Incidence of venous thromboembolism after total hip, total knee and hip fracture surgery at Waitemata District Health Board following a peer-reviewed audit.

AIM: The incidence of venous thromboembolism (VTE) following arthroplasty and hip fracture surgery remains an important metric for quality and financial reasons. An audit at our institution between 2006-2010 showed a higher VTE rate than international data did at the time. This study aims to determine rates of DVT and PE in patients undergoing hip and knee arthroplasty and hip fracture surgery at Waitemata District Health Board (Waitemata DHB) between 1 January 2013 and 31 December 2016. METHODS: This study is a retrospective review of all VTE within three months of elective hip or knee replacement or hip fracture surgery. Data were identified for the period between 2013 and 2016 from Waitemata DHB patient databases, including a dedicated VTE database. RESULTS: The current rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) at our institution following hip or knee arthroplasty or hip fracture surgery are 1.5% and 0.6% respectively, a lower rate than 2.3% and 0.9% respectively in 2006-2010. DVTs were significantly more prevalent after hip fracture surgery than after elective hip or knee arthroplasty, and 71% of DVTs were confined to the distal veins. Of the patients undergoing surgery, 93% received post-operative chemoprophylaxis, mainly aspirin or low molecular-weight heparin (LMWH). CONCLUSION: There has been a significant reduction in VTE rates following elective hip and knee joint replacement and hip fracture surgery between the time periods. This occurred over a period when Waitemata DHB introduced a multi-modal, interdisciplinary team approach to VTE prophylaxis utilising enhanced recovery after surgery (ERAS) pathways. These measures may therefore have contributed to the reduction in VTEs.

Altered load transfer in the pelvis in the presence of periprosthetic osteolysis.

Periprosthetic osteolysis in the retroacetabular region with cancellous bone loss is a recognized phenomenon in the long-term follow-up of total hip replacement. The effects on load transfer in the presence of defects are less well known. A validated, patient-specific, 3D finite element (FE) model of the pelvis was used to assess changes in load transfer associated with periprosthetic osteolysis adjacent to a cementless total hip arthroplasty (THA) component. The presence of a cancellous defect significantly increased (p < 0.05) von Mises stress in the cortical bone of the pelvis during walking and a fall onto the side. At loads consistent with single leg stance, this was still less than the predicted yield stress for cortical bone. During higher loads associated with a fall onto the side, highest stress concentrations occurred in the superior and inferior pubic rami and in the anterior column of the acetabulum with larger cancellous defects.

Evaluation and treatment of the child with febrile seizure.

Up to 5 percent of children in North America and western Europe experience at least one episode of febrile seizure before six years of age. Most of these seizures are self-limited and patients do not require treatment. Continuous therapy after the seizure is not effective in reducing the development of afebrile seizures. Antipyretics are effective in reducing the risk of febrile seizures if given early in the illness. Immediate care for the patient who has had a febrile seizure includes stopping the seizure, if prolonged, and evaluating the patient for the cause of the fever. Bacterial infections are treatable sources of fever but are not usually the cause of the fever that triggers a seizure. The patient must be assessed for these treatable sources. Long-term consequences of febrile seizure are rare in children who are otherwise healthy. Current recommendations do not support the use of continuing or intermittent neuroleptic or benzodiazepine suppressive therapies after a simple febrile seizure.

Quality improvement efforts in prenatal care for Oklahoma Medicaid managed care patients: 1995-1998.

The Oklahoma Health Care Authority and the Oklahoma Foundation for Medical Quality analyzed documented patterns of care in the Oklahoma Medicaid urban managed care plans from 1995 through 1998. In 1995, 31.3% of the patients had started prenatal care in the first trimester, and 50.6% of the patients had first trimester prenatal care in 1998. No prenatal care was noted for 3.2% in 1995, which decreased to 2.9% for 1998. For 1995, 23.9% of the deliveries were operative and 20.8% for 1998. Similarly, the vaginal delivery after previous C-section (VBAC) rate was 36.5% for 1995, and increased to 41.0% in 1998. Very low birth weight (defined as below 1500 grams) rates were 3.7% for 1995 and 1.3% for 1998, while the low birth weight (between 1500 and 2499 grams) infants were recorded for 7.8% of the live births in 1995, and for 1998, 7.5%. While there has been improvement in rates over the four years of the study, opportunities for improvement in the provision of the prenatal care for the Oklahoma Medicaid managed care population remain.