Regional economic burden of revision total knee replacement: A cost-complexity analysis.

BACKGROUND: GIRFT tasked regional networks with addressing case-load, complexity-spread and cost of revision knee replacement (KR), but the regional cost burden is not clear. The tariff for revision KR is currently not dependent on surgical complexity. 2 years of revision KR complexity data using the validated Revision Knee Complexity Classification (RKCC) checklist as a demonstration of complexity spread in the region has previously been published. The aims of this study were to estimate the annual regional cost of revision TKR using existing data, and estimate the cost/saving of complexity-clustering using existing data from 8 revision centres. METHODS: Financial data from the regional high-volume centre for one year (2019) of RKCC data collection was obtained. Mean cost, tariff and balance was calculated for R1, R2 and R3 (RKCC), and applied to data from each revision centre to provide local estimates. Complexity clustering was considered using 3 hypothetical scenarios of high-volume centre absorbing R2s and/or R3s in place of R1s. RESULTS: Mean net loss was £2,290.08 for R1s, £6,471.42 for R2s and £6,454.26 for R3s. The estimated total annual loss for the region was £1,005,025. Complexity-clustering was associated with greater losses; £162,918 for high-volume centre taking R2s and R3s, £37,477.60 for taking just R3s and £125,440 for taking just R2s. CONCLUSION: Revision TKR surgery is expensive and insufficiently remunerated with current measures. Restructuring of regional workload would create additional financial burden on specialist centres with current tariff awards structure. Managing reimbursement at a regional or central level may help to incentivise compliance with GIRFT ideals.

Revision total knee replacement: A two-year review of complexity data and regional workload in South West England.

BACKGROUND: The GIRFT report (2012) sought to address the need for sustainable orthopaedic treatment delivered through regional "networks"; the aim being improved care, decreased cost and reduced revision rate. The aims of this study were to record the number and complexity of revision total knee replacements within a regional network using a validated classification over a two-year period and audit this against National Joint Registry (NJR) records. METHODS: A region-wide network model where revision TKR cases are assessed locally using the Revision Knee Complexity Classification (RKCC) and local multi-disciplinary team (MDT) was introduced. Data was collected from 8 revision centres over a two-year period using the RKCC. The case volume was audited against the NJR records. RESULTS: In year 1 (01/01/2018-31/12/2018) 237 RKCC forms were collected from eight centres. 46% of R2s and 63% of R3s were carried out at the higher volume centre. 211 K2 forms were received by the NJR. In year 2 (01/01/2019-31/12/2019) 252 RKCC forms were collected. 46% of R2s and 64% of R3s were carried out at the higher volume centre. 267 K2 forms were received by the NJR. CONCLUSION: This is the first published set of revision knee data showing complexity percentages across a region. The RKCC has been successfully introduced into the region and this has been sustained. The findings show that a successful network has been established and majority of complex revision knee surgery is occurring in the high-volume centre. NJR data suggests that the RKCC is capturing the complexity and volume of our work accurately.

Getting animated about trauma - Using video animation as part of informed consent.

INTRODUCTION: Trauma patients are often required to make an informed decision about surgery within a short space of time. Coming to terms with their injury may mean they have limited bandwidth for absorbing information, and it may be that they don't appreciate the risks and benefits of surgery discussed during consent. Current consent practice puts the emphasis on the clinician to ensure that all reasonable steps have been taken to explain risks and benefits to patients. We propose the use of video animations that patients can watch prior to surgery as a means of improving their understanding and overall experience. METHODS: The video script was written and evaluated so that a high standard was achieved using the "Discern" instrument. The experiences of a focus group of 5 patients were used to guide script content. Using GoAnimate (GoAnimate Inc., San Mateo) a video was made with voice over provided by local drama students. The video was shown to 30 consecutive patients over a 2 month period. We included any patient with an ankle fracture managed operatively who had been consented (form 1). Evaluation consisted of interview with patients consisting of 2 focussed questions and one open. Responses to the questions were collated and grouped into positive and negative descriptors. RESULTS: 68 (81%) positive descriptors were recorded from patients' interviews versus 16 (19%) negative. Positive descriptors related to improved retention, information giving, technical detail, consolidations of information given during consent. Negatives were caveats that video couldn't replace face-to-face consent, the degree of detail being off-putting and not adding anything to standard consent. CONCLUSION: The video was well received by patients with subjective improvements being made to their understanding, retention and sharing of technical detail. The face-to-face discussion between patient and doctor remains very important to them and the video should look to augment this.

