Appropriateness of vancomycin therapeutic drug monitoring and its outcomes among non-dialysis patients in a tertiary hospital in Singapore

Background Vancomycin therapeutic drug monitoring (TDM) is commonly performed to ensure safe and effective use of the antibiotic. Aim of Study To evaluate appropriateness of vancomycin TDM and its outcomes in Singapore General Hospital. Method A retrospective, cross-sectional study was conducted between 1 January 2014 and 28 February 2014 involving patients who received?≥?1 dose of intravenous vancomycin with TDM. Patient demographics and relevant vancomycin TDM data were collected from medical records. Results Of 746 vancomycin troughs measured among 234 patients, 459 troughs (61.5%) were taken inappropriately, with a median time of 2.6 h (interquartile range 1.1–4.3) before the next scheduled dose. Inappropriate interpretation of vancomycin troughs resulted in 41 unnecessary dose suspensions, 24 dose changes, and 102 unchanged vancomycin doses. The cost incurred due to inappropriate interpretation and measurement after discontinuation of treatment was US$7286. No differences in rates of vancomycin related nephrotoxicity, ototoxicity, recurrent infection, development of infection secondary to vancomycin resistant microorganism and mortality were observed (p?>?0.05). Conclusion This study highlighted a high incidence of inappropriate vancomycin TDM which has led to increased healthcare cost.     

Factors influencing health promoting activities of mothers caring for ventilator-assisted children

The extensive care a ventilator-assisted child (VAC) requires when cared for in the home can impact the mother's ability to participate in health promotion activities. The purpose of this study was to examine health promotion activities and the relationships among functional status of the child, impact of the illness on the family, coping, social support, and health promotion activities of mothers who care for ventilator-assisted children at home. Thirty-eight primary female caregivers, mostly mothers, participated in the study and completed the Personal Lifestyle Questionnaire (PLQ), measures of child's functional status, impact of the illness on the family, coping, social support, and demographic data. Findings revealed that the mothers scored low on the nutrition, exercise, relaxation, and general health promotion subscales of the PLQ. Functional status of the child and coping were positively correlated with participation in health promotion activities, whereas impact of the child's illness on the family was inversely related to health promotion of the mothers. Regression analysis revealed that functional status of the child and coping were significant predictors of mothers' participation in health promotion activities. The high demands associated with caring for a VAC with poor functioning can be a significant risk factor for not participating in health promotion activities. Nurses need to help mothers with coping and finding resources to help mediate the stress related to caring for their child, thereby helping the mothers to maintain their own health.     

Impact of renal disease on elective shoulder arthroplasty outcomes for glenohumeral osteoarthritis

BackgroundRenal disease including chronic renal disease and end-stage renal disease has been associated with the development of primary glenohumeral osteoarthritis. However, little is known about how renal disease affects outcomes after shoulder arthroplasty. Thus, the purpose of this study was to evaluate the impact of renal disease on outcomes of shoulder arthroplasty for glenohumeral osteoarthritis.MethodsThis was a retrospective review using the Nationwide Readmissions Database. Using International Classification of Diseases, 9th Revision, codes, patients who underwent shoulder arthroplasty (including total shoulder arthroplasty and reverse total shoulder arthroplasty) for primary glenohumeral osteoarthritis were identified. These patients were divided into 3 groups: no renal disease, predialysis chronic renal disease (including stages 1-5), and end-stage renal disease. Primary outcomes of interest included the risk of complications during index hospitalization as well as within 90 days of index surgery. Secondary outcomes included index hospitalization length of stay, cost, and discharge location.ResultsFrom 2010 to 2014, a total of 29,336 patients underwent shoulder arthroplasty for glenohumeral osteoarthritis. Of these 29,336, 27,928 (95.2%) patients had no renal disease, 1355 (4.6%) had predialysis chronic renal disease, and 53 (0.2%) patients had end-stage renal disease. Compared with patients with no renal disease, both predialysis chronic renal disease and end-stage renal disease patients had an increased risk of receiving blood transfusions (odds ratio [OR] = 2.04, P < .0001, and 5.37, P = .04, respectively) and experiencing any postoperative complication during the index hospitalization (OR = 2.31, P < .0001, and 3.94, P = .003, respectively). Specifically, predialysis chronic renal disease patients were at an increased risk for cardiac (OR = 1.96, P < .0001) and respiratory (OR = 1.55, P < .0001) complications as well as acute renal failure (OR = 14.70, P < .0001) postoperatively. End-stage renal disease patients were at an increased risk for cardiac (OR = 3.87, P = .003) complications as well as acute renal failure (OR = 10.35, P = .002) postoperatively. Within 90 days, end-stage renal disease patients had an increased risk of hospital readmission (OR = 8.01, P < .0001), dislocation (OR = 8.70, P = .039), and surgical site infection (OR = 19.06, P = .001). Finally, compared with patients with no renal disease, predialysis chronic renal disease and end-stage renal disease patients both had increased hospital length of stay and cost; predialysis chronic renal disease patients had an increased risk of discharge to a skilled nursing facility (OR = 1.39, P = .039).Discussion and ConclusionThis retrospective cohort study demonstrates that even predialysis chronic renal disease patients have worse outcomes compared with patients with no renal disease after shoulder arthroplasty for glenohumeral osteoarthritis. These findings serve to highlight the importance of close perioperative monitoring to prevent complications in a potentially overlooked patient population.     

