Is It Time to Refine? An Exploration and Simulation of Optimal Antibiotic Timing in General Surgery

Postoperative infections increase morbidity, resource use, and costs. Our objective was to examine whether within guideline recommendations an optimal time exists for an initial dose of antibiotic to reduce postoperative infections in general surgery, and to simulate the magnitude of a reduction in infections should an optimal time be implemented.

Study Design

The population consisted of 6,731 patients who underwent 7,095 general surgery procedures between January 5, 2006 and June 25, 2012. Patients with pre-existing infections, such as pneumonia and sepsis, and patients with no recorded use of antibiotics were excluded, as were patients on vancomycin and surgical procedures longer than 4 hours in duration. The final analysis dataset included 4,453 patients. The National Surgical Quality Improvement Program was used for perioperative variables and outcomes. The end point was a composite of wound disruption; superficial, deep, organ space, surgical site infections; and sepsis. Semi-parametric logistic regression was used to study the association between antibiotic timing and infection.

Results

There were 444 (10%) patients with a primary end point of infectious complication. A nonlinear “bowl-shaped” relationship between duration of interval from antibiotic administration and surgical incision and infection was observed; lowest risk corresponding to administration time close to incision was 4 minutes before incision (95% one-sided CI, 0–18 minutes). The model suggested optimal timing would result in an 11.3% reduction in the primary infection end point.

Conclusions

Risk of infectious complications decreased as antibiotic administration moved closer to incision time. These data suggest an opportunity to reduce infections by 11.3% by targeting initial antibiotic administration closer to incision.


 Koch CG et al. Is It Time to Refine? An Exploration and Simulation of Optimal Antibiotic Timing in General Surgery. J Am Coll Surg 2013; online 10. Juli

Shoulders with bony Bankart lesions show bone fragment absorption

Shoulders with bony Bankart lesions show bone fragment absorption

Bone fragment absorption in shoulders with bony Bankart lesions after traumatic anterior shoulder instability correlated with the time after trauma, according to results of this study by Japanese researchers.

“Bone fragment absorption was seen in all of the shoulders with bony Bankart lesions. Most bone fragments showed severe absorption within 1 year after the primary traumatic episode,” Shigeto Nakagawa, MD, PhD, and colleagues from Osaka, Japan, wrote in the study abstract. “Before arthroscopic Bankart repair, not only glenoid defects but also bone fragment absorption should be assessed.”

Nakagawa and colleagues prospectively analyzed 163 shoulders using CT scans. They found that 55 shoulders had no glenoid defects, 16 shoulders had erosions, and 92 shoulders had glenoid defects, according to the abstract. The average glenoid defect size was 7.9% at less than 1 year, 10.7% between 1 year and 2 years and 11.3% after 2 years. 

The results showed some bone fragment absorption in all shoulders with glenoid defects: <50% absorption was seen in 32 shoulders, >50% absorption in 45 shoulders and 100% absorption in 15 shoulders. In shoulders scanned at less than 1 year, the extent of absorption was 51.9%. Between 1 year and 2 years, the extent of absorption was 65.3%, while in shoulders scanned after 2 years the extentof absorption was 70%, according to the abstract. 

Nakagawa S. Am J Sports Med. 2013. doi:10.1177/0363546513483087

Review: Researchers unclear whether ACL reconstruction prevents long-term OA development

Review: Researchers unclear whether ACL reconstruction prevents long-term OA development

Researchers from the United States and France used results from a 23-year follow-up of a case series by researchers in Lyon, France and a systematic review of the literature to find the long-term effects of ACL reconstruction, meniscal repair and degenerative change of osteoarthritis on patients with an ACL injury.

“Data from the Lyon series indicate that patients with no evidence of degenerative change on plain films 11 years after surgery are at very low risk to develop osteoarthritis over the next 15 years,” Philippe Neyret, MD, and colleagues wrote in the study. “Similarly, if early evidence of degenerative change is visible on radiographs 11 years following surgery, the risk of significant progression of osteoarthritis over the next 15 years is quite high.”

 

Neyret and colleagues found in their literature review that patients with ACL-deficient knees showed osteoarthritis (OA) in 40% of cases after 15 years, with some studies showing 90% of patients developing OA in long-term follow-up at 25 years and 35 years. However, their literature review provided mixed results for whether ACL reconstruction reduced the long-term incidence of OA.

