Cognitive, physical, and mental health outcomes between long-term cannabis and tobacco users.

INTRODUCTION: Cannabis intoxication adversely affects health, yet persistent effects following short-term abstinence in long-term cannabis users are unclear. This matched-subjects, cross-sectional study compared health outcomes of long-term cannabis and long-term tobacco-only users, relative to population norms. METHODS: Nineteen long-term (mean 32.3years of use, mean age 55.7years), abstinent (mean 15h) cannabis users and 16 long-term tobacco users (mean 37.1years of use, mean age 52.9years), matched for age, educational attainment, and lifetime tobacco consumption, were compared on measures of learning and memory, response inhibition, information-processing, sustained attention, executive control, and mental and physical health. RESULTS: Cannabis users exhibited poorer overall learning and delayed recall and greater interference and forgetting than tobacco users, and exhibited poorer recall than norms. Inhibition and executive control were similar between groups, but cannabis users had slower reaction times during information processing and sustained attention tasks. Cannabis users had superior health satisfaction and psychological, somatic, and general health than tobacco users and had similar mental and physical health to norms whilst tobacco users had greater stress, role limitations from emotional problems, and poorer health satisfaction. CONCLUSIONS: Long-term cannabis users may exhibit deficits in some cognitive domains despite short-term abstinence and may therefore benefit from interventions to improve cognitive performance. Tobacco alone may contribute to adverse mental and physical health outcomes, which requires appropriate control in future studies.

Factors that affect fractured neck of femur outcome: Clinical commissioning groups influence length of stay and discharge destination.

BACKGROUND: The average length of stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals and there are numerous factors that can affect LOS. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be. METHODS: We analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust's catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS. RESULTS: 1847 patients were identified. After excluding deaths, missing data and extreme outliers, 1603 patients were included in the analysis. The median LOS varied from 14.9 to 23.4 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient's own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery. CONCLUSION: We have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust's performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS.

A case-control study examining inconsistencies in pain management following fractured neck of femur: an inferior analgesia for the cognitively impaired.

Previous research suggests individuals who suffer from cognitive impairment are less able to vocalise pain than the rest of the cognitively-intact population. This feature of cognitive impairment may be leading to a chronic underdetection of pain as current assessment tools strongly rely on the participation of the patient. To explore inconsistencies in pain management within the acute setting, we conducted a retrospective assessment of 224 patients presenting with fractured neck of femur at a large teaching hospital's accident and emergency (A&E) department between 2 June 2011 and 2 June 2012. These patients were split into either a cognitively-impaired or cognitively-intact cohort based on their Abbreviated Mental Test Scores. Patients with cognitive impairment, on average, received a weaker level of analgesia than individuals without impairment both in the ambulance and in A&E. In the ambulance, 45% of cognitively-impaired patients were prescribed no pain relief compared with just 8% of those individuals who remain cognitively intact. After arrival at A&E, these inconsistencies continued with 69% of the cognitively-intact cohort receiving the strongest opioid analgesia compared with just 37% of the cognitively-impaired cohort. The cognitively-impaired cohort would also wait on average an hour longer before receiving this initial pain relief. We believe that these differences stem from cognitively-impaired patients being unable to vocalise their pain through traditional assessment methods. This work discusses the potential development or adoption of a tool which can be applied in the acute setting and relies less on vocalisation but more on the objective features of pain, so making it applicable to cognitively-impaired individuals.

Demographics of 3929 ankle injuries, seasonal variation in diagnosis and more fractures are diagnosed in winter.