Evaluation of unfractionated heparin versus low-molecular-weight heparin and fondaparinux for pharmacologic venous thromboembolic prophylaxis in critically ill patients with cancer.

Essentials Critically ill cancer patients require pharmacologic prophylaxis for venous thromboembolism (VTE). Patients from 566 hospitals in the United States between 2010 and 2014 were included. Low-molecular-weight heparin (LMWH) prophylaxis was not associated in a reduction of VTE rates. LMWH prophylaxis was associated with a reduction in bleeding and heparin induced thrombocytopenia. SUMMARY: Background Critically ill patients with cancer are at increased risk of venous thromboembolism (VTE) from physical and cellular factors, requiring pharmacologic prophylaxis to reduce the risk of VTE. Objectives To assess whether low-molecular-weight heparin (LMWH) prophylaxis reduces in-hospital rates of VTE or improves clinical outcomes compared with unfractionated heparin (UFH) prophylaxis in critically ill patients with cancer. Methods We used a propensity-matched comparative-effectiveness cohort from the Premier Database. Patients aged 18 years or older with a primary diagnosis of cancer, intensive care unit admission and VTE prophylaxis within 2 days of admission between 1 January 2010 and 31 December 2014 were included. Patients were divided into LMWH or UFH prophylaxis groups. Results A total of 103 798 patients were included; 75 321 (72.6%) patients received LMWH and 28 477 (27.4%) patients received UFH. Propensity analysis matched (2 : 1) 42 343 LMWH patients and 21 218 UFH patients. Overall, LMWH was not associated with a decreased incidence of VTE (5.32% vs. 5.50%). LMWH prophylaxis was associated with a reduction in pulmonary embolism (0.70% vs. 0.99%), significant bleeding (13.3% vs. 14.8%) and heparin-induced thrombocytopenia (HIT) (0.06% vs. 0.19%). In non-metastatic solid disease, LMWH was associated with decreased VTE (4.27% vs. 4.84%) and PE (0.47% vs. 0.95%). Conclusions The use of an LMWH for VTE prophylaxis was not associated with a reduction in the incidence of in-hospital VTE as compared with UFH, but was associated with significant reductions in PE, clinically important bleeding events, and incidence of HIT in critically ill patients with cancer.

Enhanced Human-Induced Pluripotent Stem Cell Derived Cardiomyocyte Maturation Using a Dual Microgradient Substrate.

Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) raise many possibilities for cardiac research but they exhibit an immature phenotype, which influences experimental outcomes. The aim of our research is to investigate the effects of a topographical gradient substrate on the morphology and function of commercially available hiPSC-CM. The lateral dimensions the microgrooves on the substrate varied from 8 to 100 µm space between the 8 µm grooves on one axis and from ∼5 nm to ∼1 µm in depth on the other axis. Cells were seeded homogeneously across the substrate and according to the manufacturers protocols. At days 4 and 10, measures of eccentricity, elongation, orientation, sarcomere length (SL), and contractility of the hiPSC-CM were taken. Only the deepest and widest region (8-30 µm wide and 0.85-1 µm deep) showed a significantly higher percentage of hiPSC-CM with an increased eccentricity (31.3 ± 6.4%), elongation (10.4 ± 4.3%), and orientation (<10°) (32.1 ± 2.7%) when compared with the control (flat substrate) (15.8 ± 5.0%, 3.4 ± 2.7%, and 10.6 ± 1.1%, respectively). Additionally, during stimulus-induced contraction, the relaxation phase of the twitch was prolonged (400 ms) compared to nonelongated cells (200 ms). These findings support the potential use of dual microgradient substrates to investigate substrate topographies that stimulate migration and/or maturation of hiPSC-CM.

Canine exposure to herbicide-treated lawns and urinary excretion of 2,4-dichlorophenoxyacetic acid.