The researchers noted the meniscus plays an important role at the time of ACL reconstruction: OA risk increased anywhere from twofold to tenfold for patients with a total meniscectomy compared to patients with an intact meniscus, according to the abstract.

Magnussen R. Cartilage. 2013. doi:10.1177/1947603513486559

Axa calls for three-day limit on whiplash claims

Link to Law Gazette.co.uk

Tuesday 16 July 2013 by John Hyde

Whiplash claims should be made within three days of the alleged accident and include evidence of physical injury if they are to succeed, insurance giant Axa said today.
The recommendations are part of a wishlist for the government to adopt on whiplash, copying models already in place in France and Sweden.
In its whiplash report published today at a roundtable co-hosted by former justice secretary Jack Straw, Axa said research suggests its reforms would significantly reduce the number of exaggerated or fraudulent claims.
The report recommends that whiplash injuries should not be recognised until doctors can see evidence of the injury, such as an MRI scan or x-ray. Axa says this system is already in place in France, where the average cost of an insurance premium is roughly two-thirds of that in the UK and whiplash injuries account for 3% of all bodily injury claims.
In Sweden, where Axa said insurance costs 46% less on average than in the UK, insurers generally reject cases where symptoms appear more than 72 hours after the accident.
A whiplash commission set up in 2002 created this rule of thumb to counteract the increasing number of claims and insurance costs came down as a result.
The Axa recommendations go further in asking for medical evidence than the Ministry of Justice has previously indicated. The government is expected to introduce a national accredited panel of experts to assess contested whiplash claims in the autumn.
Axa also calls on the government to extend the small-claims track limit to £10,000 – double the threshold currently proposed.
The insurer also wants existing reforms, particularly the ban on referral fees, to be more vigilantly policed, with further legislation if necessary. The report stated: ‘It seems clear that the Legal Aid, Sentencing and Punishment of Offenders Act 2012 (LASPO) is being circumvented by those who are finding creative ways around the ban.’
Chris Voller (pictured), Axa claims director, said: ‘Certain measures adopted in France and Sweden in particular offer very valuable insight into what works in practice and demonstrate several elements which could be adopted by the UK and that we believe would make a significant difference to the cost of premiums.
‘We would urge the government to look at what has worked in France and Sweden – specifically in relation to the requirement for medical evidence and the implementation of a minimum time threshold – as it considers how best to manage whiplash claims moving forward.’

ACL re-injuries are six times more likely for athletes after ACL reconstruction and return-to-sport

According to a presenter at the American Orthopaedic Society for Sports Medicine Annual Meeting, Chicago, athletes who sustained an ACL injury are at greater risk for subsequent ACL injuries during the first 2 years after reconstruction and return-to-sport compared to athletes who have not had an ACL injury. 

 “Our second injury rate in the first 24 months is relatively high. We see more contralateral injuries in female athletes than ipsilateral re-tears in the ACL reconstruction cohort, and the second ACL injury seems to occur early on after the return-to-sport,” said Mark V. Paterno, PT, PhD, MBA, SCS, ATC, from the Cincinnati Children’s Hospital, said at the American Orthopaedic Society for Sports Medicine Annual Meeting.

Paterno and colleagues studied the incidence rate of a second ACL injury in the 2 years following ACL reconstruction and return-to-sport in a young, active population. They hypothesized the incidence rate of a subsequent ACL injury would be less than the incidence rate reported within the first 12 months after return-to-sport, but greater than the ACL injury incidence rate in an uninjured cohort of young athletes.

In their prospective study, the investigators enrolled 78 patients (59 women, 19 men) aged 10 years to 25 years who underwent ACL reconstruction and returned to a pivoting/cutting sport and compared them to 47 healthy, control athletes (34 women, 13 men) without a history of ACL or lower extremity injury. All athletes were playing a pivot/cut sport for more than 50 hours per year. Each athlete was followed for injury and athletic exposure data.

Paterno and colleagues found 23 patients in the ACL reconstruction group and four athletes in the uninjured group had an ACL injury during the 24-month period. The overall incidence rate of a second ACL injury within 24 months after ACL reconstruction and return-to-sport was nearly six times greater than uninjured group.