MRI-Based Shoulder Osteoarthritis Severity score (SOAS) is predictive of functional improvement following total shoulder arthroplasty

BackgroundTotal shoulder arthroplasty (TSA) is an increasingly common treatment for end-stage glenohumeral osteoarthritis. Current established radiographic measures and classification systems do not predict patient-reported outcomes from TSA. We hypothesized that the MRI-based Shoulder Osteoarthritis Severity (SOAS) Score would correlate with subjective improvement following TSA.MethodsPatients undergoing TSA with preoperative shoulder MRIs and pre- and postoperative ASES scores with minimum 2-year follow-up were included from a prospectively collected institutional shoulder arthroplasty database. SOAS scores, which is measured from 0 to 100 with an increasing score reflecting greater global degenerative changes, were assessed by two independent reviewers, and Samilson-Prieto grade and Walch classification were scored by one reviewer. Average SOAS scores were correlated with demographic factors and pre-, post-, and change (Δ) in ASES scores. Statistical analysis was performed with STATA with Pearson's correlation, one-way ANOVA, and ROC analysis, with significance defined by p <.05.Results30 patients (age 63 ± 10 years, 14 females, 16 males) who underwent primary anatomic TSA were included. The intraclass correlation coefficient (ICC) for total SOAS scores calculated by reviewers was 0.91. SOAS score correlated significantly with ΔASES (r = 0.61, p = .0003) and preoperative ASES (r = -0.37, p = .042), with greater MRI-based degenerative change associated with greater improvement after TSA and lower preoperative ASES score. No significant relationship was found between either Samilson-Prieto or Walch classification and SOAS or ASES scores. No significant relationship was found between SOAS scores and age, sex, or BMI. Using an MCID of 21 as previously reported, an ROC curve was generated and found to have an AUC of 0.96. A SOAS score cut-point of 36.25 was found to maximize sensitivity and specificity in predicting reaching MCID.ConclusionWe observed a significant positive correlation between the MRI-based SOAS score and functional improvement following TSA measured using change in ASES scores, indicating that patients with more advanced degenerative changes on MRI had greater improvement after shoulder replacement surgery. We found that the correlation strength was highest when comparing total SOAS score to ΔASES as opposed to any individual sub-component of the SOAS score. The MRI-based SOAS score for shoulder osteoarthritis may be a valuable tool for predicting patient outcomes following TSA.Level of evidenceLevel III; Retrospective Cohort Comparison; Prognosis Study     

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01–1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001–1.01) infection (OR 2.08, 95% CI 1.06–4.07) and presence of diabetes (OR 3.77, 95% CI 1.12–12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.     

Interplay between vascular hemodynamics and the glymphatic system in the pathogenesis of idiopathic normal pressure hydrocephalus,exploring novel neuroimaging diagnostics

Neurosurgical Review - As the aging population continues to grow, so will the incidence of age-related conditions, including idiopathic normal pressure hydrocephalus (iNPH). The pathogenesis of...     

Expression of decitabine-targeted oncogenes in meningiomas in vivo

Neurosurgical Review - Treatment of meningiomas refractory to surgery and irradiation is challenging and effective chemotherapies are still lacking. Recently, in vitro analyses revealed decitabine...     

An OxPLORE Initiative Evaluating Children’s Surgery Resources Worldwide: A Cross-sectional Implementation of the OReCS Document

World Journal of Surgery - The Global Initiative for Children's Surgery (GICS) group produced the Optimal Resources for Children’s Surgery (OReCS) document in 2019, listing standards of...     

Retroperitoneal varices simulating masses

Retroperitoneal varices in portal hypertension may simulate the appearance of neoplastic masses or adenopathy. Contrast-enhanced CT scans clarify the diagnosis of large vascular channels. Three patients with large retroperitoneal varices demonstrated on CT had confirmation by angiography.     

Clinician vs mathematical statistical models: which is better at predicting an abnormal chest radiograph finding in injured patients?

Objective

The purpose of this study was to determine if statistical models for prediction of chest injuries would outperform the clinician's (MD) ability to identify injured patients at risk for a thoracic injury diagnosed by chest radiograph (CXR).

Design

A prospective observational study was done during a 12-month period.

Setting

The study was conducted in a level I trauma center.

Patients

Injured patients meeting trauma team activation criteria were enrolled to the study.

Interventions

Physical examination findings by a clinician were interpreted and CXR was performed.

Outcome measures

The accuracy of 2 mathematical models is compared against the accuracy of clinician's clinical judgment in predicting an injury by CXR. Two newly constructed multivariate models, binary logistic regression (LR) and classification and regression tree (CaRT) analysis, are compared to previously published data of clinician clinical assessment of probability of thoracic injury identified by CXR.

Results

Data for 757 patients were analyzed. Classification and regression tree analysis developed a stepwise decision tree to determine which signs/symptoms were indicative of an abnormal CXR finding.The sensitivity (CaRT, 36.6%; LR, 36.3%; MD, 58.7%), specificity (CaRT, 98.3%; LR, 98.2%; MD, 96.4%), and error rates (CaRT, 0.93; LR, 0.94; MD, 0.82) show that the mathematical decision aids are less sensitive and risk more misclassification compared to clinician judgment in predicting an injury by CXR.

Conclusion

Clinician judgment was superior to mathematical decision aids for predicting an abnormal CXR finding in injured patients with chest trauma.