Hemel Hempstead Hospital

BackgroundAtrial fibrillation (AF) affects 2% to 4.5% of the population. Catheter ablation, a key strategy for paroxysmal AF management, can be achieved through radiofrequency (RFA), cryoablation (CBA), or pulsed field ablation (PFA). While clinical outcomes are well studied, their environmental impact remains underexplored.ObjectivesThis study modeled the environmental impact of CBA and PFA ablation techniques in Europe, aiming to provide evidence to guide sustainable practices in AF treatment.MethodsAn early environmental analysis compared pentaspline PFA (Farapulse system, Boston Scientific) with CBA using a decision-analytic model. The model simulated the patient care pathway from a hospital perspective over a 1-year time horizon, considering index and redo procedures, and complications. The environmental impact, linked to resource use, was measured in kilograms of CO2 equivalents (kg CO2eq), incorporating length of stay, intervention time, anesthetic use, and complications. Probabilistic and scenario analyses, including a comparison with RFA, were performed to assess uncertainty and robustness of the results.ResultsThe environmental analysis showed that PFA resulted in total emissions of 13 899 kg CO2eq, compared with 16 383 kg CO2eq for CBA (−2483 kg CO2eq, −15.2%) per 100 patients. Monte Carlo simulation results confirmed these findings, showing median savings of 2409 kg CO2eq (95% credible interval: 581-4312 kg). Parameters, such as anesthesia time and anesthetic drug use, were key drivers of the results. In the RFA scenario analysis, PFA yielded a saving potential of −4640 kg (−25%). In Germany, for example, with approximately 24 000 CBA procedures annually, PFA adoption was projected to reduce emissions by 509 723 kg CO2eq.DiscussionPFA showed potential for reducing emissions by approximately 25 kg CO2eq per patient compared with CBA, driven by lower resource use. These findings aligned with studies identifying operating rooms and anesthetic drug use as major contributors to hospital emissions. A study limitation was the lack of data on catheter manufacturing and disposal.ConclusionsPFA was expected to reduce emissions compared with CBA in AF patients. Conscious medical device choices can foster more sustainable hospital practices. A full life-cycle analysis of catheters is needed to validate these findings.

BackgroundOrthopaedic In-Training Examination (OITE) performance is an important metric for assessing resident knowledge and directing education. ChatGPT (OpenAI, San Francisco, California, United States) is a novel artificial intelligence (AI) large language model (LLM) with the ability to emulate human conversation and provide access to large pools of knowledge. Recent reports using ChatGPT have achieved a passing performance on medical licensing (United States Medical Licensing Examination (USMLE)) and legal examinations. Whether ChatGPT can successfully complete the OITE and be used as a didactic component in the education of residents remains unknown. This study was thus conceived to compare ChatGPT OITE performance versus local and national resident performance over the last five years.PurposeAs ChatGPT and other LLMs grow in popularity, they are more commonly used by orthopaedic trainees to aid information acquisition and didactic learning. This study was conducted to elucidate the accuracy with which LLMs can answer questions on the OITE, a standardized knowledge and decision-making exam that acts as a benchmark for all orthopaedic trainees. This will help evaluate the current utility of this technology to orthopaedic trainees as a didactic tool throughout training.Patients and methodsChatGPT was provided 200 (10 sets of 20) randomly chosen questions from OITE years 2018 to 2022. All images without direct links present in the selected OITE questions were uploaded to an image hosting service, and links were provided alongside the corresponding question text when entered into ChatGPT. The primary outcome of interest was the percentage of correct responses. ChatGPT's performance was compared against institutional resident averages, as well as national orthopaedic resident averages, for each PGY class. Statistical synthesis comprised the one-sample Wilcoxon test and the Kruskal-Wallis test with the Dunn-Sidak correction.ResultsChatGPT underperformed all PGY year national averages of allopathic/Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic surgery residents (p<0.01). Local institution PGY3 (p=0.0444), PGY4 (p=0.0045), and PGY5 (p=0.0004) resident classes also performed significantly better on the OITE. ChatGPT performed best on the 2021 exam (47.3%) and worst on the 2020 exam (35.3%). Overall ChatGPT performance for all five years was not significantly different (p>0.05).ConclusionsChatGPT scored lower but statistically equivalent to PGY1-2 orthopaedic surgery residents at our institution, although performance was lower than national PGY1-5 resident averages on the 2018-2022 OITEs. This performance is likely to improve in future iterations of ChatGPT as this remains a text-based language tool, not yet validated for image interpretation. Future generative language applications of ChatGPT are broad-ranging for continuing education and the assessment of residents-in-training.Clinical relevanceAs ChatGPT continues to gain popularity, it will inevitably be used by orthopaedic trainees in preparation for the OITE and future board examinations. To our knowledge, this study is the first of its kind to evaluate ChatGPT's performance on the annual OITE, providing insight into its current accuracy and limitations. These findings help clarify its potential role as an adjunctive tool in resident education and future orthopaedic training.

