Costs of fracture-related infection: the impact on direct hospital costs and healthcare utilisation.

PURPOSE: Fracture-Related Infection (FRI) is associated with high medical costs and prolonged healthcare utilization. However, limited data is available on the financial impact. The purpose of this study was to investigate the impact of FRI on direct hospital costs and healthcare utilization. METHODS: This was a retrospective cohort study in a level-1 trauma centre in the Netherlands. Patients ≥ 18 years, after open reduction and internal fixation of a long bone fracture between January 1st 2016 and November 1st 2021, were included. Exclusion criteria were Injury Severity Score (ISS) ≥ 16, indefinable data on costs or incomplete follow-up. Hospital costs related to fracture treatment were individually calculated based on procedure codes raised with a fixed percentage of overhead expenses, in line with hospital billing policies. RESULTS: In total, 246 patients were included with a median follow-up of 1 year (IQR 0.6-1.8). A total of 45 patients developed FRI, of whom 15 patients had an FRI recurrence. Compared to non-FRI patients, median hospital costs from an FRI patient without and with recurrence, were respectively three (3.1) and seven (7.6) times higher. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries, and 21 or 55 days of intravenous antibiotic treatment. CONCLUSION: Direct healthcare costs of patients with single occurrence of FRI after long bone fracture treatment are three times higher compared to non-FRI patients. In case of FRI-recurrence, the differences in costs might even increase to sevenfold. To put this in perspective, cost of severely injured trauma patients were recently established at approximately 25.000 euros. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries and 21 or 55 days of intravenous antibiotic treatment. Not only from patient perspective but also from a financial aspect, it is important to focus on prevention of (recurrent) FRI.

Wrist actigraphy in anesthesia.

STUDY OBJECTIVES: To examine the use of wrist actigraphy during and following anesthesia or monitored sedation and its ability to objectively assess sleep-related events. DESIGN: Uncontrolled study. SETTING: 1100-bed tertiary care municipal, university-affiliated medical center. PATIENTS AND INTERVENTIONS: 18 patients who underwent minor to medium lower-body surgical procedures with spinal or epidural anesthesia with sedation by propofol, midazolam, or isoflurane-based general anesthesia. MEASUREMENTS AND MAIN RESULTS: Wrist actigraphy was measured and evaluated. The actigraphic recordings accurately indicated the presence and time of occurrence of all relevant perioperative events including those related to anesthesia. Actigraphic data were more precise than equivalent attending anesthesiologist's subjective observations. The anesthesiologist detected changes in the patient's activity with a delay of minutes after they had been picked up by the actigraph. The integrated areas of recorded phases of midazolam-induced sedation and the occurrence and reversal of paradoxical reactions were distinctly discernible as such, unlike the less specifically defined description of the anesthesiologist. CONCLUSIONS: Real time actigraphic monitoring can provide clear-cut and objective indications of changes in the depth of anesthesia or sedation and its associated events during surgery and recovery.

Mortality in sleep apnea patients: a multivariate analysis of risk factors.

During 1976-1988 we diagnosed sleep apnea syndrome (SAS) in 1,620 adult men and women monitored in the Technion sleep laboratories. Their age at the time of diagnosis ranged between 21 and 79 years. Fifty-seven patients (53 men and 4 women) had died by 1990, 53% due to respiratory-cardiovascular causes. The observed/expected (O/E) mortality rates, calculated for men only, revealed excess mortality of patients under 70 years old. Excess mortality was significant in the fourth and fifth decades (3.33, p < 0.002; 3.23, p < 0.0002, respectively). In patients older than 70 O/E was 0.33 (p < 0.0007). Hierarchical multivariate analysis with four fixed variables [age, body mass index (BMI), hypertension and apnea index] and four additional variables added manually one at a time (heart disease, lung disease, diabetes, apnea duration) was used to determine the predictors of death from all causes, cardiopulmonary causes and from myocardial infarction (MI). All four major variables were found to be significant predictors of mortality from all causes, in addition to lung disease and heart disease. Only age and BMI were significant predictors of cardiopulmonary deaths in addition to lung disease. Age, BMI and hypertension predicted MI deaths in addition to lung disease. These results were interpreted to suggest that SAS affects death indirectly, most probably by being a risk factor for hypertension.

Sleep-wake cycle in shift workers on a "clockwise" and "counter-clockwise" rotation system.

The present study investigated the effects of a 5-day rotating work schedule in the advance, or "counter-clockwise", vs. delay, or "clockwise" direction, on subjective and objective measures of sleep-wake cycles. Twenty-two workers (mean age 27.5 +/- 4.6 years) were studied in the counter-clockwise direction, and 11 workers (mean age 29.83 +/- 5.93) were studied in the clockwise direction. Each worker was studied for a complete rotation cycle (20 days). Sleep-wake cycles were measured by wrist-worn actigraphs in 1-min bins. The clockwise direction was associated with significantly earlier sleep times during the night shift, and with a better synchronization of workers' sleep-wake cycles during night and evening shifts. The present results provide support to the claim that rotating shiftworkers can better adapt to clockwise than counter-clockwise rotations.

Agonist-like effects of the benzodiazepine receptor antagonist RO 15-1788.

The present study investigated the effects of the benzodiazepine receptor antagonist RO 15-1788 on the ability to resist sleep after 1 night of sleep deprivation. Repeated administrations of RO 15-1788 to 6 subjects significantly decreased their ability to resist sleep in comparison with repeated administration of 100 mg of vitamin C, and with a nontreatment condition. Most of the hypnotic effect occurred 80-100 min after drug ingestion. RO 15-1788 also significantly enhanced sleep stage 2 spindles activity. These results demonstrate that at certain dosages RO 15-1788 has agonist-like effects.

