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Managing diffuse pollution from agricultural land requires a spatially explicit risk assessment that can be applied over large areas. Major components of such assessments are the precise definition of both channel networks that often originate as small channels and streams, and Hydrologically Sensitive Areas (HSAs) of storm runoff that occur on land surfaces. Challenges relate to regions of complex topography and land use patterns, particularly those which have been heavily modified by arterial drainage. In this study, a national scale, transferrable workflow and analysis were developed using a specifically commissioned LiDAR survey. Research on the first half of Northern Ireland (6927 km2) is reported where field-edge drain to major river channels were mapped from 1 m (16 points per metre) digital terrain models, and in-field HSAs were defined across over 400,000 fields with a median field size of 0.86 ha. Manual drainage mapping supplemented with a novel automated drainage channel correction process resulted in an unparalleled high-resolution national drainage network with 37,320 km of channels, increasing mapped channel density from 0.9 km km-2 to 5.5 km km-2. The HSAs were based on a Soil Topographic Index (STI) system using hillslope and contributing area models combined with soil hydraulic characteristics. In all, 249 km2 of runoff risk HSAs were identified by extracting the top 95th percentile of the modelled STI as the areas with the highest propensity to generate in-field runoff. At field and individual farm scale these targeted risk maps of diffuse pollution were delivered to over 13,000 farmers and form part of the nationwide Soil Nutrient Health Scheme programme.
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Failed fixation of intracapsular hip fractures in young patients is associated with high morbidity and cost. Accordingly, we set out to determine the association between unsatisfactory post-operative imaging (judged by two fellowship-trained trauma consultants and a senior trainee) and the risk of subsequent reoperation, including adjustment for potential confounding variables. Ninety-four (94) patients aged <60 were included in the study from a single major trauma centre. Exhausted patients (19%) required further surgery, with the most common reason being avascular necrosis (n=10) followed by non-union (n=6). Univariate analysis found only smokers and unsatisfactory fracture reduction to be predictive of failure (p < 0.05). Other demographics and recognised scoring systems from the literature were poor predictors of failure apart from the Haiduewych classification system, utilised to assess the quality of reduction, which showed a trend towards significance (p0.053). Multivariate analysis showed smoking and unsatisfactory fracture reduction to be strong predictors of failure (p<0.05). In those with unsatisfactory fracture reduction, 50% required reoperation compared to 17.5% of those with satisfactory reduction. This study highlights the key principles of ensuring adequate intraoperative reduction and fixation, in keeping with GIRFT principles. Avoiding secondary reoperation is crucial to prevent long-term negative outcomes for this typically high functional demand group of patients. We recommend regular, consultant peer review of post-operative imaging as a method of identifying substandard fracture fixations and those at risk of failure. This will allow opportunities for teaching, clinical improvement, and multidisciplinary team (MDT) discussions of at-risk patients.
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Aims: To examine whether natural language processing (NLP) using a clinically based large language model (LLM) could be used to predict patient selection for total hip or total knee arthroplasty (THA/TKA) from routinely available free-text radiology reports. Methods: Data pre-processing and analyses were conducted according to the Artificial intelligence to Revolutionize the patient Care pathway in Hip and knEe aRthroplastY (ARCHERY) project protocol. This included use of de-identified Scottish regional clinical data of patients referred for consideration of THA/TKA, held in a secure data environment designed for artificial intelligence (AI) inference. Only preoperative radiology reports were included. NLP algorithms were based on the freely available GatorTron model, a LLM trained on over 82 billion words of de-identified clinical text. Two inference tasks were performed: assessment after model-fine tuning (50 Epochs and three cycles of k-fold cross validation), and external validation. Results: For THA, there were 5,558 patient radiology reports included, of which 4,137 were used for model training and testing, and 1,421 for external validation. Following training, model performance demonstrated average (mean across three folds) accuracy, F1 score, and area under the receiver operating curve (AUROC) values of 0.850 (95% confidence interval (CI) 0.833 to 0.867), 0.813 (95% CI 0.785 to 0.841), and 0.847 (95% CI 0.822 to 0.872), respectively. For TKA, 7,457 patient radiology reports were included, with 3,478 used for model training and testing, and 3,152 for external validation. Performance metrics included accuracy, F1 score, and AUROC values of 0.757 (95% CI 0.702 to 0.811), 0.543 (95% CI 0.479 to 0.607), and 0.717 (95% CI 0.657 to 0.778) respectively. There was a notable deterioration in performance on external validation in both cohorts. Conclusion: The use of routinely available preoperative radiology reports provides promising potential to help screen suitable candidates for THA, but not for TKA. The external validation results demonstrate the importance of further model testing and training when confronted with new clinical cohorts.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Procesamiento de Lenguaje Natural , Selección de Paciente , Humanos , Artroplastia de Reemplazo de Rodilla/métodos , Artroplastia de Reemplazo de Cadera/métodos , Femenino , Masculino , Anciano , Persona de Mediana Edad , Algoritmos , Inteligencia ArtificialRESUMEN
