We aim to describe mortality in orthopaedic patients with Clostridium difficile associated diarrhoea (CDAD), to identify prognostic factors for 30 day mortality, and to modify a CDAD risk score to fit to orthopaedic patients. This was a two centre, retrospective, observational study including consecutive patients with a first episode of CDAD between 2005–2007. 79 patients were identified, comprising 11 elective patients (14%) and 68 emergency patients (86%). 73 patients (92%) underwent surgery and all but two patients received broad spectrum antibiotics prior to CDAD. The overall 30 day mortality was 29% (n=26). The predominant diagnosis was a fractured femoral neck (66%, n=52). The most significant multivariable model in predicting 30 day mortality comprised increasing white cell count (WCC, OR 1.20 [for 10% variable increase]; 95% CI 1.06–1.36 p=0.003) and decreasing albumin (OR 0.86 [for single unit decrease]; 0.86–0.95, p=0.003), with adjustment for age ł80 years (OR 6.39, 1.15–35.52, p=0.04). CRP was found to be not significant. Based on this, modification of the previously described Clostridium difficile prognostic index leads to a point awarded for WCC ł20, albumin Ł20, age ł80, urea ł15 or clinically severe disease (peritonitis, sepsis, ł10 episodes of diarrhoea per day). This produces low (0–1 points), medium (2–3 points) and high (4–5 points) risk of death groups, with mortalities of 15%, 47% and 75% respectively for all orthopaedic patients, and 14%, 41% and 67% respectively in only the validation cohort. CDAD in orthopaedic patients mainly affects emergency patients, in particular those with fractured femoral neck. Inpatient mortality is high, and a high white count and low albumin are significant predictors of mortality. Modification of an easily remembered scoring system based on this can help identify orthopaedic patients likely to die from an episode of CDAD, allowing early aggressive therapy and early objective referral to gastrointestinal teams.
“Cancer should be treated by cancer specialists” is often stated, but there is little proof that outcomes are different. We have investigated whether there is evidence that patients with soft tissue sarcomas (STS) do better if treated in a specialist centre compared with district general hospitals (DGH). We analysed the outcomes for all patients with soft tissue sarcomas in one health authority of the UK over a 3 year period, with minimum follow up of 5 years. During this time one third of patients were treated at a specialist musculoskeletal oncology centre whilst the remainder had treatment centred in a DGH. We have investigated appropriateness of treatment, adequacy of surgery, and outcomes in terms of local control and overall survival. Data was obtained from the Cancer Intelligence Unit and the specialist centre. Results were stratified for known risk factors for local control and survival (grade, depth and size for survival). 260 patients were diagnosed as having STS over the 3 year period (incidence = 17.4 per million per year). 37% of patients had the majority of treatment at the specialist centre under the care of 2 surgeons, whilst the other 63% were treated at a total of 38 different hospitals. The most significant factor affecting survival was tumour grade (relative risk 5.5). Overall survival shows that patients treated for STS have greater chance of survival at the ROH. 5 year survival for Stage III tumours was 41% at the ROH, but only 14% at DGHs. Percentage of adequate margins achieved at the DGHs and ROH were approximately equal, but there were significantly more local recurrences at the DGHs (37% DGH vs 20% ROH), suggesting the margins at the ROH are in fact better achieved. Soft tissue sarcomas are rare. Centralisation of treatment improves survival, local control and patients care.
