Short-term morbidity factors associated with length of hospital stay (LOS): development and validation of a hip fracture specific postoperative morbidity survey (HF-POMS)

Background: We aimed to describe and quantify postoperative complications in the older hip fracture population, develop and validate a hip fracture postoperative morbidity survey tool (HF–POMS). Methods: A prospective clinical observation study of patients (≥ 70 years) admitted for emergency hip fracture surgery, was conducted across three English National Health Service hospitals. Outcome data items were developed from the Postoperative Morbidity Survey (POMS), Cardiac-POMS, hip fracture postoperative literature and orthogeriatric clinical team input. Postoperative outcome data were collected on days 1, 3, 5, 8 and 15; 341 patients participated. Results: A 12-domain HF-POMS tool was developed with acceptable construct validity on all HF–POMS days. Patients with high perioperative risk scores as measured by the NHFS and ASA grade were more prone to develop HF–POMS defined morbidities. High morbidity rates occurred in the following domains; renal, ambulation assistance, pain and infectious. Presence of any morbidity on postoperative days 8 and 15 was associated with subsequent length of stay of 3.08 days (95% CI 0.90 – 5.26, p= 0.005) and 15.81 days (95% CI 13.35 – 18.27, p = 0.001) respectively. Observed average length of stay was 16.9 days. HF–POMS is a reliable and valid tool for measuring early postoperative complications in hip fracture patients. Additional domains are necessary to account for all morbidity aspects in this patient population compared to the original POMS. Conclusion: Many patients remained in hospital for non-medical reasons. HF-POMS may be a useful tool to assist in discharge planning and randomised control trial outcome definitions

Control-Alt-Incomplete? Using Technology to Assess Digital Natives

Law students matriculating today were “born digital.” As digital natives, they have never known a world without digital technology, and therefore, they think and process information differently than previous generations. Although law school student bodies have changed, law school assessment methods have remained static, with students nearly universally being evaluated entirely by one exam at the end of the course. Best Practices, the Carnegie Report, and more recently the ABA, have acknowledged that this system of evaluation is contrary to learning theory and that periodic assessment of student learning is crucial to improving the performance of both students and teachers. Nevertheless, change has yet to occur. It is time to change. Using technology to assess student learning is one way to begin effectuating this change. Digital Natives are comfortable with technology and expect to have it integrated into the curriculum. Moreover, incorporating technology as a means to assess student learning will help prepare future lawyers for the realities of law practice today. Technology also allows law professors to conduct meaningful assessments of large numbers of students more efficiently. This article therefore introduces several examples of how to use a number of today’s technologies - both inside the classroom and outside the classroom - in the hopes of initiating further exploration into effective means of using technology to assess student learning at the course level

Parthenolide eliminates leukemia-initiating cell populations and improves survival in xenografts of childhood acute lymphoblastic leukemia

Key Points First report demonstrating in vivo elimination of multiple LIC populations from childhood ALL cases using animal models. In vivo models of leukemia are essential for drug evaluation studies.</jats:p

Control-Alt-Incomplete? Using Technology to Assess Digital Natives

Law students matriculating today were “born digital.” As digital natives, they have never known a world without digital technology, and therefore, they think and process information differently than previous generations. Although law school student bodies have changed, law school assessment methods have remained static, with students nearly universally being evaluated entirely by one exam at the end of the course. Best Practices, the Carnegie Report, and more recently the ABA, have acknowledged that this system of evaluation is contrary to learning theory and that periodic assessment of student learning is crucial to improving the performance of both students and teachers. Nevertheless, change has yet to occur. It is time to change. Using technology to assess student learning is one way to begin effectuating this change. Digital Natives are comfortable with technology and expect to have it integrated into the curriculum. Moreover, incorporating technology as a means to assess student learning will help prepare future lawyers for the realities of law practice today. Technology also allows law professors to conduct meaningful assessments of large numbers of students more efficiently. This article therefore introduces several examples of how to use a number of today’s technologies - both inside the classroom and outside the classroom - in the hopes of initiating further exploration into effective means of using technology to assess student learning at the course level

