Is ethnicity a risk factor for mortality in major trauma? A single-centred cohort study.

INTRODUCTION: Many studies have found varying health outcomes in patients from different minority ethnic groups. There has been limited research into the outcomes in major trauma dependent on ethnicity. The aim was to analyse whether ethnicity was an independent risk factor for 30-day mortality in patients presenting to a major trauma centre when adjusting for confounders. METHODS: This was a retrospective review of all patients presenting to a single major trauma centre from 2010 to 2020. Data were collected on patient demographics and variables including mechanism and injury severity score. Logistic regression was used to determine significant predictors of mortality. RESULTS: There were 10,668 data sets with ethnicity data; of these 9,098 were of White ethnicity, 1,143 were Asian and 427 were classified as Black. The 30-day mortality rate was 7.76% for White ethnicities, 6.91% for Asian ethnicity and 5.15% for people of Black ethnicity. On multivariate logistic regression, ethnicity (p = 0.076) was not associated with 30-day mortality. Age, Injury Severity Score (ISS), Probability of Survival (PS) score, shock and Glasgow Coma Scale (GCS; p < 0.001) were associated with 30-day mortality. White ethnicity had an odds ratio (OR) of mortality of 1.16 (95% confidence interval [CI] 0.658-2.040) (p = 0.609) compared with Black ethnicity and an OR of 0.74 (95% CI 0.546-1.001) (p = 0.050) compared with Asian patients. Black patients had an OR of mortality of 0.65 (95% CI 0.351-1.193) (p = 0.164) compared with the Asian population. CONCLUSION: Ethnicity is not a significant risk factor for 30-day mortality in trauma patients.

Hip arthroplasty practice across the Organisation for Economic Co-operation and Development (OECD) over the last decade.

INTRODUCTION: There are large variations in the number of hip replacements performed between countries, demonstrating large health inequalities; however, there has been limited research on this variation. The aims of this paper were to compare rates of hip replacements using Organisation for Economic Co-operation and Development (OECD) data for the period 2008-2018. The study also compared changes in the number of hip replacements in the total population and in only those aged over 65, and looked for a correlation of health expenditure and gross domestic product (GDP) with rates of hip replacements. METHODS: The OECD collects annual data from all member countries on the numbers of hip replacements, healthcare expenditure and GDP. Data analysis was undertaken using STATA. Descriptive statistics and Pearson's correlation coefficient were performed. RESULTS: The mean number of hip replacements performed in OECD countries in 2018 was 191.5 per 100,000 population per year. The largest number was 310.6 in Germany and the lowest was 8.6 in Mexico. There has been a 21.7% increase in the mean number of hip replacements across OECD countries. There was a moderate and significant Pearson coefficient of 0.468 (p = 0.009) between the number of hip replacements performed per 100,000 population in 2018 and GDP per person, and a strong and significant correlation with health expenditure (R = 0.784, p < 0.001). There was a moderate correlation (R = 0.645, p = 0.003) between the percentage change in the number of hip replacements performed per 100,000 population and the percentage change in healthcare expenditure per person between 2008 and 2018. CONCLUSIONS: There is 36-fold variation in the practice of hip replacements across the OECD and the number of hip replacements has increased by more than 20% over the past decade. The number of hip replacements performed appears to be correlated with health expenditure in each country and may indicate a need that can only be met by increasing health expenditure.

Fracture admission trends in England over a ten-year period.

