Does the Use of Magnetic Resonance Imaging Scan in Occult and Suspected Metastatic Pathological Neck of Femur Fractures Affect the Choice of Surgical Intervention?

Background: Magnetic resonance imaging (MRI) is often employed as the diagnostic modality of choice in occult and suspected pathological femoral neck fractures. We evaluated the clinical utility of MRI scan in this patient population. Method: Retrospective observational analysis of cases with a radiologically occult or suspected metastatic pathological neck of femur fracture. Results: From a total of 894 femoral neck fractures treated in our institution, 100 patients had and MRI scan pre-operatively for either occult fracture or suspected fracture secondary metastatic disease. Magnetic resonance imaging confirmed the presence of 13 simple fractures. A total of 14 patients had pathological features suggestive of metastasis, of which 12 were clearly visible on plain radiographs. Surgical plan did not change after MRI for any of these pathological fractures. Conclusion: Results of this study demonstrate that an MRI scan had an impact on treatment selection only when a simple but radiographically occult fracture is suspected and but not in the context of suspected metastatic pathological fractures.

Evaluation of the Use of Argatroban or Bivalirudin for the Management of Suspected Heparin-Induced Thrombocytopenia in the Setting of Continuous Renal Replacement Therapy

Studies have shown an association between continuous renal replacement therapy (CRRT) and thrombocytopenia. Patients on CRRT usually receive unfractionated heparin (UFH), and heparin-induced thrombocytopenia (HIT) is frequently suspected as a potential cause of thrombocytopenia. In the setting of HIT suspicion, changes in anticoagulation may put patients at risk of developing thromboembolic events or adverse medication effects. Purpose: The purpose of this study was to investigate current management of anticoagulation in patients with suspected HIT while on CRRT and identify complications associated with anticoagulation in this setting. Methods: This is a retrospective study of patients on CRRT with suspicion for HIT. Prevalence of HIT and anticoagulant use were collected for all patients. Outcomes included thromboembolic and bleeding events, final therapeutic doses of each anticoagulant, and time to reach therapeutic range. Thromboembolic and bleeding outcomes were compared between anticoagulants. Results: From January 2013 through December 2015, 74 patients were identified with suspicion of HIT while on CRRT. During the period of HIT suspicion, 20 patients received argatroban, 18 received bivalirudin, 1 received fondaparinux, 4 received UFH infusions, 10 received prophylactic dosing subcutaneous UFH, and 21 received no anticoagulation. The median final therapeutic doses of argatroban and bivalirudin were 1.00 μg/kg/min and 0.075 mg/kg/h, respectively, with no difference in time to therapeutic range (17.6 h vs 18.2 h, P = .485). Compared with bivalirudin, patients treated with argatroban had significantly more therapeutic activated partial thromboplastin time (aPTT) values (54.5% vs 42.8%, P = .008). Four patients (20.0%) treated with argatroban and 5 patients (27.8%) treated with bivalirudin experienced major bleeding ( P = .709). Three patients (15.0%) treated with argatroban and 4 patients (22.2%) treated with bivalirudin experienced thromboembolic events ( P = .687). Conclusion: Argatroban and bivalirudin were associated with similar rates of bleeding and thromboembolic events during the period of concurrent CRRT and thrombocytopenia, although patients treated with argatroban had more therapeutic aPTT values.

Agreement and Correlation of Arterial and Venous Blood Gas Analysis in a Diverse Population

Introduction: Agreement and correlation of arterial blood gases (ABGs) and venous blood gases (VBGs) at near normal values are well described but have not been well validated at extremes of values. We evaluated the agreement and correlation of ABG and VBG at extremes of values and assessed the utility of VBG as a screening tool. Methods: We performed a retrospective, observational study of ABG and VBG collected at the same time. Statistical analysis included Bland-Altman plot analysis, Pearson correlations, and sensitivity/specificity tests. For limits of agreement (LOA), we set a threshold of ±0.10 units for pH and ±2.4 mm Hg for partial pressure of carbon dioxide (pCO2). A threshold of 80% sensitivity was considered appropriate for VBG to be used as a screening tool for abnormal ABG values. Results: There were 1684, 1744, and 1769 paired pH, pCO2, and HCO3¯ results, respectively. Mean difference (MD) for arterial and venous pH was 0.017 (95% confidence interval [CI]: 0.014-0.020; 95% LOA: −0.11 to 0.15), and Pearson correlation was 0.78 ( P < .0001). At venous pH <7.35, MD was 0.025 (95% CI: 0.019-0.030; 95% LOA: −0.12 to 0.17). Sensitivity of venous pH <7.35 identifying arterial pH <7.35 was 85.0%. MD for arterial and venous pCO2 was −2.5 (95% CI: −2.9 to −2.0; 95% LOA: −21.7 to 16.8), and Pearson correlation was 0.70 ( P < .0001). At venous pCO2 >45 mm Hg, MD was −4.1 (95% CI: −4.9 to −3.3; 95% LOA: −25.7 to 17.5). Sensitivity of venous pCO2 >45 mm Hg identifying arterial pCO2 >45 mm Hg was 67.6%. MD for arterial and venous HCO3¯ was −0.3 (95% CI: −0.4 to −0.2; 95% LOA: −4.8 to 4.2), and Pearson correlation was 0.90 ( P < .0001). Conclusions: Venous blood gases cannot reliably replace ABGs due to poor agreement in acidemia and hypercarbia. Venous blood gases can be used as a screening tool for acidemia but are unsuitable for hypercarbia.