INTRODUCTION: An audit took place to look at the diagnostic or pick-up rate of ankle fractures. A seasonal variation was discovered. Although it is expected that more fractures may be seen in wet or icy periods, an excess of X-rays taken in the summer months has not been previously registered. METHOD: An automated X-ray system was looked at to see the number of X-rays taken and the diagnostic yield. RESULTS: We reviewed ankle X-rays of 3929 patients over a 24-month period between 1 July 2009 and 31 June 2011; of which, 612 patients were found to have fractured their ankle giving a pick-up rate of 0.16. This is less than what might be expected with strict application of Ottawa rules. The pick-up rate fluctuated each month from an admirable 0.35 fractures per X-ray ordered in December 2009 to a lowly 0.06 fractures per X-ray in May 2010. The same pattern was noted for the other year. For both Decembers, the fewest number of X-rays were taken at 80 and 140, the most at 200 and 240 in May for both years. Less X-rays were taken in for all winter months. For younger age groups, males dominated with the crossover to females dominating in the fifth decade. CONCLUSION: We postulate that summertime sports and recreational injuries may cause less fractures than at winter periods but result in more X-rays taken. We have reviewed our practice to try to improve our diagnostic rates; the basic tenets of Ottawa rules including the presence of bony tenderness and weight-bearing status have been reinforced in our teaching sessions. It is highly likely that strict application of these methods will decrease the number of X-rays taken and improve our pick-up rates.

Femoral cement pressurisation for hip arthroplasty in previously fixated hips: an experimental study.

INTRODUCTION: It is common to use a cemented total hip replacement following failed hip screw fixation of a fractured femoral neck; this solution, however, is complicated by the presence of the holes that are left in the femur when the screws are removed. These holes can allow cement to leak out while being pressurised. The aim of this study was to look at the cement femoral pressures proximally and distally in a sawbone model with pre-drilled holes to assess if the commonest surgical technique of occluding the holes with fingers could maintain the cement pressure high enough. MATERIALS AND METHODS: We used eight synthetic proximal femurs, four with dynamic hip screw holes drilled in them on the lateral surface ("drilled femurs") and four with no holes ("undrilled femurs"). We used pressure sensors positioned in holes drilled in the proximal and distal parts of the medial surface to measure the pressure in the cement as it was being delivered and pressurised into the femur canal. The tests were conducted while the femur was clamped at its distal end and, in the case of the drilled femurs, while the screw holes were occluded manually. RESULTS: We found that on the proximal side, the peak cement pressure in undrilled femurs was significantly greater than in drilled femurs (p=0.006). On the distal side, the difference in peak cement pressure between the two study groups was not significant (p=0.22). At both the proximal and distal positions, the time over which the cement pressure exceeded both 5 and 100 kPa was significantly longer in undrilled femurs than in drilled femurs (p<0.05). CONCLUSION: Our results show that it is difficult to fully occlude the drill holes completely with finger tips, especially when using pressurised cement. There are significant differences in the peak cement pressures between drilled and undrilled femurs with possible consequences for patients undergoing total hip replacement.

Does the number of trauma lists provided affect care and outcome of patients with fractured neck of femur?

INTRODUCTION: Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival. PATIENTS AND METHODS: The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit. RESULTS: A total of 883 patients were included in the audit (35-126 per hospital). Overall, 5-15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5-19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with > 10 lists per week (n = 6) and those with < 10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with > 10 lists (34.6% of patients versus 28.9%; P = 0.09). CONCLUSIONS: Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.

Underestimation of severity of previous whiplash injuries.

INTRODUCTION: We noted a report that more significant symptoms may be expressed after second whiplash injuries by a suggested cumulative effect, including degeneration. We wondered if patients were underestimating the severity of their earlier injury. PATIENTS AND METHODS: We studied recent medicolegal reports, to assess subjects with a second whiplash injury. They had been asked whether their earlier injury was worse, the same or lesser in severity. RESULTS: From the study cohort, 101 patients (87%) felt that they had fully recovered from their first injury and 15 (13%) had not. Seventy-six subjects considered their first injury of lesser severity, 24 worse and 16 the same. Of the 24 that felt the violence of their first accident was worse, only 8 had worse symptoms, and 16 felt their symptoms were mainly the same or less than their symptoms from their second injury. Statistical analysis of the data revealed that the proportion of those claiming a difference who said the previous injury was lesser was 76% (95% CI 66-84%). The observed proportion with a lesser injury was considerably higher than the 50% anticipated. CONCLUSIONS: We feel that subjects may underestimate the severity of an earlier injury and associated symptoms. Reasons for this may include secondary gain rather than any proposed cumulative effect.

A repeat audit of spinal board usage in the emergency department.

