Evaluation of Factors Delaying Discharge in Acute Orthopedic Wards: a Prospective Study

Abstract Introduction: Prolonged hospitalization due to delayed discharge not only increases cost, it also increases the risk of medical complications e.g., hospital acquired infections. Length of stay (LOS) is one of the indicators that reflect total cost of care during hospitalization. The study was planned to evaluate the factors affecting delay in discharges from hospital and whether these factors are avoidable. Hypothesis: The LOS in an acute orthopedic trauma ward is mainly determined by relative contribution patient derived factors which are present even prior to admission, rather than organisational/administrative factors. Materials and Methods: Four hundred and fifty-three case notes were reviewed for 6 months prospectively from an acute care hospital. Information was collected on demographic profile, functional and cognitive function, past medical and social history, admitting diagnosis, discharge limiting and delaying factors. Results: Out of 453 patients admitted from Jan 2005 to Jun 2005, 50 patients stayed longer than 28 days in the study group. The mean ages of the patients were 84 years (SD 4.5). The mean Abbreviated mental test score of the study was 5 (range 1–10). On admission, 78% of the patients had co-morbidities with 40% of patients having three or more associated medical problems. The two main factors limiting discharge were social issues in 33 patients (66%) and sepsis in 14 patients (28%). Conclusion: Older patients with co-morbidities are more prone to long stay due to de-conditioning requiring social input and nosocomial infection. The study thus proved the hypothesis and suggested that early identification of social issues and prompt discharge planning helps to avoid delay in discharge.     

Cortical correlates of the basic and first harmonic frequency of Parkinsonian tremor

ObjectiveIt has been hypothesized that the basic and first harmonic frequency of Parkinsonian tremor are somewhat independent oscillations the biological basis of which remains unclear.MethodsWe recorded 64-channel EEG in parallel with EMG of the forearm muscles most affected by rest tremor in 21 PD patients. EMG power spectrum, corticomuscular coherence spectra and EEG power spectra for each EEG electrode were calculated. The dynamics of the coherence and relative EMG and EEG power at the basic (tremor) frequency were calculated by a sliding, overlapping window analysis. Corticomuscular delays and direction of interaction were analysed by the maximizing coherence method for narrow band signals.ResultsThe contralateral EEG electrodes with maximal coherence were different for the basic and first harmonic frequency. The dynamical coherence curves showed non-parallel time courses for the two frequencies. The mean EEG-EMG and EMG-EEG delays were all around 15–20 ms but significantly longer for the first harmonic than for the basic frequency.ConclusionsOur data indicate different cortical representations and corticomuscular interaction of the basic and first harmonic frequencies of Parkinsonian tremor.SignificanceSeparate central generators seem to contribute to the tremor via different pathways. Further studies on this complex tremor network are warranted.     

The parietal role in the sense of self-ownership with temporal discrepancy between visual and proprioceptive feedbacks

One hypothesis on how we recognize an image of, for example, an arm as our own is through the co-occurrence of multiple sensory feedbacks, especially visual and proprioceptive feedbacks, in this process. It has been suggested that the parietal lobe is the region where proprioceptive and visual information of one's own body is integrated. This study investigated parietal cortical activity during a visual-proprioceptive synchrony judgment task in which visual feedback of the subjects' own passively moving hand was delayed. The subjects were required to judge whether or not there was a delay between the proprioceptive and visual feedbacks. Parietal cortical activity, which was measured using a 48-channel near-infrared spectroscopy (NIRS) apparatus, appeared to be modulated by the length of the delay between the visual and proprioceptive feedbacks. The bilateral superior/middle parietal areas were involved in experiencing the synchrony between the visual and proprioceptive feedbacks, whereas the right inferior parietal areas were strongly activated when discrepancy between the two feedbacks was detected. We postulate that the superior portion of the parietal lobe is essential for maintaining one's own body image, while the right inferior portion is involved in detecting movements of others.     

The optimal duration and delay of first aid treatment for deep partial thickness burn injuries

Using our porcine model of deep dermal partial thickness burn injury, various durations (10 min, 20 min, 30 min or 1 h) and delays (immediate, 10 min, 1 h, 3 h) of 15 °C running water first aid were applied to burns and compared to untreated controls. The subdermal temperatures were monitored during the treatment and wounds observed weekly for 6 weeks, for re-epithelialisation, wound surface area and cosmetic appearance. At 6 weeks after the burn, tissue biopsies were taken of the scar for histological analysis. Results showed that immediate application of cold running water for 20 min duration is associated with an improvement in re-epithelialisation over the first 2 weeks post-burn and decreased scar tissue at 6 weeks. First aid application of cold water for as little as 10 min duration or up to 1 h delay still provides benefit.     

Delay Discounting Behavior and White Matter Microstructure Abnormalities in Youth With a Family History of Alcoholism

Background: Youth with family history of alcohol abuse have a greater risk of developing an alcohol use disorder (AUD). Brain and behavior differences may underlie this increased vulnerability. The current study examined delay discounting behavior and white matter microstructure in youth at high risk for alcohol abuse, as determined by a family history of alcoholism (FH+), and youth without such family history (FH?). Methods: Thirty‐three healthy youth (FH+ = 15, FH? = 18), ages 11 to 15 years, completed a delay discounting task and underwent diffusion tensor imaging. Tract‐based spatial statistics ( Smith et al., 2006 ), as well as follow‐up region‐of‐interest analyses, were performed to compare fractional anisotropy (FA) between FH+ and FH? youth. Results: FH+ youth showed a trend toward increased discounting behavior and had significantly slower reaction times (RTs) on the delay discounting paradigm compared to FH? youth. Group differences in FA were seen in several white matter tracts. Furthermore, lower FA in the left inferior longitudinal fasciculus and the right optic radiation statistically mediated the relationship between FH status and slower RTs on the delay discounting task. Conclusions: Youth with a family history of substance abuse have disrupted white matter microstructure, which likely contributes to less efficient cortical processing and may act as an intrinsic risk factor contributing to an increased susceptibility of developing AUD. In addition, FHP youth showed a trend toward greater impulsive decision making, possibly representing an inherent personal characteristic that may facilitate substance use onset and abuse in high‐risk youth.     