Periodic leg movements in sleep: effect of clonazepam treatment.

Periodic leg movements in sleep were diagnosed in 8 patients with insomnia and in 12 patients with hypersomnia. Polysomnography did not reveal any difference in the number of leg movements in these groups, the mean duration of a leg movement, or the number of activity epochs. Those with insomnia, however, had a shorter intermovement interval than those with hypersomnia, with more leg movements in each activity epoch. Treatment with 0.5 to 2 mg clonazepam improved subjective complaints and decreased the number of leg movements without affecting the intermovement interval or movement duration.

Ultrashort sleep-waking schedule. II. Relationship between ultradian rhythms in sleepability and the REM-non-REM cycles and effects of the circadian phase.

Eight subjects aged 20-30 years spent two 24 h periods in the sleep laboratory after having an adaptation night. At 16.00 h subjects began a strict 15 min waking-5 min sleeping schedule until 24.00 h. At 24.00 subjects retired for an uninterrupted monitored nocturnal sleep. Subjects were awakened after 6-7 h of sleep, either from REM sleep (in one experimental period) or 25 min after the end of a REM period (in the other experimental period) in a counterbalanced order, and a second 8 h 15 min waking-5 min sleeping schedule was initiated. There were no significant differences between the percentages of sleep stages 1 and 2 in the afternoon, evening and morning experiments. In each, stage 1 occurred in about 10 of the 24 'sleep attempts' and accounted for 15-19% of the total recording time; sleep stage 2 occurred in 2-5 sleep attempts and accounted for 3-8% of total recording time. Four of the 8 subjects showed REM sleep in 8 sleep 'attempts;' only one appeared during an evening period. Orthogonal spectral analysis revealed a dominant ultradian frequency of about 7.2 c/day during both experimental schedules. However, synchronizing the individual morning time series with the last nocturnal REM period resulted in the appearance of a single spectral peak at 14.4 c/day, which is the dominant ultradian frequency of the nocturnal REM-non-REM cycles.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of partial and complete mechanical occlusion of the nasal passages on sleep structure and breathing in sleep.

The influence of partial and complete mechanical obstruction of the nasal passages was investigated in 10 normal young adults (5 males and 5 females) without any ENT abnormalities. Nasal obstruction caused a significant increase in the number of apneas during sleep, in the number of microarousals associated with non-apneic breathing disorders in sleep, and in the amount of wake-time within sleep.

Excessive daytime sleepiness and insomnia.

Twenty-five adults with a deviated nasal septum, who complained about excessive daytime sleepiness, chronic fatigue, and nocturnal insomnia, were studied for one to two nights in a sleep laboratory. Recordings disclosed disordered breathing during sleep in the form of pronounced periodic breathing of alternating hypopneas and hyperpneas, isolated hypopneic episodes and central apneas and periodic sighs, all combined with electrophysiologic "microarousals," and a mixture of alpha and delta EEG wave activities. Surgical treatment of the deviated septum in 14 patients resulted in a subjective improvement in the level of diurnal alertness and in the quality of nocturnal sleep in 12 patients. Follow-up sleep recordings in seven of the patients who reported subjective improvement in sleep disclosed notably less waking and abnormal breathing during sleep. These results suggest that increased upper airway resistance can cause nonapneic breathing disorders in sleep and, consequently, sleep disturbances.

Breathing disorders in sleep associated with "microarousals' in patients with allergic rhinitis.

The influence of obstructed nasal passages was investigated in l4 patients with allergic rhinitis. Disordered breathing in sleep was found in all patients in the form of periodic breathing, and hypopneic and hyperpneic episodes, associated with characteristic "microarousals' from sleep. Patients had an average of 50 "microarousals' from sleep, ten times more than normal controls. It is suggested that increased upper airway resistance and increased nasal discharge are responsible for the disordered breathing in sleep and for the "microarousals'.

Across-night lengthening of sleep apneic episodes.

Systematic trends in the length of apneas were investigated in 8 sleep apnea patients, all of whom had more than 200 apneas per night. Regression analysis performed on the length of apneas by thirds of the night revealed significant linear trends for apneas in sleep stage 2, and for apneas in all sleep stages pooled together. There were no significant trends in the index of apnea density. We suggest that the across-night lengthening of apneas reflects a progressive increase in the arousal threshold, either by a compensatory deepening of sleep or by progressive changes in respiratory chemoreceptor sensitivity. The lack of significant trends in rapid eye movement (REM) sleep supports the conclusion that apnea termination in REM sleep is mediated by a different mechanism than in non-REM sleep.

Further observations on sleep abnormalities in Kleine-Levin syndrome: abnormal breathing pattern during sleep.

In two adolescent and two adult patients with Kleine-Levin syndrome, polygraphic sleep recording performed during somnolent and non-somnolent periods revealed various forms of abnormal breathing patterns during sleep. These included periodic breathing and hypopnoeic episodes associated with brief arousals and, in one adult patient, a full blown sleep apnoea syndrome. It is suggested that abnormal breathing in sleep in this syndrome may result from central hypoexcitability.

"It's time, you must wake up now".

Seven subjects who claimed to be able to awake accurately from sleep at a predetermined time were required to awake in the sleep laboratory at 03:30 and 05:30 on two separate nights. Eight of the 12 spontaneous awakenings were within +/- 20 min. from the target time, and 8 awakenings were from REM sleep. The two best performing subjects were tested for additional 7 nights in the laboratory but accuracy deteriorated considerably with only 2 awakenings within +/- 20 min. from target time. Approximately 50% of all awakenings, however, were from REM sleep. It is concluded that some individuals are able to awake at predetermined times and that this ability might be dependent on motivational level and the sleep stage.