INTRODUCTION: Fractures are a common reason for admission to hospital around the world. Varying incidences have been reported but these are mainly based on small studies from individual centres. The aim of our study was to analyse fracture admissions in England over a ten-year period. METHODS: Data were collated from the Hospital Episodes Statistics database. Since 2004, data have been collected for all admitted patients in England using the International Classification of Diseases codes for the primary diagnosis. Data were analysed for the ten-year period between 2004-2005 and 2013-2014. RESULTS: There were 2,489,052 fracture admissions in England over the 10-year study period. The risk of admission for fracture was 47.84 per 10,000 population. The rate of fracture admission has remained stable. Hip fractures were the most common fracture requiring hospitalisation (n=641,263), followed by distal radius fractures (n=406,313), ankle fractures (n=332,617) and hand fractures (n=244,013). Hip fractures accounted for 58% of hospital bed days, ankle fractures for 10%, and femoral shaft fractures and subtrochanteric femoral fractures for 5% each. The number of bed days per year for hip fractures has reduced from 1,549,939 bed days in 2004-2005 to 1,319,642 in 2013-2014. CONCLUSIONS: This study provides an updated picture of the incidence of fractures that required hospital admission over a ten-year period in England. It may be used as a platform from which the effect of modern patient treatment pathways can be monitored.

Mortality in patients sustaining a periprosthetic fracture following a previous extracapsular hip fracture fixation.

BACKGROUND: Mortality rates following hip fractures are decreasing. As these outcomes improve, it increases the potential for further falls and the potential to sustain a periprosthetic fracture. The aim of this study was to analyse the 1 year mortality of periprosthetic fractures around an implant used to treat an extracapsular hip fracture. Secondary outcomes included 30 day mortality, complications and risk factors associated with mortality. METHODS: A retrospective case note and radiographic review of all patients who presented to a single institution with a periprosthetic femoral fracture around an implant previously used to treat an extracapsular hip fracture between 1st January and 2008 and 31st May 2015. RESULTS: 29 patients with a mean age of 75.8. 6 males and 23 females. 20 (69.0%) patients had capacity to consent for surgery. Pre-operatively 34.5% mobilised independently without any walking aids. 79.3% lived at home. 62.1% had a Charlson co-morbidity score of 0 or 1, 27.6% a score of 2 or 3, 6.9% a score of 4 and 5, and 3.4% a score of more than 5.3.4% was ASA grade 1, 13.8% ASA2, 65.5% ASA 3 and 17.2% were ASA 4. The previous implant a dynamic hip screw in 75.9% dynamic hip screws and an intramedullary nail in 24.1%. There were 4 (13.8%) in-patient deaths. The 30 day mortality 17.2% (5 patients) was and the 1 year mortality was 44.8% (13 patients). There were 0 complications that required return to surgery during admission. 1 patient with a revision intramedullary nail had dynamisation performed due to delayed union 7 months following surgery. 1 patient required removal of metalwork 2 years following surgery for infection. When comparing risk factors for mortality, there were no significant risk factors found in this study for 30 day and 1 year mortality. CONCLUSIONS: This paper suggests that periprosthetic fractures sustained after the surgical treatment of extra capsular neck of femur fractures have higher mortality rates than hip fractures. These patients should be given the same priority as these patients in there management.

A comparison of two different navigated hip replacement techniques on leg length discrepancy.

We hypothesised that a femoral array placed into bone or an external (pinless) reference marker made no difference to leg length discrepancy in patients undergoing navigated total hip arthroplasty. Consecutive patients undergoing navigated total hip arthroplasty. 162 patients. No statistical difference between preoperative leg length discrepancy (p = 0.524). Mean intraoperative change was 3.7 mm and 4.6 mm (p = 0.262). The mean change in leg length measure post operatively was 4.2 mm and 4.1 mm (p = 0.656). No significant difference in leg length discrepancy between a pinless reference markers and a femoral array placed into the bone.

An HPLC method for the simultaneous quantitation of quinidine, procainamide, N-acetylprocainamide, and disopyramide.

A high performance liquid chromatographic method is reported, which incorporates three internal standards (I-cinchonidine, N-propylprocainamide, and para-chlorodisopyramide) for the simultaneous quantitation of four commonly prescribed antiarrhythmic drugs: quinidine, procainamide, N-acetylprocainamide, and disopyramide. Compounds were separated using combined ion-pairing and adsorption chromatography on a silica column. Inter-run variation was 5.9 CV% for all drugs.

