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1.  Acute kidney injury associated with rhabdomyolysis after coronary artery bypass graft: a case report and review of the literatures 
BMC Research Notes  2014;7:152.
Post-operative rhabdomyolysis is a well-known complication, especially after bariatric and orthopaedic surgeries. There are few published reports of rhabdomyolysis following cardiac surgery. Acute kidney injury had been distinguished as a serious complication of cardiac surgery. We report a case of 55-years-old male patient who developed rhabdomyolysis precipitated acute kidney injury after coronary artery bypass graft.
Case presentation
The patient underwent urgent coronary artery bypass graft surgery, with a long duration of surgery due to technical difficulty during grafting. He developed rhabdomyolysis induced acute kidney injury necessitating hemodialysis. The patient in turn developed heart failure, which along with acute kidney injury lead to prolonged ventilation. There was supervening sepsis with prolonged intensive care unity stay and eventually prolonged hospitalization. The peak creatine kinase level was 39000 IU/mL and peak myoglobin was 40000 ng/ml. Reviewing the patient, surgery was prolonged due to technical difficulties encountered during grafting, leading to rhabdomyolysis induced acute kidney injury. The pre-operative use of statins by the patient could also have contributed to the development of rhabdomyolysis. He developed post-operative right heart failure and sepsis. The patient’s renal function gradually improved over 4 week’s duration. Favorable outcome could be achieved but after prolonged course of renal replacement therapy in the form of hemodialysis.
Prolonged duration of surgery is a well-recognized risk factor in the development of rhabdomyolysis. Early recognition of rhabdomyolysis induced acute kidney injury is important in reducing the post-operative morbidity and mortality in patients. A protocol based approach could be applied for early recognition and management.
PMCID: PMC3984756  PMID: 24636137
Acute kidney injury; Rhabdomyolysis; Coronary artery bypasses graft; Prolonged surgery
2.  Risk Factors for Acute Kidney Injury in Severe Rhabdomyolysis 
PLoS ONE  2013;8(12):e82992.
Acute kidney injury (AKI) is a life-threatening complication of severe rhabdomyolysis. This study was conducted to assess risk factors for AKI and to develop a risk score for early prediction.
Retrospective observational cohort study with a 9-year follow-up, carried out in an acute-care teaching-affiliated hospital. A total of 126 patients with severe rhabdomyolysis defined as serum creatine kinase (CK) > 5,000 IU/L fulfilled the inclusion criteria. Univariate and logistic regression analyses were performed to determine risk factors for AKI. Based on the values obtained for each variable, a risk score and prognostic probabilities were estimated to establish the risk for developing AKI.
The incidence of AKI was 58%. Death during hospitalization was significantly higher among patients with AKI, compared to patients without AKI (19.2% vs 3.6%, p = 0.008). The following variables were independently associated with AKI: peak CK (odds ratio [OR] 4.9, 95%CI 1.4-16.8), hypoalbuminemia (< 33 mg/dL, [OR 5.1, 95%CI 1.4-17-7]), metabolic acidosis (OR 5.3, 95%CI 1.4-20.3), and decreased prothrombin time (OR 4.4, 95% CI 1.3-14.5). A risk score for AKI was calculated for each patient, with an OR of 1.72 (95%CI 1.45-2.04). The discrimination value of the predictive model was established by means of a ROC curve, with the area under the curve of 0.871 (p<0.001).
The identification of independent factors associated with AKI and a risk score for early prediction of this complication in patients with severe rhabdomyolysis may be useful in clinical practice, particularly to implement early preventive measures.
PMCID: PMC3867454  PMID: 24367578
3.  Risk factors and distribution of symptomatic venous thromboembolism in total hip and knee replacements: prospective study 
International Orthopaedics  2012;36(6):1299-1305.
Venous thromboembolism (VTE) is a common complication of orthopaedic surgery in the industrialised world; though there may be variability between population groups. This study aims to define the incidence and risk factors for symptomatic VTE following primary elective total hip and knee arthoplasty surgery in a single centre in Eastern Europe.
This prospective study included 499 adult patients undergoing total hip and knee arthroplasty for symptomatic osteoarthritis over a two-year period at the Clinic of Orthopaedic Surgery and Traumatology, Belgrade.
The overall rate of confirmed symptomatic VTE during hospitalisation was 2.6%. According to the univariate logistic regression, an age greater than 75 years (OR = 3.08; 95%CI = 1.01–9.65), a family history of VTE (OR = 6.61; 95% CI = 1.33–32.90), varicose veins (OR = 3.13; 95% CI = 1.03–9.48), and ischemic heart disease (OR = 4.93; 95% CI = 1.61–15.09) were significant risk factors for in-hospital VTE. A family history of VTE and ischemic heart disease were independent risk factors according to multivariate regression analysis. Preoperative initiation of pharmacological thromboprophylaxis (p = 0.03) and a longer duration of thromboprophylaxis (p = 0.001) were protective for postoperative DVT. Though thromboprophylaxis was safe, with very few patients suffering major haemorrhage or heparin-induced thrombocytopenia, there was a general reluctance by our local surgeons to use prolonged thromboprophylaxis.