Background/Objectives: Hip fractures exert a substantial burden on hospital systems. Within Scotland 20% of the population resides rurally, warranting investigation of how this impacts prompt access to surgical care. This study aims to determine whether indirect hospital admission via hospital transfer affects the likelihood of surgical management within 36 h for hip fracture patients. Methods: A retrospective cohort study was performed. This used Scottish Hip Fracture Audit data including patients aged ≥50 split into two propensity matched groups based on their transfer status. Descriptive analysis compared patient characteristics. Regression assessed achieving surgery within 36 h of admission in the unmatched and matched cohorts. Secondary outcomes included time to surgery, mortality, mobilization, returning to residence and length of stay. A sensitivity analysis was undertaken to assess for residual confounding effects. Results: The unmatched analysis included 20,132 patients. Transfer patients were younger (p = 0.007) and less-comorbid (p < 0.001). In the matched population, 711 (63.6%) transfer patients had surgery with 36 h of presentation to hospital, compared to 852 (75.3%) non-transfer patients. Transfer patients had 43% reduced odds of timely surgery (OR (95% CI) 0.57 (0.48 to 0.69); p < 0.001). No disparities emerged in mortality, mobilisation or returning to residence., Transfer patients experienced a significant increase in length of stay in hospital (median (IQR) 16 (8 to 33) vs. 13 (8 to 30); p = 0.024). Conclusions: Hospital transfer is associated with significantly reduced odds of timely surgery, a longer time to surgery and longer length of stay. Development of structured network pathways that minimize delay to transfer are required to potentially optimize outcomes and reduce associated cost.
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INTRODUCTION: The aim of this study was to evaluate noise exposure to the operating room staff consisting of the surgeon, assistant, anaesthetist and Mako Product Specialist (MPS) during Mako robotic-arm assisted total knee arthroplasty (TKA) and total hip arthroplasty (THA). We aimed to determine whether employees were exposed to noise at or above a lower exposure action value (LEAV) set out by the Noise at Work Regulations 2005, Health and Safety Executive (HSE), UK. MATERIALS AND METHODS: We prospectively recorded intra-operative noise levels in Mako robotic-arm assisted TKA and THA over a period of two months using the MicW i436 connected to an iOS device (Apple), using the Sound Level Meter App (iOS) by the National Institute for Occupation Safety and Health (NIOSH). Data obtained was then used to calculate "worst case" daily exposure value to assess if sound levels were compliant with UK guidelines. Comparison between operating room staff groups was performed with ANOVA testing. RESULTS: A total of 19 TKA and 11 THA operations were recorded. During TKA, for the primary surgeon and the assistant, the equivalent continuous sound pressure level (LAeq) was over 80 dB, exceeding the LEAV set out by the Noise at Work Regulations by HSE. During THA, the average LAeq and peak sound pressure levels did not exceed the LEAV. The calculated daily exposure for the primary surgeon in TKA was 82 dB. A Tukey post hoc test revealed that LAeq was statistically significantly lower in the anaesthetist and MPS (p < .001) compared to the primary surgeon and assistant in both TKA and THA. CONCLUSIONS: Operating room staff, particularly the primary surgeon and assistant are exposed to significant levels of noise during Mako robotic-arm assisted TKA and THA. Formal assessments should be performed to further assess the risk of noise induced hearing loss in robotic-arm assisted arthroplasty.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Ruido en el Ambiente de Trabajo , Exposición Profesional , Quirófanos , Procedimientos Quirúrgicos Robotizados , Humanos , Procedimientos Quirúrgicos Robotizados/métodos , Artroplastia de Reemplazo de Cadera/métodos , Exposición Profesional/prevención & control , Estudios Prospectivos , Artroplastia de Reemplazo de Rodilla/métodosRESUMEN
