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Early Screening for Confusion and Vitamin D Deficiency in Elderly Hip Fracture Patients: A Quality Improvement Initiative to Mitigate the Risk of Postoperative Delirium (2024)

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Type of publication:

Journal article

Author(s):

Younis, Zubair; *Gurukiran, Gurukiran; *Abdullah, Faliq; *Kumar, Sairam; Ford, David; Hamid, Muhammad A; Wani, Kubra Farooq.

Citation:

Cureus. 16(12):e75099, 2024 Dec.

Abstract:

Background Postoperative delirium (POD) is a common and debilitating complication in elderly hip fracture patients, associated with significant clinical and functional consequences. Early identification of risk factors, such as cognitive impairment and vitamin D deficiency, is essential to mitigate its impact. However, preoperative screening practices are often inconsistent. This quality improvement initiative aimed to assess and improve compliance with early confusion and vitamin D screening in elderly hip fracture patients, with the goal of facilitating timely interventions to reduce the risk of POD. Methods A two-cycle audit was conducted in the Trauma and Orthopaedics Department at Royal Shrewsbury Hospital. The first cycle (April-June 2023) assessed baseline compliance with confusion (Abbreviated Mental Test Score (AMTS)) and vitamin D screening within 24 hours of admission. Identified barriers informed an intervention consisting of educational sessions, visual prompts, and checklist integration. The second cycle (August-October 2023) evaluated the impact of these measures. Compliance rates, timing of
assessments, and prevalence of abnormal biochemical and cognitive screening results were analyzed using Fisher's exact test (p < 0.05). Results Baseline compliance with screening was 27 patients (27%) out of 100, with primary barriers including lack of awareness and logistical challenges. Post-intervention compliance improved significantly for 54 patients (52.4%) out of 103 (p = 0.0003). Screening timeliness also increased, with 45 patients (83.33%) out of 54 screenings completed within 24 hours in cycle 2 compared to 14 patients (51.85%) out of 27 in cycle 1 (p = 0.0039). Biochemical analysis revealed persistently high rates of vitamin D deficiency, underscoring the need for early detection. AMTS scores correlated with abnormal confusion screens but highlighted limitations in cognitive-only assessments. Conclusion This quality improvement (QI) initiative demonstrated the efficacy of targeted interventions in improving screening compliance for confusion and vitamin D deficiency in elderly hip fracture patients. The findings advocate for integrating proactive, dual-focused screening protocols into clinical workflows to address modifiable risk factors for POD. Future research should explore the long-term impact of such measures on POD incidence, recovery trajectories, and functional outcomes while emphasizing the need
for sustained adherence to screening protocols.

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Functional Outcomes in the Distal End of Radius Fracture: A Prospective Study in a Tertiary Care Center (2024)

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Type of publication:

Journal article

Author(s):

*Thusoo, Varun; Chakrapani, Arjun S; Nehru, Ashish; Kudyar, Sachin; Nagpal, Brahmpreet; Kv, Alok; S, Ebin; Jose, Akhil.

Citation:

Cureus. 16(11):e74226, 2024 Nov.

Abstract:

OBJECTIVES: The objectives of this study are to determine the functional outcomes and compare them between conservative and surgical management in patients managed for closed-type intra-articular distal end of radius fractures.

METHODS: A prospective observational study was done on 150 patients who underwent treatment for closed-type intra-articular distal end of radius fractures. As per Frykman Classification, they were type III. patients were either managed conservatively, i.e. 100 patients out of 150 and surgical management was done in 50 cases. For surgical management, implants used were K-wires, Schanz pins, and Ellis Plate. The functional outcomes were noted in terms of pain and range of motion, in the follow up of six months. Union was noted clinically and radiologically.