VTE is common following hip and knee arthroplasty surgery. Orthopaedic patients with a family history of VTE, heart failure and coronary heart disease are at a considerable risk of thromboembolic complications in the postoperative period. There may be a role for preoperative thromboprophylaxis in addition to prolonged postoperative treatment.
PMCID: PMC3353084  PMID: 22215369
4.  Risk Factors of Postprocedural Hypotension Following Carotid Artery Stenting 
Interventional Neuroradiology  2006;12(Suppl 1):205-210.
This study is performed to investigate risk factors of hypotension in response to elective carotid stenting. Forty-four lesions of 40 consecutive patients (mean age 70.4 ± 8.2 years) were retrospectively analyzed. Easy Wall stent was applied in 15 lesions and SMART stent in 29 lesions. We investigated correlations between the occurrence rate of postoperative hypotension below 90 mmHg and persisting over three hours and findings of preoperative angiograms, ultrasonograms and clinical characteristics. Postprocedural hypotension occurred in 19 patients (47.5%) and medical treatment (intravenous administration of catecholamines) was required in eleven patients (27.5%). Although there was no permanent neurological deficits related with postprocedural hypotension, transient neurological deficits were found in three patients. Risk factors of prolonged postprocedural hypotension were statistically analyzed. On angiographic characteristics; 1) distance between the carotid bifurcation and the lesion with maximum stenosis (≦10 mm vs. >10 mm: p = 0.031), 2) type of stenosis (eccentric vs. concentric: p = 0.014) On ultrasonographic characteristics; 1) calcifications at the carotid bifurcation (present vs. absent: p< 0.001). Other variables, including age and degree of stenosis, were not associated with postprocedural hypotension after carotid stenting. These angiographic and ultrasonographic variables can be used to identify patients at risk for postprocedural hypotension after carotid stenting. Such identification may help in selection of patients who will benefit from appropriate pharmacological treatment.
PMCID: PMC3387954  PMID: 20569633
stent, postprocedural hypotension, prolonged, carotid artery
5.  A Case of Rhabdomyolysis Associated with Use of a Pneumatic Tourniquet during Arthroscopic Knee Surgery 
The common causes of rhabdomyolysis include trauma, hypoxia, drugs, toxins, infections and hyperthermia. Operative insults, including direct trauma and ischemia, have the potential to cause the development of rhabdomyolysis. Pneumatic tourniquets used during arthroscopic knee surgery to prevent blood loss have led to many complications such as nerve paralysis and vascular injuries. Rhabdomyolysis can also be caused by prolonged pneumatic tourniquet application without a midapplication release, and also from an increased application pressure, but the actual incidence of this is low. In order to prevent rhabdomyolysis, the clinicians must be aware of such risks and follow strict guidelines for the application time, the midapplication release and also the inflation pressure. Vigorous hydration and postoperative patient surveillance are helpful to prevent rhabdomyolysis. We have recently experienced a case of rhabdomyolysis after the arthroscopic knee surgery, and the rhabdomyolysis could have been associated with the use of a pneumatic tourniquet.
PMCID: PMC2829407  PMID: 20195412
Rhabdomyolysis; Tourniquets; Kidney failure, acute
6.  Myofascial-entheseal dysfunction in chronic whiplash injury: an observational study 
JRSM Short Reports  2012;3(8):57.
To document any consistent clinical findings in a large cohort of patients with whiplash associated disorder.
Four-year observational study.
Large orthopaedic medicolegal practice in the UK.
1025 consecutive cases of chronic whiplash associated disorder.
Main outcome measures
Observational study of the clinical features of whiplash associated disorder: detailed examination
Three consistent clinical features: neck pain; reduced cervical spine range of motion; and myofascial-entheseal dysfunction. With regards to the myofascial-entheseal dysfunction there were trigger points in the upper, middle or lower trapezius; with or without enthesopathy in the lower or middle trapezius.
On the basis of this large observational experience we propose a clinically-based definition of chronic whiplash associated disorder: a painful syndrome following acceleration-deceleration injury with neck stiffness; and myofascial-entheseal dysfunction.