Analysis of ethchlorvynol (Placidyl): evaluation of a comparison performed in a clinical laboratory.

Common techniques for analyzing ethchlorvynol (Placidyl) by colorimetry and gas liquid chromatography are evaluated. Matrix effects are thoroughly examined to determine their contribution to the validity of results.

The quantitative conversion of morphine 3-beta-D glucuronide to morphine using beta-glucuronidase obtained from Patella vulgata as compared to acid hydrolysis.

Methods to confirm morphine in urine require hydrolysis to liberate morphine from its 3-beta-D glucuronide (M-3G) conjugate. Lengthy enzyme hydrolysis procedures prolong testing turnaround time whereas rapid enzyme methods may produce a low conversion of M-3G to morphine. The purpose of this study was to evaluate the quantitative conversion of M-3G to morphine in human urine using a thermally stable beta-glucuronidase isolated from Patella vulgata; to compare these findings with those obtained from acid hydrolysis; and to compare between-run imprecision for both hydrolysis methods. We found both enzyme and acid hydrolysis techniques to be efficient, giving 90.4% and 92.8% conversion of M-3G to morphine, respectively. Also, both methods were found to be reproducible. Over a 14 week period, 20 opiate confirmation batches were analyzed by each hydrolysis method; the coefficient of variation for morphine liberated from M-3G was 5.5% for enzyme hydrolysis and 2.7% for acid hydrolysis.

Improving ion mass ratio performance at low concentrations in methamphetamine GC-MS assay through internal standard selection.

In federally regulated drug testing, laboratories must identify and quantitate drugs and their breakdown products by gas chromatography-mass spectrometry (GC-MS) to a concentration that is at least 60% below the cutoff concentration for reconfirmation purposes. Use of methamphetamine-d5 as an internal standard in routine testing with derivatization by HFBA was found to contribute m/z 91 and 118 ions to the same ions from the nondeuterated methamphetamine in the specimen. This resulted in poor chromatography and occasionally caused the 91/254 and 118/254 ion mass ratios to exceed the +20% acceptance limit established in the calibration process at low concentrations. The analogues methamphetamine-d8 and -d11 were evaluated for contributions to the nondeuterated methamphetamine ion fragments. Methamphetamine-d8 produced m/z 91 and 118 ions, but in less abundance than methamphetamine-d5. Methamphetamine-d11 was found to produce little or no detectable m/z 91 or 118. Replacing methamphetamine-d5 with methamphetamine-d11 eliminates this problem and allows the assay to consistently produce ion mass ratios and acceptable chromatography sufficient for identifying and quantitating methamphetamine at 60% below the 500-ng/mL cutoff concentration.

A high-performance liquid chromatographic method for quantitating bupropion in human plasma or serum.

We report a high-performance liquid chromatographic (HPLC) procedure for quantitating bupropion in serum or plasma for the purpose of therapeutic monitoring. Bupropion and its internal standard, a fluorinated analogue of bupropion, are extracted into hexane-isoamyl alcohol (96:4) after the addition of 400 microL 0.1N KOH. The organic phase is evaporated, reconstituted with 200 microL acetonitrile, and then analyzed on a silica column using a mobile phase consisting of 95% methanol and 5% NH4H2PO4. The ultraviolet detector is set to monitor 248 nm. Within-run and total precision at a therapeutic concentration of 30 ng/mL are 5.2 and 8.5%, respectively. The lower limit of quantitation is 5 ng/mL, and the upper limit of linearity is 400 ng/mL. More than two dozen drugs and metabolites were tested for interference; fluoxetine was the only analyte demonstrating a retention time that would interfere with bupropion quantitation. Chromatographic analysis time per injection is less than 7 min. This procedure combines a single-step extraction with HPLC analysis to provide rapid and reliable analysis of bupropion.

Factors affecting the analysis of cefoperazone in cerebral spinal fluid.

