6%) and had stayed in the hospital for ≤7 days (56.6%). The prevalence of antibiotic prescription upon discharge to hospice was 21.1%. Among patients discharged with an antibiotic prescription, 70.8% had a documented infection during their index admission. Among documented infections, 40.3% were bloodstream infections, septicemia, or endocarditis, and 38.9% were pneumonia. Independent risk factors for receiving an antibiotic prescription were documented infection during the index admission (adjusted odds ratio [AOR]=7.00; 95% confidence interval [95% CI]=4.68 to 10.46), discharge to home hospice care (AOR=2.86; 95% CI=1.92 to 4.28), and having a cancer diagnosis (AOR=2.19; 95% CI=1.48 to 3.23). These data suggest that a high proportion of patients discharged from acute care to hospice care receive an antibiotic prescription upon discharge.

Computer-assisted navigation of volar percutaneous scaphoid placement.

PURPOSE: To investigate a computer-assisted technique for retrograde insertion of a percutaneous scaphoid screw and compare insertion time, accuracy, and radiation exposure to the traditional technique. We hypothesize that computer-assisted navigation of volar percutaneous scaphoid screw placement would improve accuracy, require less time, and diminish radiation exposure when compared to the traditional technique. METHODS: Ten matched pairs of cadaveric wrists were randomized to computer-assisted versus traditional volar percutaneous scaphoid screw placement. Time of the overall procedure, set-up time, time for ideal guide wire placement, and radiation time were recorded. Number of K-wire attempts was also recorded. Finally, accuracy of planned screw axis and actual screw axis were compared. Student's t-tests and rank sums were used to determine whether the differences in outcome variables between computer-assisted and traditional techniques was significant, with an alpha level of 0.05. RESULTS: Although the overall time of the 2 procedures and the set-up time were not different between the 2 groups, the time for placement of the K-wire was halved in the computer-assisted percutaneous scaphoid fixation group, and the number of K-wire attempts needed for accurate screw placement approached clinical significance. Although the radiation exposures for the individual components of set-up time and final check time were not different, the radiation exposures for global time of the procedure, K-wire placement, and screw placement were clinically significant. CONCLUSIONS: Computer-assisted navigation of volar percutaneous scaphoid screw placement takes no more time that traditional methods and significantly reduces the amount of radiation exposure to the patient. Although not statistically significant, the technique reduced the number of incorrect passes of the K-wire, requiring a single attempt in 4 of the 5 specimens.

A computational approach to the "optimal" screw axis location and orientation in the scaphoid bone.

PURPOSE: The development of small cannulated screws permitted minimally invasive percutaneous fixation of acute scaphoid fractures. There are known mechanical advantages to increased screw length and central screw placement, as well as documented deleterious effects of screw malposition, including articular protrusion, proximal pole fracture, and nonunion. The purpose of this study was to compare 2 methods of calculating a screw axis accessible via a volar surgical approach. METHODS: To prevent screw protrusion through the surface of the scaphoid, we required the central screw axis to be contained completely within a "safe zone," defined as a 3-dimensional region located a fixed distance from the inner cortical surface. Safe zones were calculated based on computed tomography-generated models of the right scaphoid from 10 healthy subjects. Two methods for screw axis calculation were compared: (1) maximum screw length (MSL) within the safe zone and (2) a cylinder best-fit (CYL) to the safe zone. The volar approach was defined as percutaneous screw placement through the scaphoid tubercle without violation of the trapezium. Resultant screw axes were compared between the 2 methods for volar accessibility, screw length, and location of the screw axis. RESULTS: The MSL axes were completely accessible without violating the trapezium in all but 2 subjects. The average MSL axes were 11% longer than the CYL axes and passed significantly closer to the scaphoid tubercle than did the CYL axes (1.8 mm vs 6.4 mm). The MSL axes passed significantly farther (1.6 mm) from the bone centroid than did the CYL axes (0.4 mm). All 10 MSL axes were located in the central one-third of the proximal pole. CONCLUSIONS: Without violation of the trapezium, MSL axis can be attained via the volar percutaneous approach to the scaphoid. Using this approach, the ideal starting point for maximal screw length was located 1.7 mm dorsal and 0.2 mm radial to the apex of the scaphoid tubercle.

Microbial colonization of tourniquets used in orthopedic surgery.

This study analyzed tourniquets used for orthopedic surgery in our hospital to determine the frequency and type of microbial contamination. Group A tourniquets were from our main operating room, Group B tourniquets were from our ambulatory surgicenter, Group C tourniquets were unused, prepackaged, sterile tourniquets from our main operating room, and Group D tourniquets were sterilely packed tourniquets from our ambulatory surgicenter. Tourniquets from Groups A, B, C, and D had 100%, 40%, 0%, and 0% microbial growth, respectively. For Group A tourniquets, coagulase-negative staphylococci, Bacillus, and Staphylococcus aureus were present in 100%, 60%, and 20% of tourniquets, respectively. Twenty percent were contaminated either with Streptococcus sanguis, Aerococcus viridans, or Cornyebacterium species. Coagulase-negative staphylococci and Bacillus were present in 40% and 30% of Group B tourniquets, respectively. Tourniquet contamination may be a risk factor for the development of surgical site infection in orthopedic surgery.