PMCID: PMC3434435  PMID: 23301145
7.  Early postoperative statin therapy is associated with a lower incidence of acute kidney injury following cardiac surgery 
To test the hypothesis that perioperative statin use reduces acute kidney injury (AKI) following cardiac surgery
Retrospective analysis of prospectively collected data from an ongoing clinical trial
Quaternary-care university hospital
Three hundred twenty-four elective adult cardiac surgery patients
Measurements and Main Results
We assessed the association of preoperative statin use, early postoperative statin use, and acute statin withdrawal with the incidence of AKI. Early postoperative statin use was defined as statin treatment within the first postoperative day. Statin withdrawal was defined as discontinuation of preoperative statin treatment prior to surgery until at least postoperative day 2. Logistic regression and propensity score modeling were used to control for AKI risk factors. Sixty-eight of 324 patients (21.0%) developed AKI. AKI patients stayed in the hospital longer (P=0.03) and were more likely to develop pneumonia (P=0.002) or die (P=0.001). Higher body mass index (P=0.003), higher central venous pressure (P=0.03), and statin withdrawal (27.4 vs. 14.7%, P=0.046) were associated with a higher incidence of AKI, while early postoperative statin use was protective (12.5 vs. 23.8%, P=0.03). Preoperative statin use did not affect risk of AKI. In multivariate logistic regression, age (P=0.03), male gender (P=0.02), body mass index (P<0.001), and early postoperative statin use (OR 0.32, 95% CI 0.14–0.72, P=0.006) independently predicted AKI. Propensity score-adjusted risk assessment confirmed the association between early postoperative statin use and reduced AKI (OR 0.30, 95% CI 0.13–0.70, P=0.005).
Early postoperative statin use is associated with a lower incidence of AKI among both chronic statin users and statin-naïve cardiac surgery patients.
PMCID: PMC2992577  PMID: 20599398
acute kidney injury; acute renal failure; cardiac surgery; statin; oxidative stress; obesity
8.  Safe pharmacologic treatment strategies for osteoarthritis pain in African Americans with hypertension, and renal and cardiac disease. 
Arthritis is the leading cause of disability in the United States. Osteoarthritis, the most common form of arthritis, is a degenerative joint disease affecting both whites and African Americans similarly. African Americans have a high incidence rate of comorbidities, including hypertension, cardiovascular disease (CVD) risk factors and diabetes. Treatment of osteoarthritic pain in patients with comorbidities is often complicated by potential safety concerns. Traditional nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase 2 (COX-2) specific NSAIDs have been shown to increase blood pressure in hypertensive patients taking antihypertensive medications. Patients with CVD risk factors taking low-dose aspirin for secondary prevention may be at increased risk for gastrointestinal bleeding with NSAIDs. Diabetics face an increased risk of renal complications. Because NSAIDs are associated with adverse renal effects, they should be used cautiously in patients with advanced renal disease. Acetaminophen is the most appropriate initial analgesic for African Americans with chronic osteoarthritic pain and concurrent hypertension, CVD risk factors or diabetes, and is recommended by the American College of Rheumatology as first-line treatment. Many of the adverse effects commonly associated with NSAIDs are not associated with acetaminophen. Safety concerns surrounding pharmacologic treatment of osteoarthritis in African Americans are reviewed.
PMCID: PMC2569481  PMID: 16895283
9.  Cystatin C Concentration as a Predictor of Systolic and Diastolic Heart Failure 
Journal of cardiac failure  2008;14(1):19-26.
Risk factors for heart failure (HF) may differ according to ejection fraction (EF). Higher cystatin C, a marker of kidney dysfunction, is associated with incident HF, but prior studies did not determine EF at diagnosis. We hypothesized that kidney dysfunction would predict diastolic HF (DHF) better than systolic HF (SHF) in the Cardiovascular Health Study.
Methods and Results
Cystatin C was measured in 4,453 participants without HF at baseline. Incident HF was categorized as DHF (EF ≥ 50%) or SHF (EF < 50%). We compared the association of cystatin C with risk for DHF and SHF, after adjustment for age, sex, race, medications, and HF risk factors. Over eight years of follow-up, 167 participants developed DHF and 206 SHF. After adjustment, sequentially higher quartiles of cystatin C were associated with risk for SHF [competing risks hazard ratios 1.0 (reference), 1.99 (95% CI 1.14, 3.48), 2.32 (1.32, 4.07), 3.17 (1.82, 5.50), P for trend <0.001]. Risk for DHF was apparent only at the highest cystatin C quartile [hazard ratios 1.0 (reference), 1.09 (0.62, 1.89), 1.08 (0.61, 1.93), 1.83 (1.07, 3.11)].
Cystatin C levels are linearly associated with incidence of systolic HF, whereas only the highest concentrations of cystatin C predict diastolic HF.
PMCID: PMC2258307  PMID: 18226769
Heart failure; cystatin C; systolic heart failure; diastolic heart failure; estimated glomerular filtration rate; elderly; ejection fraction.