An audit of spinal board usage in 2002 was repeated [Malik MHA, Lovell ME. Current spinal board usage in emergency departments across the UK. Int J Care Injured 2003;34:327-9]. It is acknowledged that this device should be used for extrication and transport, with usual removal after the primary survey. This repeat audit was carried out to try and discover whether there have been changes regarding the use of spinal boards since its publication. We found improvements have been made in some areas including the removal of patients from boards with 21% now removing patients immediately (5% previously) and 58% removing patients following clearance on the lumbar and thoracic spine by a senior clinician after log roll (52% previously). In 2006, 21% (43% previously) are still leaving patients on spinal boards routinely until radiological evidence provides clearance, 45% will place patients on boards after their arrival even if they were not on one in pre-hospital management (48% previously) and the number of boards the department owns, remained similar. In house audits of usage remained largely unchanged at 22%. We recommend ongoing departmental review of practice.

Relationship between occupation, social class and time taken off work following a whiplash injury.

INTRODUCTION: Little has been published about occupational and social factors in relation to time off work following a whiplash injury. PATIENTS AND METHODS: We analysed 800 medicolegal case sheets from a consultant orthopaedic surgeon's practice. RESULTS: Of those injured, 596 were working and 204 were unemployed or retired. The working group was further analysed. Severity of injury was estimated by analysing velocity of injury combined with vehicular damage. Mean time off work for a minor injury was 10.6 days, moderate 12.1 days, severe 13.8, and very severe 24.9 (P < 0.05). Looking at work categories as previously described in the literature, 20.5 days were taken off by heavy manual workers, light manual 15.7, driving 13.9, secretarial 9.2 and sedentary 12.8 (P < 0.05). Analysing as per social class showed that professionals required 7.0 days, intermediate 14.7 days, skilled non-manual 16.1 days, skilled manual 34.2 days, semi-skilled manual 33.2 days, and unskilled manual 11.5 days (P < 0.05). Nearly a third (31.2%) required no time off work, after 4 days off, 52.1% had returned to work and 90.1% were back at work after 30 days. Time off lasting more than 12 weeks occurred in 29 cases (4.9%). CONCLUSIONS: Job style, severity of injury and social class have a bearing on time taken off work after road traffic accidents causing whiplash injury.

Current spinal board usage in emergency departments across the UK.

The spinal board is widely used as a means of extrication and efficient transport during the pre-hospital phase of trauma management. A number of concerns have been raised regarding its subsequent usage once the patient arrives in the emergency department. We undertook a telephone study of 100 A+E departments in the United Kingdom to ascertain current spinal board usage. Our study demonstrated great variability in practice across the UK and a marked lack of on-going audit or defined protocols governing spinal board usage following the pre-hospital phase of trauma management.

Injury and injury rates in Muay Thai kick boxing.

OBJECTIVE: To determine the type and number of injuries that occur during the training and practice of Muay Thai kick boxing and to compare the data obtained with those from previous studies of karate and taekwondo. METHODS: One to one interviews using a standard questionnaire on injuries incurred during training and practice of Muay Thai kick boxing were conducted at various gyms and competitions in the United Kingdom and a Muay Thai gala in Holland. RESULTS: A total of 152 people were questioned, 132 men and 20 women. There were 19 beginners, 82 amateurs, and 51 professionals. Injuries to the lower extremities were the most common in all groups. Head injuries were the second most common in professionals and amateurs. Trunk injuries were the next most common in beginners. The difference in injury distribution among the three groups was significant (p< or =0.01). Soft tissue trauma was the most common type of injury in the three groups. Fractures were the second most common in professionals, and in amateurs and beginners it was sprains and strains (p< or =0.05). Annual injury rates were: beginners, 13.5/1000 participants; amateurs, 2.43/1000 participants; professionals, 2.79/1000 participants. For beginners, 7% of injuries resulted in seven or more days off training; for amateurs and professionals, these values were 4% and 5.8% respectively. CONCLUSIONS: The results are similar to those found for karate and taekwondo with regard to injury distribution, type, and rate. The percentage of injuries resulting in time off training is less.