简易精神状态筛查联合延迟记忆和言语流畅性检查对阿尔茨海默病诊断的意义

①目的探讨简易精神状态筛查（MMSE）联合延迟记忆和言语流畅性检查对阿尔茨海默病（AD）诊断的意义,为AD的早期诊断提供依据。②方法使用MMSE、Fuid物体记忆测验（FOM）和快速词汇检测（RVR）量表测定AD患者,选择年龄、性别和文化程度相匹配的正常对照组各41例,使用临床痴呆评定量表（CDR）评估AD患者并利用判别分析和ROC曲线分析AD诊断的特异度、灵敏度和总的准确率及ROC曲线下面积。③结果AD总体认知功能在轻、中、重度阶段呈持续性明显减退趋势（MMSE分值分别为17.71±3.71、13.20±3.55、3.29±4.46）;言语流畅性功能变化趋势与总体认知功能损害相似（RVR分值分别为16.58±5.50、10.30±3.09、2.29±4.54）;延迟记忆功能在AD早期即出现衰退,在中、重度阶段均已明显衰退（FOM分值分别为9.75.±4.60、5.80±3.85、2.57±3.95）。判别分析各量表诊断AD总准确率依次为FOM〉RVR〉MMSE,特异度依次为FOM〉MMSE〉RVR,灵敏度依次为RVR〉MMSE〉FOM。而ROC曲线下面积依次为RVR〉FOM〉MMSE。④结论MMSE与FOM、RVR中1个或2个量表联合应用时,区分AD和正常对照组总的准确率均有所提高,诊断AD的特异度和敏感度也较单用任何一个认知量表明显增高。     

Delay discounting, impulsiveness, and addiction severity in opioid-dependent patients

Individuals who abuse drugs show higher delay discounting (DD) rate and impulsiveness scores compared with controls; however, it is unclear if DD rate covaries with severity of the addiction or if an individual's discounting rate can be changed by effective substance abuse treatment. This study compared methadone maintenance treatment (MMT) patients (n = 30) who had not used illegal drugs for 2 years with drug-using MMT patients (n = 30) and controls (n = 25) in terms of addiction severity, DD rate, and impulsiveness. Methadone patients abstinent from illegal drugs scored significantly lower on a number of addiction severity measures than the drug-using methadone patients. In addition, both groups of MMT patients showed significantly higher rates of DD and impulsiveness than the control group; however, no differences in DD rate or impulsiveness were found between the groups of patients. Results suggest that DD rate and impulsiveness may not covary with indicators of addiction severity in MMT patients.     

Laparoscopic ischaemic conditioning of the stomach may reduce gastric-conduit morbidity following total minimally invasive oesophagectomy

Objective: Oesophagectomy, whether open or minimal access, is associated with a significant incidence of gastric-conduit-related complications. Previous animal and human studies suggest that ischaemic conditioning of the stomach prior to oesophagectomy improves perfusion of the gastric conduit. We have adopted laparoscopic ligation of the left gastric artery 2 weeks prior to minimally invasive oesophagectomy, having identified a relative high incidence of gastric-tube complications through a cumulative summation (CUSUM) analysis. Methods: This study included 77 consecutive patients who underwent a Total MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric tube formation, cervical anastomosis). The ligation group comprised 22 consecutive patients, excluding those with middle-third squamous tumours or early-stage adenocarcinoma, who underwent ligation 2 weeks prior to MIO at staging laparoscopy. The control group comprised 55 patients who did not undergo ischaemic conditioning in this way. We have defined conduit-related complications as: leak managed conservatively (L); tip necrosis requiring resection and re-anastomosis (TN) and conduit necrosis needing resection and oesophagostomy (CN). The values are reported as medians. The effect of ligation of the left gastric artery was followed with a CUSUM analysis. Results: Ligation was performed 15.5 days pre-operatively (median). There were no complications and the length of hospital stay was 1 day. Although gastric mobilisation at MIO was technically more difficult after ligation, there was no significant difference in operating time (ligation, 407 min; control, 425 min) or blood loss (ligation and control, 500 ml). There was less gastric-conduit morbidity in the ligation group (two of 22, 10%; one L, one CN) compared with the control group (11 of 55, 20%; four L, five TN, two CN), but these differences did not reach statistical significance (p = 0.211 and p = 0.176 Fisher's exact test). The CUSUM analysis showed that during ligation of the left gastric artery, conservatively treated gastric-conduit-related morbidity (leak, resection and re-anastomosis or conduit necrosis) remained within safe limits (10%). Conduit-related-morbidity increased after stopping ligation. Conclusion: In this non-randomised clinical setting, our results suggest that ischaemic conditioning of the stomach prior to MIO is safe. There is a trend to reduced morbidity related to gastric-conduit ischaemia, which was demonstrated by a CUSUM analysis. A randomised trial is needed before ligation of the left gastric artery can be routinely recommended.     

Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications

Purpose  

To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children.