Case Report: Halting terminal osseous overgrowth post tibia amputation in children: a report of three cases.

Terminal osseous overgrowth is a common complication after trans-diaphyseal amputation in children, leading to pain, soft tissue problems, and recurrent surgical procedures. We report three different cases with post-amputation issues of osseous overgrowth, ulceration, and deformity over the amputation site. The first case involves a 9-year-old boy with a right leg congenital amputation secondary to amniotic band syndrome. The right below-knee stump later experienced recurrent episodes of osseous overgrowth, leading to ulceration. After the prominent tibia was resected and capped with the ipsilateral proximal fibula, a positive outcome was achieved with no more recurrent overgrowth over the right leg stump. The second case involves a 9-year-old girl born with an amniotic constriction band over both legs. Her left leg remained functional after a circumferential Z-plasty, but the right leg was a congenital below-knee amputation. Multiple refashioning surgeries were performed on the right leg due to osseous overgrowth but the patient continued to experience recurrent overgrowth causing pain and difficulty fitting into a prosthesis. We performed osteocartilaginous transfer of the proximal part of the ipsilateral fibula to the right tibial end, successfully preventing the overgrowth of the tibia without any complications. The third case involves an 11-year-old boy with a history of meningococcal septicemia who underwent a right below-knee amputation and left ankle disarticulation due to complications of septic emboli. He experienced a prominent right distal tibia stump, which later developed into valgus deformity as a result of the previous insult to the proximal tibial growth plate. We performed a corrective osteotomy over the proximal right tibia and capped the entire tibia with the ipsilateral fibula as an intramedullary splint for the osteotomy site. Post-operatively, we achieved satisfactory deformity correction and successfully halted the recurrent overgrowth over the right tibia stump. The method of ipsilateral fibula capping is safe and effective in managing the osseous overgrowth complications in trans-diaphyseal amputations among children. Therefore, it is a reasonable option during primary below-knee amputations in children compared to multiple refashioning surgeries.

Identifying Potentially Avoidable Readmissions: A Medication-Based 15-Day Readmission Risk Stratification Algorithm.

BACKGROUND: Stratifying patients according to 15-day readmission risk would be useful in identifying those who may benefit from targeted interventions during and/or following hospital discharge that are designed to reduce the likelihood of readmission. METHODS: A prediction model was derived via a case-control analysis of patients discharged from a tertiary hospital in Singapore using multivariate logistic regression. The model was validated in two independent external cohorts separated temporally and geographically. Model discrimination was assessed using the C-statistic, while calibration was assessed using the Hosmer-Lemeshow χ2 and the Brier score statistics. RESULTS: A total of 1291 patients were included with 670, 101, and 520 patients in the derivation, temporal, and geographical validation cohorts, respectively. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03, p=0.008), anemia (OR 2.08, 95% CI 1.15-8.05, p=0.015), malignancy (OR 3.37, 95% CI 1.16-9.80, p=0.026), peptic ulcer disease (OR 3.05, 95% CI 1.12-8.26, p=0.029), chronic obstructive pulmonary disease (OR 3.16, 95% CI 1.24-8.05, p=0.016), number of discharge medications (OR 1.06, 95% CI 1.01-1.12, p=0.026), discharge to nursing homes (OR 3.57, 95% CI 1.57-8.34, p=0.003), and premature discharge against medical advice (OR 5.05, 95% CI 1.20-21.23, p=0.027) were independent predictors of 15-day readmission risk. The model demonstrated reasonable discrimination on the temporal and geographical validation cohorts with a C-statistic of 0.65 and 0.64, respectively. Model miscalibration was observed in both validation cohorts. CONCLUSION: A 15-day readmission risk prediction model is proposed and externally validated. The model facilitates the targeting of interventions for patients who are at high risk of an early readmission.

Same drug, different dosing: differences in dosing for drugs approved in the United States, Europe, and Japan.

With globalization of the pharmaceutical industry, newly approved drugs nearly always become available worldwide, including the 3 major pharmaceutical regions: the United States, Europe, and Japan. One might think that these drugs would have the same recommended dosing throughout the world, but this appears not to be true in many instances. The objective of this study was to identify any patterns of differences in labeled dosing. Approved labeling, for the most widely prescribed proprietary drugs in the United States, was used as a basis for this study. Dosing was compared, for common indications, for the United States, Europe, and Japan. Overall, these data indicate that there are numerous differences in approved dosing for drugs approved in all 3 regions. For about half of the drugs studied, dosing in Japan is considerably lower than the United States or Europe. Some differences in dosing are also apparent between the United States and Europe.