Early mortality outcomes of patients with fragility hip fracture and concurrent SARS-CoV-2 infection: a systematic review and meta-analysis

AimsHip fracture is a common condition of the older, frailer person. This population is also at risk from SARS-CoV-2 infection. It is important to understand the impact of coexistent hip fracture and SARS-CoV-2 for informed decision-making at patient and service levels.MethodsWe undertook a systematic review and meta-analysis of observational studies of older (> 60 years) people with fragility hip fractures and outcomes with and without SARS-CoV-2 infection during the first wave of the COVID-19 pandemic. The primary outcome was early (30-day or in-hospital) mortality. Secondary outcomes included length of hospital stay and key clinical characteristics known to be associated with outcomes after hip fracture.ResultsA total of 14 cohort and five case series studies were included (692 SARS-CoV-2 positive, 2,585 SARS-CoV-2 negative). SARS-CoV-2 infection was associated with an overall risk ratio (RR) for early mortality of 4.42 (95% confidence interval (CI) 3.42 to 5.82). Early mortality was 34% (95% CI 30% to 38%) and 9% (95% CI 8% to 10%) in the infected and noninfected groups respectively. Length of stay was increased in SARS-CoV-2 infected patients (mean difference (MD) 5.2 days (3.2 to 7.2)). Age (MD 1.6 years (0.3 to 2.9)); female sex (RR 0.83 (95% CI 0.65 to 1.05)); admission from home (RR 0.51 (95% CI 0.26 to 1.00)); presence of dementia (RR 1.13 (95% CI 0.94 to 1.43)); and intracapsular fracture (RR 0.89 (95% CI 0.71 to 1.11)) were not associated with SARS-CoV-2 infection. There were statistically, but not clinically, significantly greater Nottingham Hip Fracture Scores in infected compared with non-infected patients (MD 0.7 (0.4 to 0.9)).ConclusionSARS-CoV-2 infection is associated with worse outcomes after hip fracture. This is not explained by differences in patient characteristics. These data can be used to support informed decision-making and may help track the impact of widespread adoption of system-level and therapeutic changes in management of the COVID-19 pandemic

Digital Pro Bono: Leveraging Technology to Provide Access to Justice

(Excerpt) Part I of this Article explores the United States justice system’s failure to adequately serve all people irrespective of wealth and position. Next, Part II discusses the ABA’s call to leverage technology to increase access to justice. Part III explores ABA Free Legal Answers Online, the program that the ABA pioneered to help confront the justice gap in the United States. Subsequently, Part IV illustrates how law schools can leverage technology to increase access to justice for low-income communities while providing pro bono opportunities for attorneys and students in their state. This Part highlights Massachusetts as an example of a state that has adopted the ABA Free Legal Answers Online platform and how students and alumni at a Massachusetts law school partnered with a nonprofit organization to be part of a solution to the access to justice problem. Finally, Part V briefly concludes by emphasizing the role that law students—as future leaders of the legal profession—can play in closing the legal aid gap

Investigating CD99 Expression in Leukemia Propagating Cells in Childhood T Cell Acute Lymphoblastic Leukemia:Relevance of CD99 Overexpression in T-ALL