Is There Evidence that the Percutaneous Compression Plate Method of Internal Fixation for Intertrochanteric Hip Fractures Leads to Better Intraoperative and Postoperative Outcomes than the Dynamic Hip Screw?

Background: Hip fractures are common, expensive and lead to considerable morbidity and mortality. An ageing population in the United Kingdom means that rates of this injury are increasing, making them a pressing public health issue. The National Institute of Health and Care Excellence (NICE) recommends that extramedullary implants are used over intramedullary nails to fix intertrochanteric fractures, which make up half of all hip fractures. However, there is currently no guidance on the preferred type of extramedullary device whether this be the commonly used dynamic hip screw (DHS) or another newer device. It has been suggested that a percutaneous compression plate (PCCP) can reduce complications and improve functional outcome compared with the traditional DHS. Review Question: In patients with intertrochanteric hip fractures, is the PCCP more effective than the DHS in terms of relevant intraoperative and postoperative outcomes such as blood loss, implant failure, and mortality? Literature Search: We first searched for relevant information in the NICE Clinical Guideline on Hip Fracture Management (CG124), then National Health Service (NHS) evidence for Clinical Knowledge Summaries, then the Cochrane library for systematic reviews. Finally, we conducted an electronic search of the PubMed database. Review Findings: We selected five systematic reviews and eight primary studies for review. The main findings were that the PCCP was associated with significantly less blood loss, fewer blood transfusions, and shorter operating times compared with the DHS. However, no significant differences were found in postoperative pain, orthopaedic performance, and mortality rates between the two methods. There was no comparison of cost-effectiveness between the two methods. Conclusions: The PCCP is superior to the DHS in terms of intraoperative blood loss and, potentially, non-orthopaedic postoperative complications such as deep vein thrombosis and nosocomial infection. However, there was no significant difference in mortality rates between the two methods. Current studies on this topic have several methodological issues and some are of relatively poor quality. Further higher quality research and cost-effectiveness are necessary to further evaluate the efficacy of these methods.

Nutritional Support of the Critically Ill Pediatric Patient: Foundations and Controversies

Critically ill children require nutritional support that will give them nutritional and non-nutritional support to successfully deal with their disease. In the past few years, we have been able to better understand the pathophysiology of critical illness, which has made possible the establishment of nutritional strategies resulting in an improved nutritional status, thus optimizing the pediatric intensive care unit (PICU) stay and decreasing morbidity and mortality. Critical illness is associated with significant metabolic stress. It is crucial to understand the physiological response to stress to create nutritional recommendations for critically ill pediatric patients in the PICU.

A Novel Electronic Device for Measuring Urine Flow Rate: A Clinical Investigation