RESULTS: The mean age of the study patients was 42.32 +/- 15.77 years. Out of 150 patients, there were 100 (66.67%) male patients. Compared to conservative management, surgical management had significantly lesser time of union (12 vs. 20 weeks, P<0.0001); significantly more excellent results (44% vs. 30%), more good results (32% vs. 15%) (P=0.003); comparable pain score (P=0.236); and comparable functional score (P=0.661). Regarding radiological outcomes, surgical management had significantly more volar tilt (9.6+/-2.5degree vs. 8+/-5degree, P=0.035); lesser Ulnar variance (3+/-2 vs. 4+/-2 mm, P=0.004), lesser grip strength <50% (26% vs. 65%, P<0.0001); comparable radial inclination (21+/-4degree vs. 20+/-5degree, P=0.661); and comparable radial height (11+/-3 vs. 10+/-5 mm, P=0.195)

CONCLUSION: To conclude, surgery for distal radius fractures promotes faster healing, lesser pain, lesser malunion, and better functional outcomes. However, it is not without potential risks. Non-surgical treatment is still a suitable option, for patients with contraindications to surgery or having lower need for functional improvement.

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Functional Outcomes and Complications After Open Reduction and Internal Fixation of Mid-shaft Clavicle Fractures: A Retrospective Study (2024)

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Type of publication:

Journal article

Author(s):

Hamid, Muhammad A; *Younis, Zubair; Mannan, Muhammad; Shrivastava, Nayan; Prabhu, Rudra M.

Citation:

Cureus. 16(11):e74302, 2024 Nov.

Abstract:

INTRODUCTION: Clavicle fractures are routinely encountered in orthopedic clinical practice and have often been the subject of debate when it comes to optimal treatment. Clavicle fracture surgery has come a long way with excellent pre-contoured superior locking plates available for fixation. This study aimed to evaluate a cohort of patients operated for displaced mid-shaft clavicle fractures by open reduction and internal fixation using superior clavicle locking plates.

MATERIALS AND METHODS: This is a retrospective cohort study of mid-shaft clavicle fracture patients who were operated on and had their fractures fixed using superior clavicle locking plates. We identified a total of 29 patients to be included in this study. The primary outcome measure was the quickDASH score at the time of discharge (12 weeks from surgery). Secondary outcome measures were the pattern and frequency of complications, and the need for metalwork removal.

RESULTS: Our study had a male preponderance, with 19 (65.5%) patients being male. The most common mode of trauma was fracture secondary to a road traffic accident in 12 (41.4%) patients. All but one fracture united uneventfully. The mean quickDASH score was 0.94 at 12-week follow-up. Complications were noted in 12 (41.4%) patients, and the most common complication was hardware irritation in seven (24.1%) patients, followed by dysesthesia around the surgical scar in five (17.2%) patients.

CONCLUSION: Open reduction and internal fixation of the clavicle give a high likelihood of fracture union along with good shoulder function. In a particular cohort of patients, this offers a quick recovery and earlier return to activity. However, this must be balanced with the risk of complications in a considerable proportion of operated patients, some of which might necessitate a second surgery.

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Widespread non-adherence to guidelines in the operative management of diabetes-related foot disease complications (2024)

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Type of publication:

Journal article

Author(s):