Background:The use of antibiotic-loaded bone cement (ALBC) in primary total knee arthroplasty (TKA) is debated. Some argue that ALBC might only be justified in high-risk patients. This study assessed the effectiveness of ALBC vs. plain bone cement (PBC) in reducing risk of revision for periprosthetic joint infection (PJI) in TKA patients considered to have a high risk of infection.Methods:Cohort study of primary TKAs in 11 national or regional arthroplasty registries from 2010 to 2020. The 1-year risk of revision for PJI in TKAs with ALBC vs. PBC among patients with high American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and/or diabetes was compared. Cumulative percent revision (1 minus Kaplan-Meier) based on 685,818 TKAs and Cox regression analyses (adjusted Hazard Rate Ratios [aHRRs]) were performed for TKAs with ALBC (reference) vs. PBC restricted to the following high-risk subgroups of patients: (1) ASA ≥3 (n = 335,612 vs. 35,997), (2) BMI ≥35 (n = 278,927 vs. 24,737), (3) ASA ≥3 and BMI ≥35 (n = 99,407 vs. 11,407), (4) diabetes (n = 38,341 vs. 21,838), and (5) ASA ≥3, BMI ≥35, and diabetes (n = 3,347 vs. 4,261). Advanced distributed meta-analyses were performed to combine all aggregate data and assess 1-year risk of revision for PJI.Results:Each registry reported a 1-year cumulative percent revision of ≤1.6% for PJI following TKAs both for ALBC and PBC in all high-risk subgroups. Similar 1-year risks of revision for PJI were found in TKAs with ALBC (reference) and PBC among patients with ASA ≥3 (aHRR: 1.09; 95% CI, 0.90-1.31); BMI ≥35 (1.06; 0.54-2.12); ASA ≥3 and BMI ≥35 (1.12; 0.83-1.50); diabetes (0.95; 0.74-1.20); and ASA ≥3, BMI ≥35, and diabetes (1.40; 0.86-2.29).Conclusions and Relevance:Similar 1-year revision risk of PJI was found for TKAs with ALBC vs. PBC in high-risk patients. Confirmation of the efficacy of ALBC in high-risk TKA patients needs to be evaluated in clinical trials.Level of Evidence:Level III. See Instructions for Authors for a complete description of levels of evidence.

Oligonucleotides have emerged as an important new class of therapeutic. Due to their structural complexity, this presents significant challenges for the development of analytical methods to characterise and determine their impurity profile. In this study, we introduce a sensitive ion-pair reverse phase method interfaced with mass spectrometry for analysis of antisense oligonucleotides and small interfering RNAs. Liquid chromatography-mass spectrometry analysis of antisense oligonucleotides and small interfering RNAs was performed using hexylamine: hexafluoro-2-propanol mobiles phases. LC-MS analysis was performed in both negative and positive ion mode. Electrospray ionisation source conditions including collision energy and temperature were optimised to minimise in-source generated impurities and alkylamine adducts in the analysis of oligonucleotide therapeutics. The results show that under low or no in-source collision energy the presence of hexylamine adducts are observed and are predominantly on the lowest charge states present. As the in-source collision energy is increased, a reduction of hexylamine adducts is observed in conjunction with an increase in nucleobase loss in the gas phase, therefore generating in-source impurities. In comparison to tributylammonium acetate, increased MS sensitivity, higher charge states and effective removal of hexylamine adducts using mild source conditions was achieved. Optimisation of the mild source conditions in conjunction with high pH mobile phases was combined with high-resolution accurate mass spectrometry analysis and automated deconvolution workflows to develop a simplified and streamlined approach for characterising oligonucleotide therapeutics and their related impurities.