10.  The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis 
BMC Surgery  2007;7:16.
Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.
Indication for elective resection is one episode of diverticulitis in patients < 50 years and two episodes in patient > 50 years or in case of progressive abdominal complaints due to strictures caused by a previous episode of diverticulits. The diagnosis is confirmed by CT-scan, barium enema and/or coloscopy.
It is required that the participating surgeons have performed at least 15 laparoscopic and open sigmoid resections. Open resection is performed by median laparotomy, laparoscopic resection is approached by 4 or 5 cannula. Sigmoid and colon which contain serosal changes or induration are removed and a tension free anastomosis is created. After completion of either surgical procedure an opaque dressing will be used, covering from 10 cm above the umbilicus to the pubic bone. Surgery details will be kept separate from the patient's notes.
Primary endpoints are the postoperative morbidity and mortality. We divided morbidity in minor (e.g. wound infection), major (e.g. anastomotic leakage) and late (e.g. incisional hernias) complications, data will be collected during hospital stay and after six weeks and six months postoperative. Secondary endpoints are the operative and the postoperative recovery data. Operative data include duration of the operation, blood loss and conversion to laparotomy. Post operative recovery consists of return to normal diet, pain, analgesics, general health (SF-36 questionnaire) and duration of hospital stay.
The Sigma-trial is a prospective, multi-center, double-blind, randomized study to define the role of laparoscopic sigmoid resection in patients with symptomatic diverticulitis.
PMCID: PMC1955435  PMID: 17683563
11.  Comparison of measures of comorbidity for predicting disability 12-months post-injury 
Understanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury.
12-month Glasgow Outcome Scale – Extended (GOS-E) outcomes for 13,519 survivors to discharge were drawn from the Victorian Orthopaedic Trauma Outcomes Registry, a prospective cohort study of admitted orthopaedic injury patients. ICD-10-AM comorbidity codes were mapped to four comorbidity indices. Cases with a GOS-E score of 7–8 were considered “recovered”. A split dataset approach was used with cases randomly assigned to development or test datasets. Logistic regression models were fitted with “recovery” as the outcome and the performance of the models based on each comorbidity index (adjusted for injury and age) measured using calibration (Hosmer-Lemshow (H-L) statistics and calibration curves) and discrimination (Area under the Receiver Operating Characteristic (AUC)) statistics.
All comorbidity indices improved model fit over models with age and injuries sustained alone. None of the models demonstrated acceptable model calibration (H-L statistic p < 0.05 for all models). There was little difference between the discrimination of the indices for predicting recovery: Charlson Comorbidity Index (AUC 0.70, 95% CI: 0.68, 0.71); number of ICD-10 chapters represented (AUC 0.70, 95% CI: 0.69, 0.72); number of six frequent chronic conditions represented (AUC 0.70, 95% CI: 0.69, 0.71); and the Functional Comorbidity Index (AUC 0.69, 95% CI: 0.68, 0.71).
The presence of ICD-10 recorded comorbid conditions is an important predictor of long term functional outcome following orthopaedic injury and adjustment for comorbidity is indicated when assessing risk-adjusted functional outcomes over time or across jurisdictions.
PMCID: PMC3562274  PMID: 23351376
Orthopaedic injury; Comorbidity; Disability outcomes; Prediction
12.  Incapacity for work in elective orthopaedic surgery: a study of occurrence and the probability of returning to work after treatment. 
STUDY OBJECTIVE--The extent to which patients undergoing elective surgery for orthopaedic disorders were incapacitated for work while they were on the waiting list and whether they were able to return to work after surgery were studied. DESIGN--This was a prospective cohort study of patients admitted to hospital for elective orthopaedic surgery. Main outcome measures were occurrence of sickness certification during the waiting time, and whether those incapacitated for work at the time of surgery returned to work during the first year after treatment. Multivariate logistic regression was used to estimate adjusted odds ratios for factors influencing return to work. SETTING--Orthopaedic department in charge of all elective orthopaedic surgery in a population of 197,354 persons in central Norway. SUBJECTS--All 2803 patients admitted to hospital for chronic orthopaedic disorders in the defined population between 1 September 1988 and 31 August 1990 were included in the study. MAIN RESULTS--Of the 1333 patients who were employed, 42% had been certified sick due to the orthopaedic disorder for some period of the waiting time. Sickness benefits from the national insurance scheme (paid from the 15th day of sickness certification) had been received by 33% and were received by 29% at the time of surgery. Of 380 patients incapacitated for work at the time of surgery, 53% returned to work within the first year after surgery. Using those treated within one month of being placed on the waiting list as the reference group, the adjusted odds ratios for not returning to work during the first year after surgery were 9.2 (p < 0.0001) for those who waited more than a year for surgery, 6.2 (p = 0.002) for those waiting nine to 12 months, and 4.9 (p = 0.02) for those waiting for six to nine months. CONCLUSIONS--A high proportion of these patients were incapacitated for work, 53% of those incapacitated returned to work within the first year after surgery. The probability of returning to work after surgery is strongly influenced by the length of time on the waiting list. Waiting for more than one year, compared with immediate treatment, was associated with an adjusted odds ratio of 9.2 for not returning to work.