Renwick B.; Gannon M.; Kerr S.; Melvin R.; Ingram A.; Bosanquet D.; Fabre I.; Yew S.; Moreau J.; Dewi M.; Lowry D.; Clothier A.; Hutchings T.; Boyle J.; Wijewardena C.; Chowdhury M.; Torre G.L.; Grewal H.; Ansaripour A.; Lawson D.; Nandhra S.; Ugwumba L.; El-Sayed T.; Altahir A.; Elkashef H.; *Jones S.; Arkle J.; Khalil R.; Ramsay J.; Nesbitt C.; Paravastu S.; Jayaprakash V.V.; Flumignan R.L.G.; Flumignan C.D.Q.; Nakano L.C.U.; Schippers P.; Pereira F.A.; Pegas N.C.; Hitchman L.; Walshaw J.; Ravindhran B.; Lathan R.; Smith G.; Shalhoub J.; Ahmad M.; Shea J.; Howard T.; Elsanhoury K.; Eskandar G.; Mekhaeil K.; Scott K.; Enc M.; Mannan F.; Chowdhury S.; Abdelmageed A.E.; Russell D.; Jones A.; Dattani N.; El-Nakhal T.; Katsogridakis E.; Duncan A.; Musto L.; Proctor D.; Parsapour S.; Lewis S.; Hassan A.; Abdelal A.; Elzefzaf N.; Yasser N.; Antoniou G.A.; Singh A.; Alhoussan L.; Venkateswaran V.; Feil F.; Dindyal S.; Lyons O.; Benson R.; Lim E.; Sze M.; Khashram M.; Hart O.; Vincent Z.; Xue N.; Pottier M.; Gormley S.; Tong C.; Pang D.; Patil A.; Ngam L.; Macleod C.; Aziz I.; Stather P.; Abuduruk A.; Manson J.; Howard D.; Hussain S.; Glatzel H.; James N.; Rafil M.; Marlow N.; Meldrum A.; Hussey K.; Jones C.; Shepherd E.; Fitridge R.; Hon K.; Kour K.; Ng S.; Hardy T.; Muse S.; Ching D.; Donoghue S.; Thompson D.; Forsythe R.; Chan S.; Powezka K.; Wu D.; Kuronen-Stewart C.; Winarski A.; Lapolla P.; Cirillo B.; *Al-Saadi N.; *Dowdeswell M.; *Mcdonald S.; *Al-Hashimi K.; *Merriman K.; Hassouneh A.; Sadia U.; Jaipersad A.; Moulakakis K.G.; Papageorgopoulou C.; Kakkos S.; Tsimpoukis A.; Papadoulas S.; Kouri N.; Nikolakopoulos K.; D'oria M.; Lepidi S.; Grando B.; Nickinson A.; Gamtkitsulashvili G.; Enemosah I.; Storer N.; Gabab K.; Dingwell M.; Premadasan Y.; Karkos C.; Mitka M.; Soteriou A.; Asaloumidis N.; Papazoglou K.; Condie N.; Abdullahi H.; Shafeek F.; Lyons T.; Ambler G.; Benson R.A.; Birmpili P.; Blair R.H.J.; Bosanquet D.C.; Gwilym B.L.; Machin M.; Onida S.; Saratzis A.; Singh A.A.; Shelmerdine L.;

Citation:

British Journal of Surgery. 111(10) (no pagination), 2024. Article Number: znae231. Date of Publication: 01 Oct 2024.

Abstract:

The incidence of diabetes is increasing. One of the most common complications is diabetes-related foot disease (DFD), which include ulcers and gangrene. If not managed appropriately, DFD can rapidly deteriorate resulting in limb loss and death.The International Working Group on the Diabetic Foot (IWGDF) and the Global Vascular Guidelines (GVG) provide recommendations on the assessment and management of DFD and chronic limb-threatening ischaemia (CLTI). It has been hypothesized that adherence to these guidelines varies and could be contributing to poor outcomes.This study aimed to capture practices of diabetic foot debridement and minor amputation in theatre, to compare practice with the IWGDF and GVG recommendations, and to report the outcomes of patients undergoing debridement or minor amputation for a DFD complication.

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Evaluation of Patient-Initiated Follow-Up (PIFU) Service in a Fracture Clinic: A Comprehensive Service Evaluation and Patient Satisfaction Audit (2024)

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Type of publication:

Journal article

Author(s):

*Younis, Zubair; Hamid, Muhammad A; *Khan, Muhammad Murtaza; Sapra, Rahul; *Gurukiran, Gurukiran; *Singh, Rohit.

Citation:

Cureus. 16(11):e73461, 2024 Nov.

Abstract:

Background Outpatient clinics are increasingly challenged by high patient volumes and rising "did not attend" (DNA) rates, leading to extended wait times and declines in patient satisfaction. Traditional follow-up (FU) models with routinely scheduled appointments contribute to inefficiencies, as stable patients may attend unnecessary visits, thus straining clinic resources. The patient-initiated follow-up (PIFU) model offers an alternative where patients schedule appointments only when necessary. This study evaluates PIFU's efficacy in improving outpatient services and patient satisfaction by reducing routine appointments and prioritizing patient-driven follow-up. Methods This service evaluation and patient satisfaction audit was conducted at the fracture clinic of Royal Shrewsbury Hospital over three months (December 2023-March 2024). Out of 3828 patients seen, 203 were assigned to PIFU based on criteria indicating stable conditions with minimal follow-up requirements. The remaining patients were either scheduled for routine follow-ups or discharged. Data were collected retrospectively from clinic records, and a structured
questionnaire assessed patient satisfaction with the PIFU service. Results Among the 203 patients assigned to PIFU, 183 (90.15%) patients received an informational leaflet, with all respondents finding it easy to understand. However, only 41 (20.2%) of patients utilized the PIFU service, primarily for concerns about pain, healing, or complications. Satisfaction among PIFU users was high, with 163 (80.3%) patients rating the service 5/5. Non-users mostly cited no perceived need for follow-up. Demographic analysis indicated that patients aged 40-60 were predominant (n=132; 65.02%) among the PIFU cohort. Conclusion The PIFU model demonstrated the potential to alleviate clinic workload by reducing routine follow-ups while maintaining high patient satisfaction. Although utilization rates were low, those who engaged found the service beneficial, suggesting PIFU's value for patients comfortable with self-management. Improved patient education may enhance engagement, supporting the broader implementation of PIFU in outpatient settings. Further research is warranted to explore barriers to patient-initiated follow-up and refine eligibility criteria for optimal outcomes.

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Proximal Humerus Fractures: A Review of Anatomy, Classification, Management Strategies, and Complications (2024)

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Type of publication:

Journal article

Author(s):

Younis, Zubair; Hamid, Muhammad A; Amin, Jebran; *Khan, Muhammad Murtaza; *Gurukiran, Gurukiran; Sapra, Rahul; *Singh, Rohit; Wani, Kubra Farooq; Younus, Zuhaib.

Citation:

Cureus. 16(11):e73075, 2024 Nov.

Abstract:

Proximal humerus fractures are prevalent in older adults, particularly women, primarily due to osteoporosis and increased fall risk. These fractures often result from low-energy falls in elderly patients, while in younger individuals, they are more likely to occur with high-energy trauma, which may involve additional injuries to soft tissue and neurovascular structures. Proper anatomical understanding, including key structures and blood supply, is crucial for effective management and to prevent complications. Several classification systems assist in guiding treatment for proximal humerus fractures, including Codman's, Neer's, Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) system, and the Codman-Hertel system, which helps predict ischemia risk. Evaluation of proximal humerus fractures begins with Advanced Trauma Life Support (ATLS) protocols, emphasizing a thorough shoulder assessment, particularly focusing on skin integrity in elderly patients. Neurological and vascular examinations are essential due to the common occurrence of nerve injuries, especially involving the axillary nerve. Imaging typically includes multiple standard views, with advanced imaging reserved for complex cases and for assessing associated soft tissue injuries. Treatment options range from conservative management for stable fractures to surgical intervention for more complex cases. Surgical choices include techniques like fixation, nailing, and various arthroplasty options, with some procedures potentially offering advantages for older adults with bone quality or soft tissue challenges. Rehabilitation is a vital component of recovery, with emphasis on early mobility and gradual strengthening to restore function, especially in older patients. Complications following open reduction and internal fixation (ORIF) for proximal humerus fractures can include issues such as non-union, malunion, osteonecrosis, infection, joint stiffness, and fixation failure. In cases where non-union or fixation failure occurs, revision surgery or arthroplasty may be necessary. Joint stiffness may require further intervention if physical therapy is insufficient, while symptomatic osteonecrosis might also need surgical management. Malunion is generally better tolerated in older patients but may require correction in younger individuals. Other surgical options, such as hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA), share similar risks, including infection, fractures, complications at the tuberosity, stiffness, and instability. RSA may be favored when there are tuberosity or rotator cuff issues. Closed reduction with percutaneous pinning carries a high risk of pin migration and malunion, which can result in deformities, pain, and dysfunction. Proper anatomical knowledge is essential to avoid neurovascular injury and to manage common issues such as pin-site infections effectively.

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Labelling of Fluids in the Sterile Field During Orthopaedic Surgery: A Quality Improvement Initiative (2024)

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Type of publication:

Journal article

Author(s):

Sweetman, Benedict; *Younis, Zubair; Khan, Sarfraz; Amin, Jebran; Mohammed, Ghulam Dastagir Faisal; Jones, Ellen Ellysia; Lemaigre, Charlotte; Pydah, Satya.