A significant number of children with T-lineage acute lymphoblastic leukemia (T-ALL) fail to respond to therapy and experience early relapse. CD99 has been shown to be overexpressed on T-ALL cells and is considered to be a reliable detector of the disease. However, the relevance of CD99 overexpression in ALL has not been investigated in a functional context. The aim of this study was to investigate the functional capacity of CD99+ cells in childhood ALL and determine the suitability of CD99 as a therapeutic target. Flow cytometric analyses confirmed higher expression of CD99 in ALL blasts (81.5±22.7%) compared to normal hemopoietic stem cells (27.5±21.9%) and T cells (3.1±5.2%, P≤0.004). When ALL cells were sorted and assessed in functional assays, all 4 subpopulations (CD34+/CD99+, CD34+/CD99-, CD34-/CD99+ and CD34-/CD99-) could proliferate in vitro and establish leukemia in NSG mice. Leukemia propagating cell frequencies ranged from 1 in 300 to 1 in 7.4x104 but were highest in the CD34+/CD99- subpopulation. In addition, all four subpopulations had self-renewal ability in secondary NSG mice. Cells in each subpopulation contained patient specific TCR rearrangements and karyotypic changes that were preserved with passage through serial NSG transplants. Despite high levels of CD99 antigen on the majority of blast cells, leukemia initiating capacity in vivo was not restricted to cells that express this protein. Consequently, targeting CD99 alone would not eliminate all T-ALL cells with the ability to maintain the disease. The challenge remains to develop therapeutic strategies that can eliminate all leukemia cells with self-renewal capacity in vivo

Concordance of copy number abnormality detection using SNP arrays and Multiplex Ligation-dependent Probe Amplification (MLPA) in acute lymphoblastic leukaemia

In acute lymphoblastic leukaemia, MLPA has been used in research studies to identify clinically relevant copy number abnormality (CNA) profiles. However, in diagnostic settings other techniques are often employed. We assess whether equivalent CNA profiles are called using SNP arrays, ensuring platform independence. We demonstrate concordance between SNP6.0 and MLPA CNA calling on 143 leukaemia samples from two UK trials; comparing 1,287 calls within eight genes and a region. The techniques are 99% concordant using manually augmented calling, and 98% concordant using an automated pipeline. We classify these discordant calls and examine reasons for discordance. In nine cases the circular binary segmentation (CBS) algorithm failed to detect focal abnormalities or those flanking gaps in IKZF1 probe coverage. Eight cases were discordant due to probe design differences, with focal abnormalities detectable using one technique not observable by the other. Risk classification using manually augmented array calling resulted in four out of 143 patients being assigned to a different CNA risk group and eight patients using the automated pipeline. We conclude that MLPA defined CNA profiles can be accurately mirrored by SNP6.0 or similar array platforms. Automated calling using the CBS algorithm proved successful, except for IKZF1 which should be manually inspected

Tight intra-operative blood pressure control versus standard care for patients undergoing hip fracture repair - Hip Fracture Intervention Study for Prevention of Hypotension (HIP-HOP) trial: study protocol for a randomised controlled trial

Background: Hypotension during anaesthesia for hip fracture surgery is common. Recent data suggest that there is an association between the lowest intra-operative blood pressure and mortality, even when adjusted for co-morbidities. This is consistent with data derived from the wider surgical population, where magnitude and duration of hypotension are associated with mortality and peri-operative complications. However, there are no trial to data to support more aggressive blood pressure control. Methods/design: We are conducting a three-centre, randomised, double-blinded pilot study in three hospitals in the United Kingdom. The sample size will be 75 patients (25 from each centre). Randomisation will be done using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be aged >70 years, cognitively intact (Abbreviated Mental Test Score 7 or greater), able to give informed consent and admitted directly through the emergency department with a fractured neck of the femur requiring operative repair. Patients randomised to tight blood pressure control or avoidance of intra-operative hypotension will receive active treatment as required to maintain both of the following: systolic arterial blood pressure >80% of baseline pre-operative value and mean arterial pressure >75 mmHg throughout. All participants will receive standard hospital care, including spinal or general anaesthesia, at the discretion of the clinical team. The primary outcome is a composite of the presence or absence of defined cardiovascular, renal and delirium morbidity within 7 days of surgery (myocardial injury, stroke, acute kidney injury, delirium). Secondary endpoints will include the defined individual morbidities, mortality, early mobility and discharge to usual residence. Discussion: This is a small-scale pilot study investigating the feasibility of a trial of tight intra-operative blood pressure control in a frail elderly patient group with known high morbidity and mortality. Positive findings will provide the basis for a larger-scale study