Heparin and fibroblast growth factors affect surfactant protein gene expression in type II cells.

The stimulation and maintenance of the pulmonary alveolar type II cell's capacity to biosynthesize, store, and secrete surfactant proteins (SPs) are modulated to a great extent by growth factors, extracellular matrix (ECM) components, and hormones. It is possible that differences in ECM composition, as exist between type I and II cells normally or as might occur with excessive cell surface shedding during inflammation or injury states, may specifically alter SP expression. Here, isolated type II cells were exposed to the model sulfated ECM heparin; desulfated heparin; and/or fibroblast growth factor (FGF)-1, -2, or -7 for 24 h to examine by quantitative real-time polymerase chain reaction their effects on SP gene expression. Aquaporin 5 (AQP-5) gene expression was also examined as a phenotypic marker for the type I cell. SP-B mRNA abundance was increased 4- to 8-fold by all three FGFs. Heparin at low concentrations (5 microg/ml) or desulfated heparin at high concentrations (500 microg/ml) enhanced the effects of FGF-2 and -7, while high heparin concentrations (500 microg/ml) were inhibitory. In contrast, SP-B mRNA abundance was increased by heparin in a dose- and sulfation-dependent manner when used in combination with FGF-1. SP-C and AQP-5 mRNA levels were increased by heparin alone in a dose- and sulfation-dependent manner, while all FGFs lacked effect on SP-C or AQP-5 mRNA levels. These data indicate that heparin can be stimulatory to SP gene expression depending on concentration, degree of sulfation, and surrounding FGF environment, and that heparin plays a significant role in modulating alveolar epithelial cell phenotype in vitro.

Giant cell tumor of tendon sheath.

Neoplasms of the hand are not common. Giant cell tumor of tendon sheath (GCTTS) is the most common primary tumor of the hand. Many different theories have recently been proposed as to whether GCTTS is a neoplasm or a localized reactive process. We believe the evidence supports a neoplastic origin. Although the origin is still not proved, the presentation, diagnosis, and treatment of GCTTS have been clear for a long time.

Thumb carpometacarpal arthroscopy: a topographic, anatomic study of the thenar portal.

Arthroscopic treatment of osteoarthritis of the thumb carpometacarpal joint has been well described; however, the current site of the 2 working portals, especially the 1-R portal, may be complicated by neurovascular morbidity. This is owing to the close proximity of these portals to important nerves and vessels surrounding the carpometacarpal joint. We studied 7 cadaveric wrists to map out the topographic, anatomic, and arthroscopic position of a new thenar portal. We hypothesized that it would increase considerably the safe zone distances of the portal from vital structures of the joint compared with the traditional portals. This study showed that the thenar portal increases considerably the safe zone of the portal from the sensory branches of the radial nerve and the radial artery and does not put the motor branch of the median nerve at risk. In addition the thenar portal allows for better visualization of the carpometacarpal joint, which leads to improved ability to perform arthroscopic trapeziectomy.

Fibular nonunion after closed rotational ankle fracture.

BACKGROUND: Historically, the standard of care for minimally or nondisplaced, closed, distal fibula fractures has been short-term immobilization and progressive weightbearing. The vast majority of such patients are expected to heal with excellent functional outcome after such treatment. There exists a subpopulation of patients sustaining these fibular fractures who develop symptomatic incomplete union or nonunion despite appropriate management, and later require operative intervention to eliminate pain. METHODS: A retrospective review of 17 referred patients with rotational fibular fractures between August 1999 and July 2003 identified six persistently symptomatic distal fibular fractures after an adequate trial of conservative treatment. Due to their persistent localized pain and difficulty with ambulation, five patients underwent operative treatment of the nonunion with autologous bone grafting with plate and screw osteosynthesis. The sixth patient has refused operative intervention despite persistent symptoms. RESULTS: All six of these patients were identified as low risk for nonunion. Two fibular nonunions were found to be complete and four were partial nonunions. One hundred percent of these patients presented with a chief complaint of pain, had reproducible tenderness with palpation directly at the fracture site, and exhibited a persistent antalgic gait pattern. Four of six patients who underwent surgery noticed complete resolution of their pain and return of their normal gait within an average of 2.3 months postoperatively, with an average follow-up of 19.5 months (range, 2-53 months). CONCLUSIONS: Distal fibula nonunion appears to be a relatively common cause of persistent lateral ankle symptoms in patients who do not enjoy a satisfactory recovery after appropriate conservative treatment. The authors believe that the persistent lateral pain in such patients results from micromotion strain at the incomplete fracture union site. Surgical stabilization of fibular nonunion seems to be a reliable means of resolving these symptoms when conservative measures fail.