Citation:

Cureus. 16(10):e72250, 2024 Oct.

Abstract:

Background Intraoperative safety protocols, including proper labelling of syringes, are critical to patient safety in surgical settings. While the Royal Pharmaceutical Society and the Royal College of Anaesthetists provide clear guidelines to prevent medication errors, ensuring consistent compliance with labelling protocols in the fast-paced and complex environment of orthopaedic surgery can still present practical challenges. The absence of proper labelling, combined with the use of multiple fluids such as normal saline, disinfectants, and local anaesthetics, increases the risk of adverse outcomes due to fluid misidentification. This quality improvement project aimed to assess current labelling practices in a district general hospital, identify barriers to compliance, and develop a cost-effective solution. Methodology The project was conducted in three orthopaedic theatres over two audit cycles. During the first audit cycle, 30 procedures were observed to assess compliance with labelling guidelines. Compliance was defined as the labelling of all syringes containing fluids present in the sterile field. Following this, an intervention was introduced, using surgical marker pens and sterile stickers for fluid labelling, along with a mandatory "tactical pause and check" and an awareness campaign. Two months later, a second audit of 34 procedures was conducted to evaluate the effectiveness of the intervention. Results In the first audit cycle, only three out of 30 procedures (10%) were compliant with labelling guidelines. Following the intervention, compliance increased dramatically to 32 out of 34 procedures (94%). The results were statistically significant (p < 0.05) as determined by Fisher's exact test. The use of sterile stickers and marker pens proved to be a simple and cost-effective solution that did not interfere with the sterile environment or increase costs. Conclusions This study demonstrates that a low-cost intervention using sterile stickers and surgical marker pens can significantly improve compliance with fluid labelling guidelines in orthopaedic surgery, thereby enhancing patient safety. While the intervention was successful, future research should explore more sustainable solutions, such as pre-printed sterile labels, and evaluate the long-term impact of such interventions across various surgical settings. Continuous education and regular audits will be essential in maintaining high compliance rates.

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Ambulatory management of acute uncomplicated diverticulitis (AmbUDiv study): a multicentre, propensity score matching study (2024)

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Type of publication:

Journal article

Author(s):

Mohamedahmed, Ali Yasen; Hamid, Mohammed; Issa, Mohamed; Albendary, Mohamed; *Sultana, Emiko; Zaman, Shafquat; Bhandari, Santosh; Sarma, Diwakar; *Ball, William; Thomas, Pradeep; Husain, Najam.

Citation:

International Journal of Colorectal Disease. 39(1):184, 2024 Nov 18.

Abstract:

INTRODUCTION: Recent studies have suggested that ambulatory management is feasible for acute uncomplicated diverticulitis (AUD); however, there is still no consensus regarding the most appropriate management settings. This study presents a multi-centre experience of managing patients presenting with AUD, specifically focusing on clinical outcomes and comparing ambulatory treatment with in-patient management.

METHODS: A retrospective multi-centre study was conducted across four hospitals in the UK and included all adult patients with computed tomography (CT) confirmed (Hinchey grade 1a) acute diverticulitis over a
12-month period (January – December 2022). Patient medical records were followed up for 1-year post-index episode, and outcomes were compared between those treated through the ambulatory pathway versus inpatient treatment using 1:1 propensity score matching (PSM). All statistical analysis was performed using the R Foundation for Statistical Computing, version 4.4.

RESULTS: A total of 348 patients with Hinchey 1a acute diverticulitis were included (260 in-patients; 88 ambulatory pathway), of which nearly a third (31.3%) had a recurrent disease. Inpatient management was dominant (74.7%), with a median of 3 days of hospital stay. PSM resulted in 172 patients equally divided between the two care settings. Ambulatory management was associated with a lower readmission rate (P = 0.02 before PSM, P = 0.08 after PSM), comparable surgical (P = 0.57 before PSM, 0% in both groups after PSM) and radiological interventions (P = 0.99 before and after PSM) within one year. In both matched and non-matched groups, a strong association between readmissions and inpatient management was noted in univariate analysis (P = 0.03 before PSM, P = 0.04 after PSM) and multivariate analysis (P = 0.02 before PSM, P = 0.03 after PSM).