The measurement of cefoperazone concentrations in cerebral spinal fluid (CSF) is important to understanding the biodisposition and pharmacokinetic behavior of the drug. We have demonstrated that cefoperazone is unstable in methanol and at alkaline pH and these factors may affect the accurate quantitation of the drug in CSF. Buffering CSF samples with acetate is recommended to improve cefoperazone stability in CSF.

Comparison of quinidine by fluorescence polarization immunoassay and high pressure liquid chromatography.

Analysis of quinidine was performed using fluorescence polarization immunoassay (Abbott TDXTM) with an ion-pairing adsorption high pressure liquid chromatography (HPLC) technique as the comparative method. Correlation of 110 clinical samples was excellent (r2 = 0.983). TDX calibration appeared stable for 14 days. There is minimal contribution to the concentration of quinidine due to the presence of metabolite. The TDX method is rapid, precise, and accurate.

Gas chromatography-chemical ionization mass spectrometry of cocaine and its metabolites in biological fluids.

A gas chromatographic-chemical ionization mass spectrometric (GC-CIMS) method is described for the determination of cocaine, benzoylecgonine, and norcocaine. The procedure uses stable isotopes as internal standards and a mixture of methane-ammonia as chemical ionization reagent gas. Run-to-run and within-run coefficients of variation (%) are less than 10% and the method has a sensitivity of less than 5 ng/mL from 1 mL or 1 gram of sample. The procedure has been applied to a number of cases involving cocaine intoxication and analytical data from these are described.

Application of the Technicon Chem 1+ chemistry analyzer to the Syva Emit ethyl alcohol assay in plasma and urine.

The performance of the Technicon Chem 1+ chemistry analyzer with the Syva Emit ethyl alcohol assay in plasma and urine was evaluated. Spiked specimens from 0 to 600 mg/dL were tested, and expected versus measured concentrations were monitored. Linear regression line equations of y = 0.9314x + 5.4 and y = 0.9005x + 4.6, and correlation coefficients (r) of 0.9997 and 0.9995, were obtained for plasma and urine, respectively. A limit of detection of 5 mg/dL for plasma and urine, and a limit of quantitation of 20 mg/dL for plasma and 15 mg/dL for urine were obtained. Recovery was within 10% of expected concentration from 20 to 600 mg/dL. Precision was evaluated, giving the following coefficients of variation: within-run precision: plasma, 1.31-2.20; urine, 1.16-1.21; total precision: plasma, 2.72-3.38; urine, 2.98-4.64. No carry-over was detected when alternating 600 mg/dL and negative specimens. No interference from acetone, isopropanol, or methanol was detected. No significant differences in evaporation of alcohol at two concentrations, or from the two matrices were observed. Evaporation from a small cup (200 microL) was more than twice as great as from a large cup (2 mL). The Chem 1+ was compared to a gas chromatographic method. Plasma specimens of 0-352 mg/dL produced a linear regression line of y = 1.0112x + 6.0, r = 0.9859; urine specimens of 0-313 mg/dL produced a line of y = 1.0493x - 0.3, r = 0.9910. The capability to separate positive and negative specimens at 20% around a cutoff concentration of 20 mg/dL was examined. Four hundred specimens were analyzed, with only one specimen incorrectly classified (a false positive). The Chem 1+ chemistry analyzer demonstrated reliable performance of the Emit ethyl alcohol assay of plasma and urine specimens.

A rapid gas chromatographic method quantitating clozapine in human plasma or serum for the purpose of therapeutic monitoring.

A gas chromatographic method using nitrogen-phosphorus detection was developed to quantitate clozapine in plasma or serum. Methyl clonazepam was used as an internal standard. Sample preparation included a single-step extraction with ethyl acetate, which was injected directly onto a wide-bore capillary column. Within-run and total precision, measured as percent coefficient of variation, were determined at low, therapeutic, and high clozapine plasma concentrations. The within-run precision for the low, therapeutic, and high clozapine plasma samples was 5.2, 2.7, and 2.4%, respectively. The total precision for the low, therapeutic, and high clozapine plasma samples was 10.0, 2.6, and 2.0%, respectively. Analytical accuracy was evaluated by comparing quantitative results with those obtained from a reference laboratory. Those samples containing therapeutic or high concentrations agreed within 3%; the sample containing a subtherapeutic concentration differed by 11.9%. The limit of quantitation was determined to be 35 ng/mL, and the upper limit of linearity was 3000 ng/mL. No significant interferences were detected after testing more than two dozen drugs and metabolites.