PMCID: PMC1059834  PMID: 8289040
13.  Five factors contributing to severe rhabdomyolysis in a 21 yr old IV drug abuser: a case report 
Cases Journal  2009;2:6479.
Rhabdomyolysis is a potentially life-threatening condition resulting from the release of large quantities of myocyte breakdown products into the circulation, following injury to striated muscles. There are several causes of rhabdomyolysis - traumatic and non-traumatic. We present a 21-year-old male intravenous drug abuser, who was referred to us with fever, altered sensorium and seizures. He developed severe rhabdomyolysis following a mixed meningeal infection by Streptococcus pneumoniae and Mycobacterium tuberculosis. This patient’s examination and investigation suggested a combination of factors leading to the severe rhabdomyolysis which proved fatal. The patient’s creatine phosphokinase was elevated to 167,000 U/L, following hyperpyrexia, seizures, meningitis (pneumococcal and tuberculous), pentazocine and alcohol abuse. The increase in mortality rate with the onset of rhabdomyolysis warrants immediate cessation of the insult and aggressive management.
PMCID: PMC2740115  PMID: 19829812
14.  The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach 
BMJ Open  2013;3(11):e003448.
The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery.
Cross-sectional study (retrospective analysis of records in a database).
The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties.
We extracted all orthopaedic error reports from the system over 1 year (2009–2010).
Outcome measures
The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention.
155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively.
The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.
PMCID: PMC3840344  PMID: 24270831
15.  Bilateral gluteal compartment syndrome and severe rhabdomyolysis after lumbar spine surgery 
European Spine Journal  2010;20(Suppl 2):180-182.
Gluteal compartment syndrome (GCS) is an extremely rare and potentially devasting disorder, most commonly caused by gluteal muscle compression in extend periods of immobilization. We report a 65-year-old obese man with hypertension, diabetes mellitus type 2 and hypercholesterolemia underwent lumbar spine surgery in knee-chest position because of degenerative lumbar stenosis. Perioperative hypotension occurred. After surgery, the patient developed increasing pain in the buttocks of both sides and oliguria with darkened urine. Stiffness, tenderness and painful swelling of patients gluteal muscles of both sides, high creatine phosphokinase level, myoglobulinuria and oliguria led to diagnosis of bilateral GCS, complicated by severe rhabdomyolysis (RM) and acute renal failure. In conclusion, obese patients with vascular risk factors and perioperative hypotension may be at risk for developing bilateral GCS and RM when performing prolonged lumbar spine surgery. Early diagnosis and treatment is important, as otherwise, the further course may be fatal.
PMCID: PMC3111522  PMID: 20617347
Gluteal compartment syndrome; Kidney failure; Lumbar spine; Neurosurgery; Rhabdomyolysis
16.  Prescription Pattern of NSAIDs and the Prevalence of NSAID-induced Gastrointestinal Risk Factors of Orthopaedic Patients in Clinical Practice in Korea 
Journal of Korean Medical Science  2011;26(4):561-567.
This is a cross-sectional observational study undertaken to explore the current prescription pattern of non-steroidal anti-inflammatory drugs (NSAIDs) and the prevalence of NSAID-induced gastrointestinal (GI) risk factors of orthopaedic patients in real clinical practice in Korea. Study cohort included 3,140 orthopaedic outpatients at 131 hospitals and clinics between January 2008 and August 2008. A self-administered questionnaire was completed by each patient and physician. A simplified risk scoring scale (the Standardized Calculator of Risk for Events; SCORE) was used to measure patients' risk for GI complications. The pattern of NSAIDs prescription was identified from medical recordings. Forty-five percents of the patients belonged to high risk or very high risk groups for GI complications. The cyclooxygenase-2 enzyme (COX-2) selective NSAID showed a propensity to be prescribed more commonly for high/very high GI risk groups, but the rate was still as low as 51%. In conclusion, physician's considerate prescription of NSAIDs with well-understanding of each patient's GI risk factors is strongly encouraged in order to maximize cost effectiveness and to prevent serious GI complications in Korea. Other strategic efforts such as medical association-led education programs and application of Korean electronic SCORE system to hospital order communication system (OCS) should also be accompanied in a way to promote physician's attention.