CONCLUSION: Our study supports the safety and efficacy of managing patients with AUD through a well-designed ambulatory care pathway. In particular, hospital re-admission rates are lower and other outcomes are non-inferior to in-patient treatment. This has implications for substantial cost-savings and better utilisation of limited healthcare resources.

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A systematic review of ultrasonography-guided transcutaneous fine needle aspiration cytology in the diagnosis of laryngeal malignancy (2024)

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Type of publication:

Journal article

Author(s):

Ahmed, A; *Yang, D; *Eastwood, M; *Saunders, T; *Ahsan, S F.

Citation:

Annals of the Royal College of Surgeons of England. 2024 Nov 15.

Abstract:

INTRODUCTION: Direct laryngoscopy and biopsy is the gold standard for obtaining a tissue diagnosis in patients with suspected laryngeal cancer. In patients with advanced disease or other medical comorbidities, this may come with significant anaesthetic risks, including tracheostomy. Ultrasonography-guided biopsy has been widely used in the diagnosis of malignancy involving cervical lymph nodes but it is not commonly employed in the diagnosis of laryngeal tumours. A systematic review was undertaken to assess the literature looking at whether ultrasonography-guided transcutaneous fine needle aspiration cytology (FNAC) is an adequate method in diagnosing laryngeal malignancy.

METHODS: Two independent researchers conducted a systematic review of the literature using the MEDLINE and Cochrane Library databases in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.

RESULTS: A total of 568 studies were identified from the search, of which 3 met the inclusion criteria, resulting in 162 patient episodes. The pooled accuracy of transcutaneous FNAC in acquiring a sample adequate for histological diagnosis was 74.9%. Data on complications were limited, with a few cases of mild haemoptysis being recorded.

CONCLUSIONS: Transcutaneous FNAC can be considered a safe and quick method for establishing a histological diagnosis of laryngeal lesions, particularly in patients who may be severely comorbid, and it could therefore could reduce the risks of general anaesthesia and tracheostomy prior to commencing definitive treatment.

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An evaluation of autonomic and gastrointestinal symptoms, and gastric emptying, in patients with systemic sclerosis (2024)

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Type of publication:

Journal article

Author(s):

Hughes M.; *Harrison E.; Herrick A.L.; Lal S.; McLaughlin J.T.

Citation:

Journal of Scleroderma and Related Disorders. (no pagination), 2024. Date of Publication: 2024.

Abstract:

Objective: Assessment of gastrointestinal and autonomic symptoms in patients with systemic sclerosis, and possible associations with gastric emptying rate. Method(s): Participant and patient disease-related characteristics were collected. Gastrointestinal and autonomic symptoms were assessed by the UCLA-SCTC GIT 2.0 and COMPASS-31 questionnaires, respectively. Potentially confounding gastrointestinal medications were discontinued where possible. Gastric emptying was assessed using a non-radioactive <sup>13</sup>C sodium acetate isotope, end-expiratory breath samples collected at baseline and then serial timepoints up to 120 min. Result(s): In total, 49 participants were studied: 17 with systemic sclerosis with variable gastrointestinal involvement, and healthy matched (n = 17) and non-matched controls (n = 15), the last to control for the impact of age rather than disease on gastric emptying and autonomic function. The total mean (range) UCLA GIT 2.0 questionnaire for patients with systemic sclerosis was 0.63 (0.0-1.5) and for both healthy matched and non-matched controls was 0.04 (0.0-0.2), and was higher in patients with systemic sclerosis across all domains. The total mean (range) COMPASS-31 score for patients with systemic sclerosis patients was 32.2 (0.0-54.9) and for healthy matched- and non-matched controls: 7.45 (0.0-24.9) and 4.25 (0.0-2.1), respectively, again higher for patients with systemic sclerosis across all domains. No association was observed between patients' UCLA GIT 2.0 total score (s = -0.039, p = 0.38), total COMPASS 31 score (s = -0.108, p = 0.68), or COMPASS-31 GI domain (s = -0.051, p = 0.85) and gastric emptying rates. Conclusion(s): Gastrointestinal and autonomic symptoms are overrepresented in patients with systemic sclerosis but did not associate with gastric emptying rates.

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