Research news in brief

Leg fractures: discharge destination may impact recovery

Outcomes for patients with isolated lower limb fractures may be better for those discharged to their home rather than to inpatient rehabilitation, according to a large observational study published by the MJA. The study, led by Alfred Hospital senior physiotherapist Dr Lara Kimmel, analysed data from adults (18–64 years old) who were treated for isolated lower limb fractures between 1 March 2007 and 31 March 2016 at four Melbourne trauma hospitals that contribute data to the Victorian Orthopaedic Trauma Outcomes Registry. “Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries,” the authors wrote. “The odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home; for the 5057 people working before their accident, the odds of return to work were reduced by 66%. Our findings provide insights directly relevant to clinical practice; in particular, all discharge options should be considered before referring patients to [inpatient rehabilitation] after lower limb trauma. Qualitative research has found discharge destination decisions for these patients are largely determined by financial considerations. Surgeons and rehabilitation physicians do not feel responsible for discharge decision-making, believing that it is driven by organisational factors and bed availability rather than patient-related factors. In light of our findings, models for delivering trauma rehabilitation in the home or in an outpatient setting should be assessed, reserving [inpatient rehabilitation] beds for patients with traumatic brain injuries and others who benefit from such treatment,” Kimmel and colleagues concluded. The authors warned that their results should be interpreted “with caution”, given residual (but statistically acceptable) covariate imbalances between the discharge destination groups. “The factors that remained unbalanced (funding source, site and cause of injury) could be examined in trials for assessing the relationship between discharge destination and outcomes after lower limb trauma,” they said. Listen to our exclusive podcast with Dr Lara Kimmel and Professor Anne Holland.

Hepatocellular carcinoma: rupture less crucial than previously thought

Australian patients with ruptured hepatocellular carcinoma (HCC) should be treated with the aim of long term survival, even though mortality caused by rupture in Asian countries is 25–75%, according to the authors of a research letter published by the MJA. The 5-year survival rate for HCC is about 16%, the authors wrote. Tumour rupture is a life-threatening complication and the third most common cause of death for people with HCC. The Melbourne researchers, led by Dr Natassia Tan from Alfred Health and colleagues from Monash University, Austin Hospital, Royal Melbourne Hospital and Eastern Health set out to investigate the impact of spontaneous HCC rupture on survival. Data from all adult patients who presented with spontaneous HCC rupture to six tertiary referral hospitals in Melbourne between January 2007 and July 2018 were compared with data from patients with non-ruptured HCC. “Median survival time was 1.3 years in the non-rupture group and 1.7 years in the rupture group,” Tan and colleagues found. “The longer survival for our cohort of patients with ruptured HCC than in other studies may be explained by their having greater hepatic functional reserve and less evidence of vascular thrombus and extrahepatic invasion than reported for other study cohorts. Curative surgical management may also have improved survival. For 26 of 33 patients in the rupture group (79%), spontaneous rupture was the first indication of HCC; lead time bias or earlier consideration of therapy after managing the rupture were therefore possible.” Tan and colleagues concluded that “given the potential for median survival times of more than 12 months, patients with ruptured HCC should be treated with the aim of long term survival. Larger prospective studies of the impact of HCC rupture on prognosis are warranted.”

Some antibiotics prescribed during pregnancy linked with birth defects

Children of mothers prescribed macrolide antibiotics during early pregnancy are at an increased risk of major birth defects, particularly heart defects, compared with children of mothers prescribed penicillin, finds a study published by The BMJ. The researchers say these findings show that macrolides should be used with caution during pregnancy and, if feasible, alternative antibiotics should be prescribed until further research is available. Macrolide antibiotics (including erythromycin, clarithromycin and azithromycin) are widely used to treat common bacterial infections. They are often used as alternatives for patients with penicillin allergy. Previous studies suggest evidence of rare but serious adverse outcomes of macrolide use, especially for unborn babies. The adverse outcomes might be associated with the pro-arrhythmic (heart rhythm problems) potential of macrolides. Policy advice about macrolide use in pregnancy varies. To address these uncertainties, researchers analysed data from 104 605 children born in the UK from 1990 to 2016, with a median follow up of 5.8 years after birth. A further 82 314 children whose mothers were prescribed macrolides or penicillins before pregnancy, and 53 735 children who were siblings of children in the study group acted as negative control cohorts. Major malformations were recorded in 186 of 8632 (2.15%) children whose mothers were prescribed macrolides at any point during pregnancy and in 1666 of 95 973 (1.74%) children whose mothers were prescribed penicillins during pregnancy. After taking account of potentially influential factors, the researchers found macrolide prescribing during the first 3 months (the first trimester) of pregnancy was associated with an increased risk of any major malformation compared with penicillin (28 v 18 per 1000) and specifically cardiovascular malformations (11 v 7 per 1000). The increased risks were not observed in children of mothers whose macrolides were prescribed in later pregnancy (during the second to third trimester). Macrolide prescribing in any trimester was also associated with a slightly increased risk of genital malformations (5 v 3 per 1000). No statistically significant associations were found for other system-specific malformations or for any of the four neurodevelopmental disorders. This is an observational study, so can’t establish cause, and the researchers point to some limitations, such as being unable to examine treatment exposure during known critical periods for specific malformations and neurodevelopmental disorders.

What’s new online at the MJA

Perspective: Bushfire smoke: how can we protect individuals and populations?
Vardoulakis et al; doi: 10.5694/mja2.50511
More nuanced health advice is needed to protect populations and individuals from exposure to bushfire smoke … OPEN ACCESS permanently

Podcast: Professor Sotiris Vardoulakis, Professor of Global Environmental Health at ANU … OPEN ACCESS permanently

Research: Discharge destination and patient-reported outcomes after inpatient treatment for isolated lower limb fractures
Kimmel et al; doi: 10.5694/mja2.50485
The impact of discharge destination on outcomes after treatment for orthopaedic trauma requires further investigation … OPEN ACCESS permanently

Podcast: Dr Lara Kimmel, Senior Physiotherapist at Alfred Hospital, and Professor Anne Holland, Clinical Chair of Physiotherapy at Monash University … OPEN ACCESS permanently

Research letter: Survival of patients with ruptured and non-ruptured hepatocellular carcinoma
Tan et al; doi: 10.5694/mja2.50483
Patients with ruptured HCC should be treated with the aim of long term survival … OPEN ACCESS permanently