PMCID: PMC3069577  PMID: 21468265
Anti-Inflammatory Agents, Non-Steroidal; GI risk factor; Cyclooxygenase 2 Inhibitors; SCORE; Korea
17.  Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors 
Orthopaedic surgery is a high-risk specialty in which errors will undoubtedly occur. Patient safety incidents can yield valuable information to generate solutions and prevent future cases of avoidable harm. The aim of this study was to understand the causative factors leading to all unnecessary deaths in orthopaedics and trauma surgery reported to the National Patient Safety Agency (NPSA) over a four-year period (2005–2009), using a qualitative approach.
Reports made to the NPSA are categorised and stored in the database as free-text data. A search was undertaken to identify the cases of all-cause mortality in orthopaedic and trauma surgery, and the free-text elements were used for thematic analysis. Descriptive statistics were calculated based on the incidents reported. This included presenting the number of times categories of incidents had the same or similar response. Superordinate and subordinate categories were created.
A total of 257 incident reports were analysed. Four main thematic categories emerged. These were: (1) stages of the surgical journey – 118/191 (62%) of deaths occurred in the post-operative phase; (2) causes of patient deaths – 32% were related to severe infections; (3) reported quality of medical interventions – 65% of patients experienced minimal or delayed treatment; (4) skills of healthcare professionals – 44% of deaths had a failure in non-technical skills.
Most complications in orthopaedic surgery can be dealt with adequately, provided they are anticipated and that risk-reduction strategies are instituted. Surgeons take pride in the precision of operative techniques; perhaps it is time to enshrine the multimodal tools available to ensure safer patient care.
PMCID: PMC3416713  PMID: 22682470
Patient safety; Errors; Orthopaedics; Trauma surgery; Quality improvement
18.  Coagulopathy in patients who experience snakebite 
Coagulopathy is a common complication of snakebite, but there is little information on the clinical importance of coagulopathy. We analyzed the characteristics of coagulopathy after envenomation.
Ninety-eight patients who experienced snakebite were enrolled in this study. We divided all the patients into three groups by the ISTH DIC scoring system: the normal, simple coagulopathy and DIC groups. The coagulopathy group included both the simple coagulopathy and DIC groups. We then conducted a case-control study.
There was a significant decrease in the Hct, protein, albumin, ALP and cholesterol levels in the coagulopathy group, and only the cholesterol level was deceased in the DIC group (p<0.05). Leukocytosis and rhabdomyolysis were significantly associated with coagulopathy, and hemolysis and rhabdomyolysis were associated with DIC (p<0.05). The presence of rhabdomyolysis was considered a risk factor for coagulopathy (p<0.05). These conditions continued for up to six to seven days after the snakebite.
Evaluation of coagulopathy with using these characteristics is helpful to properly manage the patients who experience snakebite.
PMCID: PMC2686970  PMID: 18646512
Coagulopathy; Snakebite
19.  Adolescent with Rhabdomyolysis due to Undiagnosed Hypothyroidism 
Case Reports in Pediatrics  2011;2011:670673.
Exercise-induced rhabdomyolysis has been described in military recruits, trained athletes and daily runners. Statin use, quail ingestion, infection by Epstein-Barr virus (EBV), and hypothyroidism, though rare, are risk factors for the development of rhabdomyolysis. We describe the case of a 15-year-old female who presented with myalgias, weakness, and pigmenturia following marching band practice. Laboratory tests confirmed an elevated creatine kinase (CK) level as well as a profound hypothyroid state. Muscle biopsy revealed severe muscle necrosis and myositis. Treatment with levothyroxine resulted in obtaining an euthyroid state and regain of muscle strength as well as decrease in CK levels. Although rare, hypothyroidism should be considered as a potential cause of rhabdomyolysis in pediatric patients undergoing a myopathy workup.
PMCID: PMC3350179  PMID: 22606520
20.  Identifying High-Risk Patients Undergoing Urgent and Emergency Surgery 
The aim was to identify high-risk patients undergoing non-elective orthopaedic and general surgery.
This was a retrospective cohort study of all non-elective general and orthopaedic surgical procedures performed in a 1-year interval in a district general hospital. A total of 1869 patients underwent urgent or emergency surgery in the calendar year 2000. Outcomes were identified from various related hospital databases. Case notes of those who died were reviewed. Risk factors for mortality were examined using univariate and multivariate analysis.
The mortality rates were 89/1869 (5%) at 30 days and 216 (12%) after 1 year. The high initial death rate continued for about 100 days after surgery. Increasing age (P < 0.0001), size of operation (P = 0.004) and American Society of Anesthesiologists (ASA) fitness grade (P < 0.0001) were associated with significantly higher risk of death at 1 year on multivariate analysis. A high risk group was identified of 273 patients aged over 50 years, of ASA Grade III or above who needed major surgery; they had a 30-day mortality rate of 18%.