Aims: This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality. Methods: This retrospective study included ITF patients aged 50 years and over treated with SHS fixation between 2019 and 2021 at a major trauma centre. Demographic information, fracture type, delirium status, American Society of Anesthesiologists grade, and length of stay were collected. LWT and tip apex distance were measured. Revision surgery and mortality were recorded at a mean follow-up of 19.5 months (1.6 to 48). Cox regression was performed to evaluate independent risk factors associated with revision surgery and mortality. Results: The cohort consisted of 890 patients with a mean age of 82 years (SD 10.2). Mean LWT was 27.0 mm (SD 8.6), and there were 213 patients (23.9%) with LWT < 20.5 mm. Overall, 20 patients (2.2%) underwent a revision surgery following SHS fixation. Adjusting for covariates, LWT < 20.5 mm was not independently associated with an increased revision or mortality risk. However, factors that were significantly more prevalent in LWT < 20.5 mm group, which included residence in care home (hazard ratio (HR) 1.84; p < 0.001) or hospital (HR 1.65; p = 0.005), and delirium (HR 1.32; p = 0.026), were independently associated with an increased mortality risk. The only independent factor associated with increased risk of revision was older age (HR 1.07; p = 0.030). Conclusion: LWT was not associated with risk of revision surgery in patients with an ITF fixed with a SHS when the calcar was intact, after adjusting for the independent effect of age. Although LWT < 20.5 mm was not an independent risk factor for mortality, patients with LWT < 20.5 mm were more likely to be from care home or hospital and have delirium on admission, which were associated with a higher mortality rate.
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Aims: Current levels of hip fracture morbidity contribute greatly to the overall burden on health and social care services. Given the anticipated ageing of the population over the coming decade, there is potential for this burden to increase further, although the exact scale of impact has not been identified in contemporary literature. We therefore set out to predict the future incidence of hip fracture and help inform appropriate service provision to maintain an adequate standard of care. Methods: Historical data from the Scottish Hip Fracture Audit (2017 to 2021) were used to identify monthly incidence rates. Established time series forecasting techniques (Exponential Smoothing and Autoregressive Integrated Moving Average) were then used to predict the annual number of hip fractures from 2022 to 2029, including adjustment for predicted changes in national population demographics. Predicted differences in service-level outcomes (length of stay and discharge destination) were analyzed, including the associated financial cost of any changes. Results: Between 2017 and 2021, the number of annual hip fractures increased from 6,675 to 7,797 (15%), with a rise in incidence from 313 to 350 per 100,000 (11%) for the at-risk population. By 2029, a combined average projection forecast the annual number of hip fractures at 10,311, with an incidence rate of 463 per 100,000, representing a 32% increase from 2021. Based upon these projections, assuming discharge rates remain constant, the total overall length of hospital stay following hip fracture in Scotland will increase by 60,699 days per annum, incurring an additional cost of at least £25 million per year. Approximately five more acute hip fracture beds may be required per hospital to accommodate this increased activity. Conclusion: Projection modelling demonstrates that hip fracture burden and incidence will increase substantially by 2029, driven by an ageing population, with substantial implications for health and social care services.
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Fracturas de Cadera , Humanos , Fracturas de Cadera/epidemiología , Tiempo de Internación , Alta del Paciente , Escocia/epidemiología , Incidencia , EnvejecimientoRESUMEN
Aims: Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients. Methods: A retrospective cohort study was undertaken using data from the Scottish Hip Fracture Audit between May 2016 and December 2020. Only patients undergoing THA were included, with categorization according to surgical treatment within 36 hours of admission (≤ 36 hours = 'acute group' vs > 36 hours = 'delayed' group). Those with delays due to being "medically unfit" were excluded. The primary outcome measure was 30-day survival. Costs were estimated in relation to the differences in the lengths of stay. Results: A total of 1,375 patients underwent THA, with 397 (28.9%) having surgery delayed by > 36 hours. There were no significant differences in the age, sex, residence prior to admission, and Scottish Index of Multiple Deprivation for those with, and those without, delayed surgery. Both groups had statistically similar 30-day (99.7% vs 99.3%; p = 0.526) and 60-day (99.2% vs 99.0%; p = 0.876) survival. There was, however, a significantly longer length of stay for the delayed group (acute: 7.0 vs delayed: 8.9 days; p < 0.001; overall: 8.7 vs 10.2 days; p = 0.002). Delayed surgery did not significantly affect the rates of 30-day readmission (p = 0.085) or discharge destination (p = 0.884). The results were similar following adjustment for potential confounding factors. The estimated additional cost due to delayed surgery was £1,178 per patient. Conclusion: Delayed surgery does not appear to be associated with increased mortality in patients with an intracapsular hip fracture who undergo THA, compared with those who are treated with a hemiarthroplasty or internal fixation. Those with delayed surgery, however, have a longer length of stay, with financial consequences. Clinicians must balance ethical considerations, the local provision of orthopaedic services, and optimization of outcomes when determining the need to delay surgery in a patient with a hip fracture awaiting THA.
