Avoidable 30-day mortality analysis and failure to rescue in dysvascular lower extremity amputees

Background and purpose — An enhanced treatment program may decrease 30-day mortality below 20% after lower extremity amputations (LEA). The potential and limitations for further reduction are unknown. We analyzed postoperative causes of 30-day mortality, and assessed failure to rescue (FTR) rate in LEA patients who followed an enhanced treatment program.

Patients and methods — Medical charts of 195 primary LEA procedures were reviewed independently by 3 of the authors, and deaths during hospitalization following amputation were classified according to consensus.

Results — 31 patients died within 30 days after surgery. 4 deaths were classified as “definitely unavoidable,” 4 as “probably unavoidable,” and 23 as “FTR.” Patients who died had a higher incidence of sepsis, pneumonia, and acute myocardial infarction compared with those alive. A log binominal regression analysis adjusted for age, sex, ASA score, diabetes, nursing home admission, transfemoral amputation (TFA), and BMI showed that the risk of 30-day mortality was increased for TFA (RR =2.3, 95% CI 1.1–4.8) and for patients with diabetes (RR =2.7, 95% CI 1.3–5.6). The FTR rate (patients with 30-day mortality/all patients with a severe postoperative complication) was 30%. Of the FTR deaths, 20 at some point had active lifesaving care curtailed.

Interpretation — Future initiatives should be directed at enhanced sepsis and pneumonia prophylactic actions, in addition to close monitoring of hemodynamics in anemic patients, with the potential to further reduce morbidity and mortality rates.     

A randomized controlled trial on maximal strength training in 60 patients undergoing total hip arthroplasty

Background and purpose — Total hip arthroplasty (THA) patients have reduced muscle strength after rehabilitation. In a previous efficacy trial, 4 weeks’ early supervised maximal strength training (MST) increased muscle strength in unilateral THA patients <65 years. We have now evaluated muscle strength in an MST and in a conventional physiotherapy (CP) group after rehabilitation in regular clinical practice.

Patients and methods — 60 primary THA patients were randomized to MST or CP between August 2015 and February 2016. The MST group trained at 85–90% of their maximal capacity in leg press and abduction of the operated leg (4?×?5 repetitions), 3 times a week at a municipal physiotherapy institute up to 3 months postoperatively. The CP group followed a training program designed by their respective physiotherapist, mainly exercises performed with low or no external loads. Patients were tested pre- 3, 6, and 12 months postoperatively. Primary outcomes were abduction and leg press strength at 3 months. Other parameters evaluated were pain, 6-min walk test, Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) Physical Function Short-form score.

Results — 27 patients in each group completed the intervention. MST patients were substantially stronger in leg press and abduction than CP patients 3 (43?kg and 3?kg respectively) and 6 months (30?kg and 3?kg respectively) postoperatively (p ≤ 0.002). 1 year postoperatively, no intergroup differences were found. No other statistically significant intergroup differences were found.

Interpretation — MST increases muscle strength more than CP in THA patients up to 6 months postoperatively, after 3 months’ rehabilitation in clinical practice. It was well tolerated by the THA patients and seems feasible to conduct within regular clinical practice.     

Using professional specialty competencies to guide course development

This article describes how an RN-to-BSN community health nursing (CHN) course was reconceptualized from a traditional model to a competency-based model. The traditional course assigned students to CHN preceptors and required a set number of clinical contact hours. As clinical preceptor placement opportunities diminished, students and faculty became increasingly dissatisfied with the course structure and requirements. Faculty endorsed the use of professional competencies to measure course learning outcomes and selected competencies identified by the Association of Community Health Nursing Educators. These competencies were clustered into units, with learning activities and grading criteria based on the critical knowledge, values, and clinical skills needed to demonstrate mastery of specific competencies. Course faculty, rather than agency preceptors, assessed student learning outcomes and mastery of competencies. The students demonstrated mastery of competencies and liked the degree of self-directed learning that built on their professional status as RNs.     

Wiskott—Aldrich Syndrome: Qualitative Platelet Defects and Short Platelet Survival

S ummary . Investigations of the haemostatic functions in three patients with the Wiskott-Aldrich syndrome are presented. All patients had severe thrombocytopenia and prolonged bleeding times. The platelets had abnormal morphology with reduced size and variations of shape. Electron microscopy revealed ultrastructural abnormalities with a reduced number of organelles, and many of the platelets contained large numbers of tubules. Platelet electrophoretic mobility in citrated plasma was not reduced by collagen, and platelet aggregation by collagen and ADP was deficient. Biochemical studies revealed a lack of the storage pool of adenine nucleotides. Platelet adhesiveness in vitro in whole blood was reduced. Platelet factor-3 release by kaolin, ADP and freezing and thawing was normal in one and reduced in another of the patients.
Platelet survival studies showed a normal survival time of normal donor platelets in one patient, while autologous platelets had a markedly reduced survival time in two of the patients. The bone marrow contained normal numbers of megakaryocytes. By electron microscopy of the bone marrow, blood platelets were found to be phagocytosed by macrophages and reticulum cells. The main cause of the thrombocytopenia is most probably incrcased peripheral destruction of platelets. It is suggested that the qualitatively defective platelets are recognized in the reticulo-endothelial system as foreign particles and phagocytosed.     