A simple scoring system could be used to identify high-risk patients who require non-elective surgery that could be a target for interventions to try and reduce their risk of death.
PMCID: PMC1964060  PMID: 16551406
Emergency; High-risk patients; Non-elective surgery; Scoring system
21.  Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery 
Annals of the Rheumatic Diseases  2001;60(3):214-217.
OBJECTIVES—To determine whether continued methotrexate treatment increases the risk of postoperative infections or of surgical complications in patients with rheumatoid arthritis (RA) within one year of elective orthopaedic surgery.
DESIGN—A prospective randomised study of postoperative infection or surgical complications occurring within one year of surgery in patients with RA who underwent elective orthopaedic surgery.
SUBJECTS—388 patients with RA who were to undergo elective orthopaedic surgery. Patients who were receiving methotrexate were randomly allocated to groups who either continued methotrexate (group A) or who discontinued methotrexate from two weeks before surgery until two weeks after surgery (group B). Their complication rates were compared with complications occurring in 228 patients with RA (group C) who were not receiving methotrexate and who also underwent elective orthopaedic surgery.
MAIN OUTCOME MEASURES—Signs of postoperative infection were recorded, including rubor, discharge, systemic infection, and frequency of wound dehiscence as well as the incidence of any surgical complication requiring a secondary revision procedure that occurred within one year of surgery. The frequencies of flare up activity of RA at six weeks and six months after surgery were also recorded. A flare of rheumatoid disease was defined as an increase in joint pain in two or more joints notified by the patient as well as by an increase in articular index of at least 25% after surgery.
RESULTS—Signs of infection or surgical complications occurred in two of 88 procedures in group A (2%), 11 of 72 procedures in group B (15%), and 24 of 228 (10.5%) procedures in group C. The surgical complication or infection frequency in group A was less than that in either group B (p<0.003) or group C (p=0.026). At six weeks after surgery there were no flares in group A, six flares in group B (8%), and six flares in group C (2.6%). Logistic regression analysis of the overall surgical complication rate in all the patients with RA studied showed that methotrexate, whether continued or discontinued before surgery, did not increase the early complication rate in the patients with RA who underwent elective orthopaedic surgery. Other drugs—penicillamine, indometacin, cyclosporin, hydroxychloroquine, chloroquine, and prednisolone—all did significantly increase the risk of infection or surgical complication after elective orthopaedic surgery. The risk of surgery was also increased in the presence of intercurrent chronic diseases—diabetes, hypertension, bronchiectasis, psoriasis, asthma, and ischaemic heart disease.
CONCLUSION—Continuation of methotrexate treatment does not increase the risk of either infections or of surgical complications occurring in patients with RA within one year of elective orthopaedic surgery. Thus methotrexate treatment should not be stopped in patients whose disease is controlled by the drug before elective orthopaedic surgery.

PMCID: PMC1753573  PMID: 11171680
22.  Epidemiology of Exertional Rhabdomyolysis Susceptibility in Standardbred Horses Reveals Associated Risk Factors and Underlying Enhanced Performance 
PLoS ONE  2010;5(7):e11594.
Exertional rhabdomyolysis syndrome is recognised in many athletic horse breeds and in recent years specific forms of the syndrome have been identified. However, although Standardbred horses are used worldwide for racing, there is a paucity of information about the epidemiological and performance-related aspects of the syndrome in this breed. The objectives of this study therefore were to determine the incidence, risk factors and performance effects of exertional rhabdomyolysis syndrome in Standardbred trotters and to compare the epidemiology and genetics of the syndrome with that in other breeds.
Methodology/Principal Findings
A questionnaire-based case-control study (with analysis of online race records) was conducted following identification of horses that were determined susceptible to exertional rhabdomyolysis (based on serum biochemistry) from a total of 683 horses in 22 yards. Thirty six exertional rhabdomyolysis-susceptible horses were subsequently genotyped for the skeletal muscle glycogen synthase (GYS1) mutation responsible for type 1 polysaccharide storage myopathy. A total of 44 susceptible horses was reported, resulting in an annual incidence of 6.4 (95% CI 4.6–8.2%) per 100 horses. Female horses were at significantly greater risk than males (odds ratio 7.1; 95% CI 2.1–23.4; p = 0.001) and nervous horses were at a greater risk than horses with calm or average temperaments (odds ratio 7.9; 95% CI 2.3–27.0; p = 0.001). Rhabdomyolysis-susceptible cases performed better from standstill starts (p = 0.04) than controls and had a higher percentage of wins (p = 0.006). All exertional rhabdomyolysis-susceptible horses tested were negative for the R309H GYS1 mutation.