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Artroplastia de Reemplazo de Cadera , Fracturas de Cadera , Humanos , Artroplastia de Reemplazo de Cadera/métodos , Estudios Retrospectivos , Fracturas de Cadera/cirugía , Fracturas de Cadera/etiología , Fijación Interna de Fracturas/métodos , Tiempo de InternaciónRESUMEN
BACKGROUND: Major trauma in older adults (MTOA) poses distinctive health and social care challenges, further underlined by the unique socioeconomic and geographical environment of Scotland. This study provides epidemiological trends of MTOA, to provide insight into areas where further evaluation and research are required. MATERIALS AND METHODS: Pseudonymised aggregated demographic, injury and outcome data from 2011 to 2020 were obtained from the Scottish Trauma Audit Group (STAG) Database, covering 28 hospitals across Scotland. Only individuals age ≥ 70 with an Injury Severity Score (ISS) > 15 were included. RESULTS: There was an average of 216 annual cases of MTOA, with a 259 % rise in incidence from 2011 to 2020. This was predominantly driven by a rise in low velocity trauma (fall <2 m height; 287 % increase). The proportion of all major trauma attributable to those aged ≥70 rose from 18.5 % in 2011 to 34.6 % in 2020. Death censored median (IQR) acute hospital length of stay was 18 days (9-30). Overall, 30-day survival was 65.3 %, with no improvement seen between 2011 and 2020 (p = 0.50). Independent predictors of improved 30-day survival included Ages 70-79 & 80-89 [compared to reference ≥ 90] (OR 3.12; 95 %CI 2.24,4.31; p < 0.001 and OR 1.66; 95 %CI 1.21,2.29; p = 0.002 respectively), and Extremity injury (OR 1.89; 95 %CI 1.48,2.41; p < 0.001). Head injury (OR 0.72; 95 %CI 0.54,0.96; p = 0.027) and increasing ISS score (OR 0.88, 95 %CI 0.86,0.89; p < 0.001) were associated with lower likelihood of 30-day survival. A further model also including the admission ward (from eSTAG data November 2017 onwards) demonstrated an association with reduced 30-day survival with admission to General Surgery (OR 0.42; 95 %CI 0.19,0.93; p = 0.033), Intensive Care (OR 0.25; 95 %CI 0.10,0.60; p = 0.002) and Medical Specialities (OR 0.33; 95 %CI 0.15,0.73; p = 0.007) compared to the reference (Major Trauma). Exponential Smoothing predictions revealed a further potential 184 % rise in incidence of MTOA from 2021 to 2030 (3657 per 100,000 population at risk to 10,392 per 100,000 population at risk). CONCLUSION: MTOA is likely to be a rising health care burden, requiring larger quantities of health and social care resource. Urgent preventative strategies are required to reduce low velocity trauma (standing height falls), as well as the high mortality and morbidity of MTOA.
