Robert Stapleton

Serum albumin and total lymphocyte count as predictors of outcome in hip fractures

BACKGROUND & AIMS Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a significant contributor to this, however no consensus exists as to the detection or management of this condition. We hypothesise that results of admission serum albumin and total lymphocyte count (TLC), as markers of Protein Energy Malnutrition (PEM) can help predict clinical outcome in hip fracture patients aged over 60 years. METHODS This retrospective study evaluated the nutritional status of patients with hip fractures using albumin and TLC assays and analysed their prognostic relevance. Clinical outcome parameters studied were delay to operation, duration of in-patient stay, re-admission and in-patient, 3- and 12-month mortality. RESULTS Four hundred and fifteen hip fracture patients were evaluated. Survival data were available for 377 patients at 12 months. In-hospital mortality for PEM patients was 9.8%, compared with 0% for patients without. Patients with PEM had a higher 12-month mortality compared to patients who had normal values of both laboratory parameters (Odds Ratio 4.6; 95% CI: 1.0-21.3). Serum albumin (Hazard Ratio 0.932, 95% CI: 0.9-1.0) and age (Hazard Ratio 1.04, 95% CI: 1.0-1.1) were found to be significant independent prognostic factors of mortality by Cox regression analysis. CONCLUSIONS These results highlight the relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the correlation between PEM and outcome in these patients.

INTER AND INTRA-OBSERVER VARIABILITY ASSOCIATED WITH THE USE OF THE MIRELS’ SCORING SYSTEM FOR METASTATIC BONE LESIONS

Metastatic bone disease is increasing in association with ever-improving medical management of osteophylic malignant conditions. The precise timing of surgical intervention for secondary lesions in long bones can be difficult to determine. This paper aims to evaluate a classic scoring system. All radiographs were examined twice by three orthopaedic oncologists and scored according to the Mirels’ scoring system. The Kappa statistic was used for the purpose of statistical analysis. The results show agreement between observers (κ = 0.35–0.61) for overall scores at the two time intervals. Inter-observer agreement was also seen with subset analysis of size (κ = 0.27–0.60), site (κ = 0.77–1.0) and nature of the lesion (κ = 0.55–0.81). Similarly, low levels of intra-observer variability were noted for each of the three surgeons (κ= 0.34, 0.39, and 0.78, respectively). These results indicate a reliable, repeatable assessment of bony metastases. We continue to advocate its use in the management of patients with long bone metastases.

Treatment pathways and longitudinal outcomes for opiate users: Implications for treatment policy and planning.

The aim is to model treatment pathways and outcomes of opiate users at intake and at 1- and 3-year follow-up and to assess the implications of these for treatment policy. Opiate users entering a new treatment episode were recruited. Tree diagrams were used to map treatment relapse and re-entry. A within subjects repeated measures analyses of variance was conducted on each of the outcomes. The effect of being in treatment at 1-year on the 3-year outcomes was measured controlling for the value of the outcome variable at intake. A total of 404 opiate users were recruited. Follow-up interview rates were 88.4% at 3-years. Three years after intake 15% were drug free, 70% were in treatment and 15% were not in treatment and were using illegal drugs. Analysis revealed that there were no differences between the three outcome groups at intake. Those who were not in treatment and using at 3-years had displayed little improvement at 1-year and those who were not in treatment and not using at 3-years had displayed improvements in physical and mental health outcomes at 1-year. Regardless of treatment modality, treatment policy needs to reflect, support and encourage individuals during the treatment relapse cycle.

Ongoing cocaine and benzodiazepine use: effects on acquisitive crime committal rates amongst opiate users in treatment.

Aims: Research has shown that treatment for opiate use reduces crime, however the extent to which this is maintained is open to question. The objective of this study was to measure the relationship between crime committal rates and ongoing benzodiazepine and cocaine use by clients in opiate drug treatment programs. Methods: A national, prospective, longitudinal, multi-site drug treatment outcome study was conducted, 404 participants were recruited from inpatient and outpatient settings and 97% were located at 3 years. Drug use and crimes committed were ascertained from the Maudsley Addiction Profile of Marsden et al. [Marsden, J., Gossop, M., Stewart, D., Best, D., Farrell, M., Lehmann, P., … Strang, J. (1998). The Maudsley Addiction Profile (MAP): A brief instrument for assessing treatment outcome. Addiction, 93, 1857–1867]. Findings: Analysis revealed that of those who had not committed an acquisitive crime at intake, those who used cocaine regularly at 1-year were 6.5 times more likely and those that used benzodiazepines regularly were eight times more likely to commit an acquisitive crime at 1-year. Of those who had committed an acquisitive crime at intake, those who used heroin regularly at 1-year were nine times more likely to commit acquisitive crime at 1-year than those who did not use heroin regularly at 1 year. Conclusions: Treatment must place greater emphasis on reducing substitute drug use if opiate treatment is to effectively sustain crime reduction.

Longitudinal Outcomes for Treated Opiate Use and the Use of Ancillary Medical and Social Services

Using an extended Maudsley Addiction Profile, 404 opiate users entering treatment across Ireland were interviewed at intake and at 1 year and 3 years between 2003 and 2006. At 3 years clients were abstinent, in treatment, or relapsed. Analysis of lifetime use of treatment services revealed that greater proportions of those who were drug free at 3 years had counselling in the past. Multiple regression revealed that the number of previous treatment episodes had a significant positive effect on outcomes. Findings are important during times of financial constraint when treatment providers are under pressure to cut back to core services.

Anxiety and depression among opiate users who misuse substances during treatment.

OBJECTIVES While treatment is known to improve drug and crime outcomes for opiate users, there is debate in the literature about the longitudinal effects of substance misuse and the comorbidity of mental health problems. We sought to describe and model anxiety and depression outcomes during opiate substance misuse treatment. METHODS The first national, longitudinal treatment outcome study of 404 opiate users entering a new episode of inpatient or outpatient treatment and followed up at one and three years and assessed using the Maudsley Addiction Profile instrument. RESULTS A total of 404 opiate users were recruited representing approximately 8.2% of all new treatments and 17% of all new methadone treatments at national level in Ireland in 2003. At three years 97% (n = 392) were followed-up. At one year, analysis revealed the odds of experiencing depression was between five and 15 times the odds for opiate users who also used cocaine than non cocaine using opiate users, but this had decreased at three years. At three years those who were drug free, that is, not in treatment and not using illicit drugs, were less likely to experience feeling hopeless about the future than those in treatment or those not in treatment and using, but they were also more likely to experience feeling tense. Those in treatment were more likely to feel lonely. CONCLUSION The concurrent misuse of cocaine and other substances during opiate treatment and the stage of the treatment pathway are associated with anxiety and depression among opiate users in treatment. These client factors need to be considered when implementing individualised treatment care plans.

Algorithm for determining whether various two-level fractional factorial split-plot row–column designs are non-isomorphic

The confounding and aliasing scheme for fractional factorial split-plot designs with the units within each wholeplot arranged in rows and columns is described and illustrated. Isomorphism for this design type is described, together with a procedure which considers extensions of the concepts of wordlength patterns and letter patterns that can be used to test isomorphism between designs. Using in part this isomorphism testing procedure, a construction algorithm that may be used to obtain a complete set of such non-isomorphic two-level designs is described. Software based on this construction algorithm was used to obtain a complete set of non-isomorphic designs for up to five wholeplot factors, five subplot factors and up to 64 runs, which is presented as a table of designs. To aid the experimenter in distinguishing between competing designs, the estimation capacity sequence for each design is presented.