Liver transplantation with deceased ABO‐incompatible donors is life‐saving but associated with increased risk of rejection and post‐transplant complications

ABO‐incompatible (ABOi) liver transplantation (LT) with deceased donor organs is performed occasionally when no ABO‐compatible (ABOc) graft is available. From 1996 to 2011, 61 ABOi LTs were performed in Oslo and Gothenburg. Median patient age was 51 years (range 13–75); 33 patients were transplanted on urgent indications, 13 had malignancy‐related indications, and eight received ABOi grafts for urgent retransplantations. Median donor age was 55 years (range 10–86). Forty‐four patients received standard triple immunosuppression with steroids, tacrolimus, and mycophenolate mofetil, and forty‐four patients received induction with IL‐2 antagonist or anti‐CD20 antibody. Median follow‐up time was 29 months (range 0–200). The 1‐, 3‐, 5‐, and 10‐year Kaplan–Meier estimates of patient survival (PS) and graft survival (GS) were 85/71%, 79/57%, 75/55%, and 59/51%, respectively, compared to 90/87%, 84/79%, 79/73%, and 65/60% for all other LT recipients in the same period. The 1‐, 3‐, 5‐, and 10‐year GS for A₂ grafts were 81%, 67%, 62%, and 57%, respectively. In conclusion, ABOi LT performed with non‐A₂ grafts is associated with inferior graft survival and increased risk of rejection, vascular and biliary complications. ABOi LT with A₂ grafts is associated with acceptable graft survival and can be used safely in urgent cases.     

Shifts in condom use following microbicide introduction: should we be concerned?

OBJECTIVES: Abandoning condoms for microbicides is termed 'condom migration'. This study estimated the reduction in condom use that can be tolerated following the introduction of an HIV- and sexually transmitted disease (STD)-efficacious microbicide without increasing an individual's risk of HIV infection, and explored how microbicide use affects HIV-risk. DESIGN: Development of a static mathematical model to compare how different combinations of condom and microbicide use affect individual risk of HIV and STD infection at a particular point in time. METHODS: The model is used to identify the 'break-even point' at which any increased risk associated with condom migration is counter-balanced by the protection afforded with microbicides. Data from Benin is used as a case-example. RESULTS: Considering a 50% HIV- and STD-efficacious microbicide, groups that use condoms with 25% consistency or less could cease using condoms without increasing their risk if they use microbicides in 50% or more of sex acts. However, migration may increase risk if the initial condom-consistency is high (> 70%) and microbicide-consistency is low (< 50% of non-condom-protected acts). For the Benin case-example, if condoms are initially used in 70% or less of sex acts, and if consistency of condom use is sustained following microbicide introduction, there will be a 20% or greater reduction in HIV-risk if the microbicide is used in 50% of non-condom-protected sex acts. CONCLUSIONS: There are likely to be many situations in which the benefits of microbicide use outweigh the negative impact of condom migration, and where microbicides could substantially reduce HIV-risk.     

Frequency of clonal intraepithelial T lymphocyte proliferations in enteropathy-type intestinal T cell lymphoma, coeliac disease, and refractory sprue

BACKGROUND: Clonal T cell receptor (TCR) gene rearrangements and loss of T cell antigens such as CD8 and TCR-beta in intraepithelial lymphocytes (IELs) may indicate the development of an enteropathy-type intestinal T cell lymphoma (EITCL) in patients with refractory sprue. AIMS: To define the diagnostic value of these markers in duodenal biopsies from patients with villous atrophy as a result of various underlying disorders. PATIENTS AND METHODS: Duodenal biopsies from eight patients with coeliac disease and five patients with villous atrophy caused by defined disorders were compared with three patients with refractory sprue evolving into overt EITCL, two patients with ulcerative jejunitis, and with eight patients with overt EITCL, for expression of CD3, CD4, CD8, and TCR-beta in IELs using immunohistochemistry and for clonal TCR-gamma gene rearrangements using polymerase chain reaction. In addition, biopsies from six consecutive patients with refractory sprue of uncertain cause were examined. RESULTS: Clonal TCR-gamma gene rearrangements were found in all resected tumours of patients with EITCL, in 3/8 duodenal biopsies of patients with EITCL, in 2/2 patients with ulcerative jejunitis, in 2/3 patients with refractory sprue evolving into overt EITCL, and in 1/6 patients with refractory sprue. No rearrangements were found in biopsies from patients with refractory sprue caused by defined disorders or those with coeliac disease. Clonality in duodenal biopsies was associated with an abnormal phenotype of IELs in all cases and in all but one case in patients with evidence of underlying coeliac disease. Specificity for detection of an EITCL using immunohistology was 77% for CD8 and for TCR-beta staining, and 100% for detection of a clonal TCR-gamma gene rearrangement. Sensitivity was 62% for staining with CD8 and clonality investigation, while sensitivity reached 100% for TCR-beta staining in all investigated patients with EITCL. CONCLUSIONS: Clonal proliferations of phenotypically abnormal IELs in refractory sprue represent an early manifestation of EITCL, for which the term "sprue-like intestinal T cell lymphoma" is proposed. This constellation is also found in duodenal biopsies from patients with an overt EITCL and is not related to other sprue syndromes, resulting in a high specificity for detection of an EITCL or refractory sprue evolving into EITCL. Overt EITCL may develop directly from coeliac disease without a precursor lesion (refractory sprue with clonal IELs) being demonstrable in duodenal biopsies or via a "sprue-like intestinal T cell lymphoma". This latter entity is a complication of coeliac disease.