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Hospitalización , Heridas y Lesiones , Humanos , Anciano , Puntaje de Gravedad del Traumatismo , Incidencia , Escocia/epidemiología , Heridas y Lesiones/epidemiología , Heridas y Lesiones/terapia , Estudios RetrospectivosRESUMEN
Aims: The principles of evidence-based medicine (EBM) are the foundation of modern medical practice. Surgeons are familiar with the commonly used statistical techniques to test hypotheses, summarize findings, and provide answers within a specified range of probability. Based on this knowledge, they are able to critically evaluate research before deciding whether or not to adopt the findings into practice. Recently, there has been an increased use of artificial intelligence (AI) to analyze information and derive findings in orthopaedic research. These techniques use a set of statistical tools that are increasingly complex and may be unfamiliar to the orthopaedic surgeon. It is unclear if this shift towards less familiar techniques is widely accepted in the orthopaedic community. This study aimed to provide an exploration of understanding and acceptance of AI use in research among orthopaedic surgeons. Methods: Semi-structured in-depth interviews were carried out on a sample of 12 orthopaedic surgeons. Inductive thematic analysis was used to identify key themes. Results: The four intersecting themes identified were: 1) validity in traditional research, 2) confusion around the definition of AI, 3) an inability to validate AI research, and 4) cautious optimism about AI research. Underpinning these themes is the notion of a validity heuristic that is strongly rooted in traditional research teaching and embedded in medical and surgical training. Conclusion: Research involving AI sometimes challenges the accepted traditional evidence-based framework. This can give rise to confusion among orthopaedic surgeons, who may be unable to confidently validate findings. In our study, the impact of this was mediated by cautious optimism based on an ingrained validity heuristic that orthopaedic surgeons develop through their medical training. Adding to this, the integration of AI into everyday life works to reduce suspicion and aid acceptance.
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INTRODUCTION: The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand for arthroplasty services in the future. Understanding the scale of potential change is essential to ensure adequate provision of services and prevent prolonged waiting times that can cause patient harm. METHODS: We set out to provide projections of future primary knee and hip arthroplasty out to 2038 utilising historical trend data (2008-2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age group predictions were also performed. RESULTS: The predicted rise of primary hip arthroplasty for all ages is from 120/100k/year in 2018 to 152/100k/year in 2038, a 28% increase. The predicted rise of primary knee arthroplasty for all ages is from 164/100k/year in 2018 to 220/100k/year in 2038, a 34% increase. Based on a static 3-day length of stay average this would see 4280 and 7392 additional patient bed days required for primary hip and knee arthroplasty patients respectively per annum. The associated additional cost is anticipated to be approximately £26 million. CONCLUSIONS: Anticipated future demand for arthroplasty will require significant additional resource and funding to prevent deterioration in quality of care and an increase in patient wait times, additional to that already required to clear the COVID-19 backlog. Understanding presented projections of changes to arthroplasty demand is key to future service delivery.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , COVID-19 , Osteoartritis , Humanos , Escocia/epidemiologíaRESUMEN
BACKGROUND: COVID-19 has had a detrimental impact on access to hip and knee arthroplasty surgery. We set out to examine whether this had a subsequent impact on preoperative opioid prescribing rates for those awaiting surgery. METHODS: Data regarding patient demographics and opioid utilisation were collected from the electronic health records of included patients at a large university teaching hospital. Patients on the outpatient waiting list for primary hip and knee arthroplasty as of September 2020 (COVID-19 group) were compared with historical controls (Controls) who had previously undergone surgery. A sample size calculation indicated 452 patients were required to detect a 15% difference in opioid prescription rates between groups. RESULTS: A total of 548 patients (58.2% female) were included, 260 in the COVID-19 group and 288 in the Controls. Baseline demographics were similar between the groups. For those with data available, the proportion of patients on any opioid at follow-up in the COVID-19 group was significantly higher: 55.0% (143/260) compared with 41.2% (112/272) in the Controls (p=0.002). This remained significant when adjusted for confounding (age, gender, Scottish Index of Multiple Deprivation, procedure and wait time). The proportion of patients on a strong opioid was similar (4.2% (11/260) vs 4.8% (13/272)) for COVID-19 and Controls, respectively. The median waiting time from referral to follow-up was significantly longer in the COVID-19 group compared with the Controls (455 days vs 365 days; p<0.0001). CONCLUSION: The work provides evidence of potential for an emerging opioid problem associated with the influence of COVID-19 on elective arthroplasty services. Viable alternatives to opioid analgesia for those with end-stage arthritis should be explored, and prolonged waiting times for surgery ought to be avoided in the recovery from COVID-19 to prevent more widespread opioid use.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , COVID-19 , Humanos , Femenino , Masculino , Analgésicos Opioides/uso terapéutico , Estudios Retrospectivos , Pautas de la Práctica en MedicinaRESUMEN
Cite this article: Bone Joint Res 2022;11(12):890-892.