Exertional rhabdomyolysis syndrome in Standardbred horses has a similar incidence and risk factors to the syndrome in Thoroughbred horses. If the disorder has a genetic basis in Standardbreds, improved performance in susceptible animals may be responsible for maintenance of the disorder in the population.
PMCID: PMC2904368  PMID: 20644724
23.  An observational study on rhabdomyolysis in the intensive care unit. Exploring its risk factors and main complication: acute kidney injury 
Because neither the incidence and risk factors for rhabdomyolysis in the ICU nor the dynamics of its main complication, i.e., rhabdomyolysis-induced acute kidney injury (AKI) are well known, we retrospectively studied a large population of adult ICU patients (n = 1,769).
CK and sMb (serum myoglobin) and uMb (urinary myoglobin) were studied as markers of rhabdomyolysis and AKI (RIFLE criteria). Hemodialysis and mortality were used as outcome variables.
Prolonged surgery, trauma, and vascular occlusions are associated with increasing CK values. CK correlates with sMb (p < 0.001) and peaks significantly later than sMb or uMb.
The logistic regression showed a positive correlation between CK and the development of AKI, with an OR of 2.21. Univariate logistic regression suggests that elevations of sMb and uMb are associated with the development of AKI, with odds ratios of 7.87 and 1.61 respectively. The ROC curve showed that for all three markers a significant correlation with AKI, for sMb with the greatest area under the curve. The best cutoff values for prediction of AKI were CK > 773 U/l; sMb > 368 μg/l and uMb > 38 μg/l respectively.
Because it also has extrarenal elimination kinetics, our data suggest that measuring myoglobin in patients at risk for rhabdomyolysis in the ICU may be useful.
PMCID: PMC3614462  PMID: 23497406
Rhabdomyolysis; Intensive care unit–ICU; Creatine kinase; Creatine phosphokinase; Myoglobin; Serum myoglobin; Urinary myoglobin; Acute kidney injury
24.  Prosthetic Joint Infection Risk after TKA in the Medicare Population 
The current risk of infection in contemporary total knee arthroplasty (TKA) as well as the relative importance of risk factors remains under debate as a result of the rarity of the complication and temporal changes in the treatment and prevention of infection. We therefore determined infection incidence and risk factors after TKA in the Medicare population. The Medicare 5% national sample administrative data set was used to identify and longitudinally follow patients undergoing TKA for deep infections and revision surgery between 1997 and 2006. Cox regression was used to evaluate patient and hospital characteristics. In 69,663 patients undergoing elective TKA, 1400 TKA infections were identified. Infection incidence within 2 years was 1.55%. The incidence between 2 and up to 10 years was 0.46%. Women had a lower risk of infection than men. Comorbidities also increased TKA infection risk. Patients receiving public assistance for Medicare premiums were at increased risk for periprosthetic joint infection (PJI). Hospital factors did not predict an increased risk of infection. PJI occurs at a relatively high rate in Medicare patients with the greatest risk of PJI within the first 2 years after surgery; however, approximately one-fourth of all PJIs occur after 2 years.
Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2795807  PMID: 19669386
25.  Expression of connective tissue growth factor in tumor tissues is an independent predictor of poor prognosis in patients with gastric cancer 
AIM: To examine the expression of connective tissue growth factor (CTGF), also known as CCN2, in gastric carcinoma (GC), and the correlation between the expression of CTGF, clinicopathologic features and clinical outcomes of patients with GC.
METHODS: One hundred and twenty-two GC patients were included in the present study. All patients were followed up for at least 5 years. Proteins of CTGF were detected using the Powervision two-step immunostaining method.
RESULTS: Of the specimens from 122 GC patients analyzed for CTGF expression, 58 (58/122, 47.5%) had a high CTGF expression in cytoplasm of gastric carcinoma cells and 64 (64/122, 52.5%) had a low CTGF expression. Patients with a high CTGF expression showed a higher incidence of lymph node metastasis than those with a low CTGF expression (P = 0.032). Patients with a high CTGF expression had significantly lower 5-year survival rate than those with a low CTGF expression (27.6% vs 46.9%, P = 0.0178), especially those staging I + II + III (35.7% vs 65.2%, P = 0.0027).
CONCLUSION: GC patients with an elevated CTGF expression have more lymph node metastases and a shorter survival time. CTGF seems to be an independent prognostic factor for the successful differentiation of high-risk GC patients staging I + II + III. Over-expression of CTGF in human GC cells results in an increased aggressive ability.
PMCID: PMC2701536  PMID: 18395916
Connective tissue growth factor; Gastric cancer; Prognosis; Lymph node metastasis

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