Female athletes who had an ACL reconstruction showed a four times greater rate of injury within 24 months of return-to-sport than the female control athletes. Within the ACL reconstruction group, the female athletes were two times more likely to have a contralateral injury, he said.

Overall, 29.5% of athletes had a second ACL injury within 24 months of return-to-sport with 20.5% having a contralateral injury and 9% having an ipsilateral graft re-tear injury. More women (23.7%) had a contralateral injury than men (10.5%).

Reference:

Paterno MV. Paper #2. Presented at the American Orthopaedic Society for Sports Medicine Annual Meeting; July 11-14, 2013; Chicago.

Expectations predict the outcome after injuries

Background

Individuals' expectations on returning to work after an injury have been shown to predict the duration of time that a person with work-related low back pain will remain on benefits; individuals with lower recovery expectations received benefits for a longer time than those with higher expectations. The role of expectations in recovery from traumatic neck pain, in particular whiplash-associated disorders (WAD), has not been assessed to date to our knowledge. The aim of this study was to investigate if expectations for recovery are a prognostic factor after experiencing a WAD.

Methods and Findings

Holm et al used a prospective cohort study composed of insurance claimants in Sweden. The participants were car occupants who filed a neck injury claim (i.e., for WAD) to one of two insurance companies between 15 January 2004 and 12 January 2005 (n = 1,032). Postal questionnaires were completed shortly (average 23 d) after the collision and then again 6 mo later. Expectations for recovery were measured with a numerical rating scale (NRS) at baseline, where 0 corresponds to “unlikely to make a full recovery” and 10 to “very likely to make a full recovery.” The scale was reverse coded and trichotomised into NRS 0, 1–4, and 5–10. The main outcome measure was self-perceived disability at 6 mo postinjury, measured with the Pain Disability Index, and categorised into no/low, moderate, and high disability. Multivariable polytomous logistic regression was used for the analysis. There was a dose response relationship between recovery expectations and disability. After controlling for severity of physical and mental symptoms, individuals who stated that they were less likely to make a full recovery (NRS 5–10), were more likely to have a high disability compared to individuals who stated that they were very likely to make a full recovery (odds ratio [OR] 4.2 [95% confidence interval (CI) 2.1 to 8.5]. For the intermediate category (NRS 1–4), the OR was 2.1 (95% CI 1.2 to 3.2). Associations between expectations and disability were also found among individuals with moderate disability.

Conclusions

Individuals' expectations for recovery are important in prognosis, even after controlling for symptom severity. Interventions designed to increase patients' expectations may be beneficial and should be examined further in controlled studies.

 Holm LW, Carroll LJ, Cassidy JD, Skillgate E, Ahlbom A (2008) Expectations for Recovery Important in the Prognosis of Whiplash Injuries. PLoS Med 5(5): e105. doi:10.1371/journal.pmed.0050105

Pseudotumors in metal-on-metal hips

Study: High rate of hip resurfacing wear associated with pseudotumors

In this study, researchers from the United Kingdom concluded the majority of pseudotumors seen in patients with failed metal-on-metal hip resurfacing implants are due to implant wear.

“This increased wear is associated with soft tissue necrosis and a heavy nonspecific foreign-body macrophage response coupled with a variable adaptive or specific immune response,” David W. Murray, FRCS(Orth), and colleagues wrote in the study abstract. “A minority of pseudotumors are associated with low wear and a prominent immune response.”

Murray and colleagues examined 56 metal-on-metal hip resurfacing implants – 45 cases had a symptomatic tumor as the reason for failure, according to the abstract. They found that 80% of tumors were from a “highly worn” implant and substantial necrosis and a heavy macrophage infiltrate was present in most periprosthetic soft tissue. They also noted aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) infiltrate in many patients. However, even low wear was correlated with a strong ALVAL infiltrate response, according to the abstract.

“These findings confirm that minimizing wear from metal-on-metal hip resurfacing arthroplasty prostheses would lead to a reduction in the incidence of pseudotumor,” the authors wrote. “However, a small number of pseudotumors are still likely to occur, which may be due to an exacerbated adaptive immune response.”

Grammatopoulos G. J Bone Joint Surg Am. 2013. doi:10.2106/JBJS.L.00775.