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AIMS: The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. METHODS: A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. RESULTS: A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. CONCLUSION: Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction.Cite this article: Bone Joint J 2022;104-B(11):1266-1272.
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Fracturas de Cadera , Humanos , Estudios Retrospectivos , Transfusión Sanguínea , Transfusión de Eritrocitos , Escocia/epidemiologíaRESUMEN
Passive samplers (PS) have been proposed as an enhanced water quality monitoring solution in rivers, but their performance against high-frequency data over the longer term has not been widely explored. This study compared the performance of Chemcatcher® passive sampling (PS) devices with high-frequency sampling (HFS: 7-hourly to daily) in two dynamic rivers over 16 months. The evaluation was based on the acid herbicides MCPA (2-methyl-4-chlorophenoxyacetic acid), mecoprop-P, fluroxypyr and triclopyr. The impact of river discharge parameters on Chemcatcher® device performance was also explored. Mixed effects modelling showed that time-weighted mean concentration (TWMC) and flow-weighted mean concentration (FWMC) values obtained by the HFS approach were both significantly higher (p < 0.001) than TWMC values determined from PS regardless of river or pesticide. Modelling also showed that TWMCPS values were more similar to TWMCHFS than FWMCHFS values. However, further testing revealed that MCPA TWMC values from HFS and PS were not significantly different (p > 0.05). There was little indication that river flow parameters altered PS performance-some minor effects were not significant or consistent. Despite this, the PS recovery of very low concentrations indicated that Chemcatcher® devices may be used to evaluate the presence/absence and magnitude of acid herbicides in hydrologically dynamic rivers in synoptic type surveys where space and time coverage is required. However, a period of calibration of the devices in each river would be necessary if they were intended to provide a quantitative review of pesticide concentration as compared with HFS approaches.
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Ácido 2-Metil-4-clorofenoxiacético , Herbicidas , Plaguicidas , Contaminantes Químicos del Agua , Plaguicidas/análisis , Monitoreo del Ambiente , Contaminantes Químicos del Agua/análisis , RíosRESUMEN
AIMS: The extended wait that most patients are now experiencing for hip and knee arthroplasty has raised questions about whether reliance on waiting time as the primary driver for prioritization is ethical, and if other additional factors should be included in determining surgical priority. Our Prioritization of THose aWaiting hip and knee ArthroplastY (PATHWAY) project will explore which perioperative factors are important to consider when prioritizing those on the waiting list for hip and knee arthroplasty, and how these factors should be weighted. The final product will include a weighted benefit score that can be used to aid in surgical prioritization for those awaiting elective primary hip and knee arthroplasty. METHODS: There will be two linked work packages focusing on opinion from key stakeholders (patients and surgeons). First, an online modified Delphi process to determine a consensus set of factors that should be involved in patient prioritization. This will be performed using standard Delphi methodology consisting of multiple rounds where following initial individual rating there is feedback, discussion, and further recommendations undertaken towards eventual consensus. The second stage will then consist of a Discrete Choice Experiment (DCE) to allow for priority setting of the factors derived from the Delphi through elicitation of weighted benefit scores. The DCE consists of several choice tasks designed to elicit stakeholder preference regarding included attributes (factors). RESULTS: The study is co-funded by the University of Aberdeen Knowledge Exchange Commission (Ref CF10693-29) and a Chief Scientist Office (CSO) Scotland Clinical Research Fellowship which runs from 08/2021 to 08/2024 (Grant ref: CAF/21/06). Approval from the University of Aberdeen Institute of Applied Health Sciences School Ethics Review Board was granted 22/03/2022 - Reference number SERB/2021/12/2210. CONCLUSION: The PATHWAY project provides the first attempt to use patient and surgeon opinions to develop a unified approach to prioritization for those awaiting hip and knee arthroplasty. Development of such a tool will provide more equitable access to arthroplasty services, as well as providing a framework for developing similar approaches in other areas of healthcare delivery.Cite this article: Bone Jt Open 2022;3(10):753-758.