Objective: Currently, most vital signs in the intensive care unit (ICU) are electronically monitored. However, clinical practice for urine output (UO) measurement, an important vital sign, usually requires manual recording of data that is subject to human errors. In this study, we assessed the ability of a novel electronic UO monitoring device to measure real-time hourly UO versus current clinical practice. Design: Patients were connected to the RenalSense Clarity RMS Sensor Kit with a sensor integrated within a standard sterile urinary catheter drainage tube to monitor urine flow in real time. The Clarity RMS Sensor Kit was modified to incorporate a standard urinometer (Unomedical) for the nursing staff to record UO as per their standard practice. The drainage bag was placed in a container on a scientific scale (Precisa BJ) to be used as the gold standard. Interventions: Nursing records for hourly UO were collected and compared with the electronically recorded UO. Sensor measurements and nursing staff manual records of UO were compared with the scale data. Setting: The study setting was the ICU of Hadassah Hospital, Jerusalem. Patients: Data from 23 patients with a urinary catheter were observed in this study. Measurements and main results: A total of 1046 hours of UO were recorded from 23 subjects. Compared with the scale data, the measurements of hourly urine flow measured with the RenalSense system were closer, had a better correlation, and narrower limits of agreement to gravimetrically determined values than the measurements obtained by the nurses. In addition, continuous monitoring of UO provided graphical display of response to repeated diuretic administration. Conclusions: An electronic device for recording UO has been shown to provide more reliable information of UO records and patient fluid status than current practice. Future applications of this device will provide valuable information to help set protocol goals such as decisions for timely fluid and diuretic administration and response.

Orthopedic Trauma and Recovery of Quality of Life: An Overview of the Literature

Assessment of clinical success by radiographic evidence of fracture union and surgeon-rated performance following recovery are the outcome tools of the past. Patients are now involved in the assessment of both surgeon performance and the capacity of the institutions in which they are treated to provide rehabilitation following injury. This population is increasingly involved in trials to guide most appropriate and cost-effective care. With healthcare resources globally under pressure, research focus on patient-rated outcome per unit expenditure is central to orthopedic evidence-based practice. In this era of patient-focused assessment and healthcare economics, quality of life and alterations in this status are central as outcome measures. In order to quantify the return of quality of life following injury, we present a review of the literature pertaining to this fundamental aspect of orthopedic trauma patient care.

A Review of Recent Advances in the Diagnosis and Treatment Modalities for Long Head of Bicep Tendinopathy

This article reviews the assessment and management of the pathology of the long head of the biceps tendon, a disease commonly encountered by primary care physicians and orthopedic surgeons. We include a discussion of relevant anatomy, function, pathoanatomy, natural history of the disease, diagnostic methods, and treatment options. Recent literature on the function of the long head of the bicep (LHB) is reviewed. Literature on our evolving understanding of the pathoanatomy behind LHB tendinopathy is discussed. We also discuss the effectiveness of current diagnostic and treatment modalities.

Acetabular Fractures in the Elderly

As the population ages, the incidence of osteoporotic fractures, including those of the pelvis and acetabulum, continues to rise. Treatment of the elder patients with an acetabular fracture is much more controversial than the treatment of younger patients with similar injuries, where prevention of posttraumatic arthritis and total hip replacement remains optimal to limit need for revision arthroplasty. Arthroplasty for fractures of the proximal femur is commonplace in an older population and is a mainstay of treatment to promote early mobilization and weight-bearing. However, even with acute total hip arthroplasty for a geriatric acetabular fracture, most surgeons do not permit immediate weight-bearing postoperatively. Therefore, controversy regarding optimal treatment of these challenging fractures persists. Four treatment options have emerged: nonoperative treatment with early mobilization, open reduction and internal fixation (ORIF), limited open reduction and percutaneous screw fixation, and acute total hip arthroplasty. The exact indications and benefits of each treatment remain unknown. This article serves as a review of these four treatments and the data existing to support them.

Short-term Fluconazole Therapy for the Treatment of Candiduria in ICU and ICU Step-down Patients

Objective Candiduria is very common in critically ill patients. It is often benign; however, it can develop into a serious systemic infection and treatment is suggested in symptomatic critically ill patients. The optimal duration of therapy is unclear. Long-term therapy (14 days) is recommended by the current guidelines, but previous data suggest that shorter-duration therapy may be effective. Minimizing the use of antifungal agents is desirable to avoid fungal resistance and adverse events. The purpose of this study was to determine the efficacy of short-term treatment of candiduria. Methods This was an observational study in medical, surgical, and trauma intensive care unit (ICU) and ICU step-down patients. A pathway utilizing a 3-day course of fluconazole for candiduria was implemented. The candiduria recurrence rate was compared in patients treated before (control groups with short-term, ie, ≤3 days, or long–term, ie, ≥7 days, therapy) and after the implementation of the pathway (study group: ≤3 days). Results Thirty-seven study patients were compared to 59 control patients. There were statistically no differences in the recurrence rate for candiduria among study patients, control patients with long-term therapy, and control patients with short-term therapy (32% vs 55% vs 38%, respectively; P > 0.05). Conclusion Three days of fluconazole treatment for candiduria appeared to be as effective as long-term therapy in this population.