A recent study by Hayes et al. (J. Natl. Cancer. Inst., 83: 1226-1231, 1991) found an increased risk of malignant lymphoma associated with exposure to 2,4-dichlorophenoxyacetic acid (2,4-D) in pet dogs. We conducted a study to determine the extent to which dogs absorb and excrete 2,4-D in urine after contact with treated lawns under natural conditions. Among 44 dogs potentially exposed to 2,4-D-treated lawns an average of 10.9 days after application, 2,4-D concentrations greater than or equal to 10.0 micrograms/l were found in 33 dogs (75%) and concentrations of > or = 50 micrograms/l were found in 17 (39%). Among 15 dogs with no known exposure to a 2,4-D-treated lawn in the previous 42 days, 4 (27%) had evidence of 2,4-D in urine, 1 at a concentration of > or = 50 micrograms/l. The odds ratio for the association between exposure to a 2,4-D-treated lawn and the detection of > or = 50 micrograms/l 2,4-D in urine was 8.8 (95% confidence interval, 1.4-56.2). Dogs exposed to lawns treated within 7 days before urine collection were more than 50 times as likely to have 2,4-D at concentrations > or = 50 micrograms/l than dogs with exposure to a lawn treated more than 1 week previously (odds ratio = 56.0; 95% confidence interval, 10.0-312.2). The highest mean concentration of 2,4-D in urine (21.3 mg/l) was found in dogs sampled within 2 days after application of the herbicide.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of topical treatment by timolol versus pilocarpine on visual field progression in chronic simple glaucoma.

OBJECTIVES: The objective of this study was to compare the intraocular pressure-lowering capacity, tolerability, and visual field conservation of topical timolol and pilocarpine at the concentrations usually prescribed.

Effect of timolol versus pilocarpine on visual field progression in patients with primary open-angle glaucoma.

BACKGROUND: Relatively few studies have been conducted linking decreasing intraocular pressure (IOP) to preservation of visual field. This investigation was conducted to determine if this link could be made and to compare the long-term effect of two ocular hypotensive agents on preservation of visual field. METHODS: In an observer-masked study, 189 patients with primary open-angle glaucoma received either timolol or pilocarpine by random allocation. The dose of antiglaucoma agent was increased from 0.25% to 0.5% twice daily for timolol or from 2% to 4% four times daily for pilocarpine if the initial IOP response was inadequate. After an on-treatment baseline, visual fields were followed every 4 months for 2 years using the Octopus program 32. RESULTS: Compared with timolol, significantly more patients receiving pilocarpine discontinued use because of inadequate IOP control (P < or = 0.01). By comparing the mean visual field scores, it can be seen that the pilocarpine group had a significantly worse score at all timepoints from month 4 to month 24. The pilocarpine group also had a greater mean number of test loci with decreased sensitivity of 5 or more decibels (dB) at all timepoints. The mean within-patient regression slope for timolol was 0.01 dB/month and for pilocarpine was -0.06 dB/month (P < 0.01). The study has shown that over a 2-year period, patients treated with pilocarpine 2% or 4% four times daily experienced a significantly greater visual field deterioration than that seen in patients receiving either 0.25% or 0.5% timolol twice daily. CONCLUSION: Although these data do not support a link between lowering of IOP and visual field preservation, treatment with timolol was associated with significantly less visual field loss than treatment with pilocarpine.

Non-seminomatous germ cell testicular tumours: residual masses after chemotherapy.

Twenty-three consecutive patients with metastatic non-seminomatous germ cell testicular tumours were treated with a combination of cisplatinum, vinblastine and bleomycin. Nineteen had elevated serum tumour marker levels (alpha-fetoprotein and beta-subunit HCG) prior to chemotherapy. In 11 of the 19, residual masses were present on the completion of induction chemotherapy despite normal serum tumour marker levels (residual mass after chemotherapy). The management of these 11 patients was based on a policy of observation rather than routine resection of residual deposits and all are currently alive (32-58 months) with ten free of active disease. Two of the eleven required additional chemotherapy when serial tumour marker levels became elevated during follow-up. Another six have been observed without further intervention and have remained well with stable or diminishing deposits. The remaining three have required resection of residual masses, in each case because of mass enlargement despite persistently negative tumour marker levels. None of the masses showed histological evidence of malignancy. A more selective approach to resection of residual masses after chemotherapy is advocated.

Mitolactol chemotherapy for malignant melanoma: a phase II study.

Fifty-one patients (43 evaluable) with malignant melanoma were treated with mitolactol in an intermittent oral schedule. There were four objective tumor responses, all occurring in patients previously treated with dacarbazine.

The assessment of response to therapy of bone metastases in breast cancer.