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BACKGROUND: Hip and knee osteoarthritis is substantially prevalent worldwide, with large numbers of older adults undergoing joint replacement (arthroplasty) every year. A backlog of elective surgery due to the COVID-19 pandemic, and an aging population, has led to substantial issues with access to timely arthroplasty surgery. A potential method to improve the efficiency of arthroplasty services is by increasing the percentage of patients who are listed for surgery from primary care referrals. The use of artificial intelligence (AI) techniques, specifically machine learning, provides a potential unexplored solution to correctly and rapidly select suitable patients for arthroplasty surgery. OBJECTIVE: This study has 2 objectives: (1) develop a cohort of patients with referrals by general practitioners regarding assessment of suitability for hip or knee replacement from National Health Service (NHS) Grampian data via the Grampian Data Safe Haven and (2) determine the demographic, clinical, and imaging characteristics that influence the selection of patients to undergo hip or knee arthroplasty, and develop a tested and validated patient-specific predictive model to guide arthroplasty referral pathways. METHODS: The AI to Revolutionise the Patient Care Pathway in Hip and Knee Arthroplasty (ARCHERY) project will be delivered through 2 linked work packages conducted within the Grampian Data Safe Haven and Safe Haven Artificial Intelligence Platform. The data set will include a cohort of individuals aged ≥16 years with referrals for the consideration of elective primary hip or knee replacement from January 2015 to January 2022. Linked pseudo-anonymized NHS Grampian health care data will be acquired including patient demographics, medication records, laboratory data, theatre records, text from clinical letters, and radiological images and reports. Following the creation of the data set, machine learning techniques will be used to develop pattern classification and probabilistic prediction models based on radiological images. Supplemental demographic and clinical data will be used to improve the predictive capabilities of the models. The sample size is predicted to be approximately 2000 patients-a sufficient size for satisfactory assessment of the primary outcome. Cross-validation will be used for development, testing, and internal validation. Evaluation will be performed through standard techniques, such as the C statistic (area under curve) metric, calibration characteristics (Brier score), and a confusion matrix. RESULTS: The study was funded by the Chief Scientist Office Scotland as part of a Clinical Research Fellowship that runs from August 2021 to August 2024. Approval from the North Node Privacy Advisory Committee was confirmed on October 13, 2021. Data collection started in May 2022, with the results expected to be published in the first quarter of 2024. ISRCTN registration has been completed. CONCLUSIONS: This project provides a first step toward delivering an automated solution for arthroplasty selection using routinely collected health care data. Following appropriate external validation and clinical testing, this project could substantially improve the proportion of referred patients that are selected to undergo surgery, with a subsequent reduction in waiting time for arthroplasty appointments. TRIAL REGISTRATION: ISRCTN Registry ISRCTN18398037; https://www.isrctn.com/ISRCTN18398037. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37092.
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INTRODUCTION: The COVID-19 pandemic has led to unprecedented delays for those awaiting elective hip and knee arthroplasty. Current demand far exceeds available resource, and therefore it is integral that healthcare resource is fairly rationed to those who need it most. We therefore set out to determine if pre-operative health-related quality of life assessment (HRQoL) could be used to triage arthroplasty waiting lists. METHODS: Data regarding demographics, perioperative variables and patient reported outcome measures (PROMs) (pre-operative and 1-year post-operative EuroQOL five dimension (EQ-5D-3L) and Oxford hip and knee scores (OHS/OKS) were retrospectively extracted from electronic patient health records at a large university teaching hospital. Patients were split into two equal groups based on pre-operative EQ-5D TTO scores and compared (Group1 [worse HRQoL] = -0.239 to 0.487; Group2 [better HRQoL] = 0.516-1 [best]). RESULTS: 513 patients were included. Patients in Group1 had significantly greater improvement in post-operative EQ-5D-3L scores compared to Group2 (Median 0.67 vs. 0.19; p < 0.0001), as well as greater improvement in OHS/OKS (Mean 22.4 vs. 16.4; p < 0.0001). Those in Group2 were significantly less likely to achieve the EQ-5D-3L minimum clinically important difference (MCID) attainment (OR 0.13, 95%CI 0.07-0.23; p < 0.0001) with a trend towards lower OHS/OKS MCID attainment (OR 0.66, 95%CI 0.37-1.19; p = 0.168). There was no clinically significant difference in length of stay (Median 3-days both groups), and no statistically significant difference in adverse events (30 days and 1 year readmission/reoperation). CONCLUSIONS: A pre-operative EQ-5D-3L cut-off of ≤0.487 for hip and knee arthroplasty prioritisation may help to maximise clinical utility and cost-effectiveness in a limited resource setting post COVID-19.