An evaluation of the TDX fluorescence polarization immunoassays for procainamide and n-acetylprocainamide.

The TDX fluorescence polarization assays (FPIA) for procainamide (PA) and n-acetylprocainamide (NAPA) were evaluated. Coefficients of variation for within- and between-assay precision studies were less than 6%. Both methods correlated well with a referenced HPLC technique; r2 values for PA and NAPA were 0.980 and 0.986, respectively.

Plasma and urine disposition of 1-alpha-acetylmethadol and its principal metabolites in man.

The disposition of 1-alpha-acetylmethadol (LAAM) in plasma and urine was monitored by GC/CIMS following oral administration of 10 doses (0.73-1.5 mg/kg) over 42 days, to twelve human subjects. Plasma concentration-time course profiles fitted a two-compartment, first order kinetic model. Mean plasma t1/2 alpha for LAAM was 2.4 hours; t1/2 beta was 37.5 hours for the first dose and 46.8 hours for the last dose. The mean terminal half-life for nor-LAAM was 38.2 hours for first and 64.6 for last dose; for dinor-LAAM t1/2 beta was 168 hours, last dose. Drug accumulation occurred in some subjects, but within the study range, dosage was not related to maximum plasma levels nor to accumulation. In urine, the sum of LAAM, nor-LAAM, and dinor-LAAM represented 25% of the dose, and unconjugated methadol metabolites, 1.6-1.7%.

Stability of delta 9-tetrahydrocannabinol (THC), 11-hydroxy-THC, and 11-nor-9-carboxy-THC in blood and plasma.

The stabilities of delta 9-tetrahydrocannabinol (THC) and two of its metabolites, 11-hydroxy-delta 9-tetrahydrocannabinol (HO-THC) and 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (COOH-THC), were determined in blood and plasma stored at -10 degrees C, 4 degrees C, and room temperature. Each of the cannabinoids was added to freshly-drawn blood and plasma to give concentrations of 20 ng/mL. Two-mL aliquots were stored in silanized tubes and the cannabinoid concentrations were monitored by gas chromatography/mass spectrometry over a 6-month period. No significant changes were observed in the concentrations of the cannabinoids for the first month of storage. However, the concentrations of THC and HO-THC in blood stored at room temperature had decreased significantly at 2 months. No statistically significant changes were detected in cannabinoid concentrations in plasma or blood stored at 4 degrees or -10 degrees C for up to 4 months. After 6 months at room temperature, the blood concentrations of THC and HO-THC had decreased by 90 and 44%, respectively, whereas the concentration of COOH-THC was not significantly different from the control. The possibility of loss of cannabinoids from blood due to adsorption onto the grey stoppers used in Venoject tubes was also investigated. Over a 24-hr period, no significant differences were detected in any of the cannabinoid concentrations regardless of sample size (1.3 or 8 mL), differences in temperature (-10 degrees C, 4 degrees C, or room temperature), or extent of contact with the tube's stoppers.

Twin transfusion syndrome: successful in utero treatment with digoxin.

A pregnancy complicated by twin transfusion syndrome is presented. When signs of cardiac failure (edema, ascites and hydramnios) persisted in the recipient twin, maternal digoxin therapy was instituted at 27 weeks' gestation. The signs of failure resolved, and the twins were delivered electively by cesarean section at 34 weeks. At birth, the syndrome was confirmed by examination of the infants and placenta. Both infants survived. Digoxin therapy is recommended for fetal heart failure from circulatory overload in twin transfusion.