Serial bone scans, x-rays and records of bone pain were reviewed in order to determine the relative contributions of these parameters in the assessment of response of bone metastases to treatment. Twenty-seven patients with abnormal bone scans due to metastatic breast cancer were studied. Ten of the patients showed an early temporary flare on bone scan including five with apparent new lesions. Confirmation that such new lesions did not denote progressive disease was provided by subsequent improvement in symptoms and reduction in intensity and number of lesions on a follow-up bone scan, without any change in systemic therapy. Serial x-rays were found to be unreliable as a sole method for assessing response to therapy or disease progression, as in only seven of the 27 patients could a definitive radiological assessment of response be made. In only one patient did x-rays improve the accuracy of the scan by distinguishing between a healing flare and progressive disease. In contrast, this distinction was made in seven of the 10 patients on the basis of improvement in bone pain at the time of the flare. The other 3 patients had no bone pain prior to therapy or at the time of the flare. Tentative response criteria incorporating bone scan, x-ray and symptoms are suggested. The criteria incorporate recognition of the fact that new lesions appearing on a bone scan within six months of initiation of therapy may comprise part of a healing flare response.

Possible infectious etiology of six cases of Ewing's sarcoma in Western Australia.

Six cases of Ewing's sarcoma occurring in Western Australia during a 2-year period are reported. All six patients lived in rural habitats and reported exposure to farm animals. There was evidence of direct contact between two patients over a 3-year period preceding the diagnosis of their tumors. These features raise the possibility that Ewing's sarcoma has an infectious etiology.

Adjuvant immunotherapy with BCG in stage II malignant melanoma.

Forty-one patients were treated with BCG immunotherapy following block dissection of lymph nodes involved with malignant melanoma. A control group of similar patients who received no immunotherapy was drawn from a population consisting of all patients with malignant melanoma diagnosed in Western Australia in the period from January 1, 1975 to December 31, 1976. The disease-free survival and overall survival of BCG-treated patients were not different from that of the control group, who received no immunotherapy. The findings do not support the use of this type of immunotherapy as an adjuvant to surgery in the treatment of patients with stage II malignant melanoma.

Serial bone scans in the assessment of response to therapy in advanced breast carcinoma.

Twenty-seven patients taking part in an advanced breast cancer trial in Australia and New Zealand were studied to assess the predictive value of serial bone scans as an indicator of response to therapy. The report of serial bone scans in 20 of the 27 patients correctly reflected the clinical outcome. Of the 20 patients, all had an initial subjective response and 15 had an objective response. Of the seven patients whose bone scan report did not reflect the clinical situation, five had increased uptake in known lesions and new lesions and one had increased uptake in known lesions only within six months of commencing therapy. These scan reports indicated progression of disease rather than a healing or "flare" response which was later proved to exist. One patient had clinical progression of bone metastases which was confirmed by x-ray but was not reflected in the bone scan until months later. Clinical progression of disease was accurately reflected in the bone scans of 11 of 12 patients. Recognition that a "'flare" effect in the first months of therapy may also cause new lesions to be seen should enhance the accuracy of bone scintigraphy.

Phase II study of cyclophosphamide, vincristine and D.T.I.C. +/- B.C.G. in the treatment of malignant melanoma.

Fifty-three patients with advanced metastatic malignant melanoma were treated with DTIC, vincristine and cyclophosphamide in a 28 day cycle. In addition, 39 were vaccinated with BCG. The BCG treated group showed no significant advantage in response or survival over those treated with chemotherapy alone. Response rate in nodes draining vaccinated areas was not greater than that in equivalent nodes in non-BCG treated patients. Of 50 patients evaluable for response, two showed CR, 15 PR for an overall response rate of 34% (median duration 20 weeks, range 4-77 + weeks). Metastatic sites did not influence response rate. Median survival of all treated patients was 26 weeks, responders 42 weeks, non-responders 18 weeks, p less than 0.025. This regimen may be superior to DTIC alone.

Effect of oral zinc sulphate and penicillamine on zinc metabolism in patients with rheumatoid arthritis.

Whole body zinc and zinc absorption were measured in 14 patients with classical rheumatoid arthritis (RA). Half of these patients were treated with penicillamine for a period of 8 wk and the other half received zinc sulphate orally for a similar period of time. Whole body zinc and zinc absorption were not significantly affected by either therapy. These observations suggest that any pharmacological effect of oral zinc sulphate or penicillamine on patients with RA is not mediated by their effect on zinc metabolism in such patients.