The aim of this audit was to assess and improve the completeness and accuracy of the National Joint Registry (NJR) dataset for arthroplasty of the elbow. It was performed in two phases. In Phase 1, the completeness was assessed by comparing the NJR elbow dataset with the NHS England Hospital Episode Statistics (HES) data between April 2012 and April 2020. In order to assess the accuracy of the data, the components of each arthroplasty recorded in the NJR were compared to the type of arthroplasty which was recorded. In Phase 2, a national collaborative audit was undertaken to evaluate the reasons for unmatched data, add missing arthroplasties, and evaluate the reasons for the recording of inaccurate arthroplasties and correct them. Phase 1 identified 5,539 arthroplasties in HES which did not match an arthroplasty on the NJR, and 448 inaccurate arthroplasties from 254 hospitals. Most mismatched procedures (3,960 procedures; 71%) were radial head arthroplasties (RHAs). In Phase 2, 142 NHS hospitals with 3,640 (66%) mismatched and 314 (69%) inaccurate arthroplasties volunteered to assess their records. A large proportion of the unmatched data (3,000 arthroplasties; 82%) were confirmed as being missing from the NJR. The overall rate of completeness of the NJR elbow dataset improved from 63% to 83% following phase 2, and the completeness of total elbow arthroplasty data improved to 93%. Missing RHAs had the biggest impact on the overall completeness, but through the audit the number of RHAs in the NJR nearly doubled and completeness increased from 35% to 70%. The accuracy of data was 94% and improved to 98% after correcting 212 of the 448 inaccurately recorded arthroplasties. The rate of completeness of the NJR total elbow arthroplasty dataset is currently 93% and the accuracy is 98%. This audit identified challenges of data capture with regard to RHAs. Collaboration with a trauma and orthopaedic trainees through the British Orthopaedic Trainee Association improved the completeness and accuracy of the NJR elbow dataset, which will improve the validity of the reports and of the associated research.

Abstract Cutaneous T-cell lymphomas (CTCLs) are a group of rare conditions with diagnostic and management challenges and reduced patient quality of life (QoL). Optimal management requires haematology, dermatology and referral to a local skin specialist multidisciplinary team (MDT), with further referrals to a regional supranetwork skin MDT for some patients. An annual CTCL clinic day was established to bring the MDT to the patient and address the challenges of CTCL. Objectives included establishing a local database of patients with CTCL including staging, adjusting treatment as appropriate, upskilling local clinicians, educating patients and initiating annual QoL assessments. Currently two annual clinics have taken place with a third planned. Patients with both known and suspected CTCL were invited. The clinics included nurse-led patient education and a 30-min dermatology-led consultation with access to a specialist haematology consultant and regional CTCL expert. On-the-day blood tests and diagnostic biopsies were performed if needed. Patients completed pre- and postclinic questionnaires for feedback, itch visual analogue scale and Dermatology Life Quality Index and mycosis fungoides (MF)-QoL assessments, and clinician feedback was sought. A total of 31 patients attended one (n = 17) or both (n = 14) clinics following an average 28% late-cancellation/no-show rate. Across the two clinics, it was determined that a total of eight patients did not have CTCL. All patients with CTCL were appropriately staged. Of those attending both annual clinics only 1 patient had a stage progression (IA to IB) and the majority had stable or improved QoL (9 of 13, MF-QoL). Four patients had unplanned hospital visits between clinics, all due to symptom or disease progression. Of the 23 patients with CTCL, 10 had their treatment type changed at one or both of the clinics, 3 had the frequency changed, 3 stopped treatment and 7 had no change in treatment. Patient feedback regarding the clinic was positive with 93% rating the outcome of the clinic as excellent or very good, and 97% responding that they would attend a similar clinic in the future. Some patients retained knowledge from the first clinic education session, whereas others did not and these patients benefited from repeat education. Clinician feedback also reported high value. The outcome of the first two annual CTCL MDT clinic days demonstrated the value patients placed on the service and the need to tailor education frequency to individual needs. In summary, the annual clinic efficiently delivers patient-centred management and care, and education to both patients and clinical teams, and ensures close working relationships between departments within the Trust. This project was a joint working partnership between the Trust and Recordati Rare Diseases UK.

ObjectivesPulsed field ablation (PFA) is a promising new ablation modality for the treatment of atrial fibrillation (AF) that has recently become available in the UK National Health Service (NHS). We provide the first known economic evaluation of the technology.MethodsA cost-comparison model was developed to compare the expected 12-month costs of treating AF using the pentaspline PFA catheter compared with cryoablation for a single hypothetical patient. Model parameters were based on a recent cost-effectiveness analysis by the National Institute for Health and Care Excellence where possible or published literature otherwise. Deterministic sensitivity, scenario and threshold analyses were conducted.ResultsCosts for a single patient treated with PFA were −3% (−£343) less over 12 months than those who received treatment with cryoablation. PFA was associated with 16% higher catheter costs but repeat ablation costs were over 50% less, driven by a reduction in repeat ablations required. Costs of managing complications were −£211 less in total for PFA compared with cryoablation.ConclusionsRoutine adoption of PFA with the pentaspline PFA catheter looks to be as affordable for the NHS as current treatment alternative cryoablation.