Review of the financial and medicolegal implications of nasal fractures seen at St Luke’s Hospital

Simple nasal bone fractures are the third most common type of all fractures leading to numerous patient visits at the Accident & Emergency department. Nasal fractures are commonly over-investigated in St Luke’s hospital leading to a substantial financial burden on our health system. In this article we review the frequency of simple nasal fractures as well as the necessity or otherwise of nasal x-ray imaging in addition to the financial and health consequences that result from nasal x-ray imaging. These issues are also discussed from a legal perspective.peer-reviewe

Validation and psychometric properties of the Maltese version of the Duke Anticoagulation Satisfaction Scale (DASS)

Purpose: Assessing treatment satisfaction can guide specific interventions to improve anticoagulation adherence and reduce adverse outcomes. We aimed to assess the psychometric properties (reliability and validity) of the Maltese translation of the Duke Anticoagulation Satisfaction Scale (DASS). Patients and methods: The DASS explores three dimensions (limitations, hassles/burdens, psychological impact). The translation process included forward and backward translations. Reliability was evaluated through internal consistency and reproducibility. Validity was evaluated through floor/ceiling effect, convergent/discriminant validity, construct validity, and known-group validity. Results: The Maltese version of the DASS, administered to 174 patients on warfarin for different clinical indications, showed good reliability (Cronbach’s alpha 0.87; intraclass correlation coefficient for test–retest 0.73). Floor effect was identified mainly in the limitations and hassles/burdens subscales. Significant positive correlations were found between the DASS total score and its subscales (limitations 0.80, hassles/burdens 0.85, psychological impact 0.68). Female sex, shorter warfarin treatment duration (≤5 years), previous hospitalization and history of bleeding were associated with lower satisfaction. Conclusion: Psychometric properties of the Maltese DASS were comparable to the original English version. The Maltese version of the DASS is a valid and reliable instrument that can be used by health care professionals to assess the level of satisfaction of Maltese-speaking anticoagulated patients

Reliability and validity of the Maltese version of the perception of anticoagulant treatment questionnaire (PACT-Q)

Purpose: Anticoagulant therapy has an impact on the health-related quality of life, as it is a chronic treatment for most clinical indications and also requires some lifestyle changes. Since there was no validated questionnaire available in the Maltese language, the aim of our study was to translate and validate the Perception of Anticoagulant Treatment Questionnaire (PACT-Q2). Patients and methods: The PACT-Q2 explores two dimensions (convenience and anticoagulant treatment satisfaction). Forward and backward translations were performed. The Maltese version of the PACT-Q2 was administered to 174 patients on warfarin treatment enrolled from different anticoagulation clinics in Malta. Reliability was assessed through internal consistency (Cronbach’s alpha) and test-retest (intraclass correlation coefficient [ICC]). Validity was assessed through floor/ceiling effect, factor analysis (root mean square error of approximation [RMSEA], standardized root mean squared residual [SRMR], goodness-of-fit index [GFI], adjusted goodness-of-fit index [AGFI], comparative fit index [CFI]), subscales correlation and known-group validity. Results: Reliability was very good for the convenience subscale (Cronbach’s alpha 0.86, ICC 0.87), but less good for the satisfaction subscale (Cronbach’s alpha 0.62, ICC 0.40). Floor effect was 0%; ceiling effect was low (6.3% convenience, 1.2% satisfaction). Fit parameters were close to acceptable cut-offs (RMSEA =0.09, SRMR =0.10, GFI =0.82, AGFI =0.78, CFI =0.79). There was no correlation between the two subscales (r=0.01, p=0.83). Patients with history of bleeding showed lower convenience (r=−0.16, p=0.08) and lower satisfaction (r=−0.21, p=0.01). Conclusions: Our results support the finding that the Maltese translation of the PACT-Q2 is a valid and reliable instrument

Stakeholders' views and experiences of care and interventions for addressing frailty and pre-frailty:a meta-synthesis of qualitative evidence

Frailty is a common condition in older age and is a public health concern which requires integrated care and involves different stakeholders. This meta-synthesis focuses on experiences, understanding, and attitudes towards screening, care, intervention and prevention for frailty across frail and healthy older persons, caregivers, health and social care practitioners. Studies published since 2001 were identified through search of electronic databases; 81 eligible papers were identified and read in full, and 45 papers were finally included and synthesized. The synthesis was conducted with a meta-ethnographic approach. We identified four key themes: Uncertainty about malleability of frailty; Strategies to prevent or to respond to frailty; Capacity to care and person and family-centred service provision; Power and choice. A bottom-up approach which emphasises and works in synchrony with frail older people's and their families' values, goals, resources and optimisation strategies is necessary. A greater employment of psychological skills, enhancing communication abilities and tools to overcome disempowering attitudes should inform care organisation, resulting in more efficient and satisfactory use of services. Public health communication about prevention and management of frailty should be founded on a paradigm of resilience, balanced acceptance, and coping. Addressing stakeholders' views about the preventability of frailty was seen as a salient need

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - An observational study in 29 countries

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (V T) size was 500 ml, or 7 to 9 ml kg−1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P ˂ 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P ˂ 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high V T and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome.</p

Burden of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay associated with bloodstream infections due to Escherichia coli resistant to third-generation cephalosporins

Objectives: This study determined excess mortality and length of hospital stay (LOS) attributable to bloodstream infection (BSI) caused by third-generation-cephalosporin-resistant Escherichia coli in Europe. Methods: A prospective parallel matched cohort design was used. Cohort I consisted of patients with thirdgeneration-cephalosporin-resistant E. coli BSI (REC) and cohort II consisted of patients with third-generationcephalosporin-susceptible E. coli BSI (SEC). Patients in both cohorts were matched for LOS before infection with patients free of the respective BSI. Thirteen European tertiary care centres participated between July 2007 and June 2008. Results: Cohort I consisted of 111 REC patients and 204 controls and cohort II consisted of 1110 SEC patients and 2084 controls. REC patients had a higher mortality at 30 days (adjusted odds ratio=4.6) and a higher hospital mortality (adjusted hazard ratio=5.7) than their controls. LOS was increased by 8 days. For SEC patients, these figures were adjusted odds ratio=1.9, adjusted hazard ratio=2.0 and excess LOS=3 days. A 2.5 times [95% confidence interval (95% CI) 0.9-6.8] increase in all-cause mortality at 30 days and a 2.9 times (95% CI 1.2-6.9) increase in mortality during entire hospital stay as well as an excess LOS of 5 days (95% CI 0.4-10.2) could be attributed to resistance to third-generation cephalosporins in E. coli BSI. Conclusions: Morbidity and mortality attributable to third-generation-cephalosporin-resistant E. coli BSI is significant. If prevailing resistance trends continue, high societal and economic costs can be expected. Better management of infections caused by resistant E. coli is becoming essential.This work was funded by DG-Sanco (grant number 2005203), the Netherlands National Institute for Public Health and the Environment, and the University Medical Centre Groningen.peer-reviewe