Direct anterior compared to posterior approach for hip hemiarthroplasty following femoral neck fractures

The differences in complication rates between the direct anterior and posterior approaches for hemiarthroplasty in elderly patients with femoral neck fractures are not yet fully understood.Dislocation,a severe complication associated with increased mortality and often requiring additional surgery,may occur less frequently with the direct anterior approach compared to the posterior approach.Careful consideration of patient demographics is essential when planning the surgical approach.Future research in this area should focus on robust randomized controlled trials involving elderly patients recovering from femoral neck fractures.

Smoking cessation prior to elective total joint arthroplasty results in sustained abstinence postoperatively

BACKGROUND Tobacco use is a well-documented modifiable risk factor for perioperative complications.AIM To determine the tobacco abstinence rates of patients who made cessation efforts prior to a total joint arthroplasty(TJA)procedure.METHODS A retrospective evaluation was performed on 88 self-reported tobacco users who underwent TJA between 2014-2022 and had tobacco cessation dates within 3 mo of surgery.Eligible patients were contacted via phone survey to understand their tobacco use pattern,and patient reported outcomes.A total of 37 TJA patients participated.RESULTS Our cohort was on average 61-years-old,60%(n=22)women,with an average body mass index of 30 kg/m^(2).The average follow-up time was 2.9±1.9 years.A total of 73.0%(n=27)of patients endorsed complete abstinence from tobacco use prior to surgery.Various cessation methods were used perioperatively including prescription therapy(13.5%),over the counter nicotine replacement(18.9%),cessation programs(5.4%).At final follow up,43.2%(n=16)of prior tobacco smokers reported complete abstinence.Patients who were able to maintain cessation postoperatively had improved Patient-Reported Outcomes Measurement Information System(PROMIS)-10 mental health scores(49 vs 58;P=0.01),and hip dysfunction and osteoarthritis outcome score for joint replacement(HOOS.JR)scores(63 vs 82;P=0.02).No patients in this cohort had a prosthetic joint infection or required revision surgery.CONCLUSION We report a tobacco cessation rate of 43.2%in patients undergoing elective TJA nearly 3 years postoperatively.Patients undergoing TJA who were able to remain abstinent had improved PROMIS-10 mental health scores and HOOS.JR scores.The perioperative period provides clinicians a unique opportunity to assist active tobacco smokers with cessation efforts and improve postoperative outcomes.

Subsequent total joint arthroplasty: Are we learning from the first stage?

BACKGROUND With the increasing incidence of total joint arthroplasty(TJA),there is a desire to reduce peri-operative complications and resource utilization.As degenerative conditions progress in multiple joints,many patients undergo multiple proce-dures.AIM To determine if both physicians and patients learn from the patient’s initial arth-roplasty,resulting in improved outcomes following the second procedure.METHODS The institutional database was retrospectively queried for primary total hip arth-roplasty(THA)and total knee arthroplasty(TKA).Patients with only unilateral THA or TKA,and patients undergoing same-day bilateral TJA,were excluded.Patient demographics,comorbidities,and implant sizes were collected at the time of each procedure and patients were stratified by first vs second surgery.Outcome metrics evaluated included operative time,length of stay(LOS),disposition,90-d readmissions and emergency department(ED)visits.RESULTS A total of 642 patients,including 364 undergoing staged bilateral TKA and 278 undergoing bilateral THA,were analyzed.There was no significant difference in demographics or comorbidities between the first and second procedure,which were separated by a mean of 285 d.For THA and TKA,LOS was significantly less for the second surgery,with 66%of patients having a shorter hospitalization(P<0.001).THA patients had significantly decreased operative time only when the same sized implant was utilized(P=0.025).The vast majority(93.3%)of patients were discharged to the same type of location following their second surgery.However,when a change in disposition was present from the first surgery,patients were significantly more likely to be discharged to home after the second procedure(P=0.033).There was no difference between procedures for post-operative readmissions(P=0.438)or ED visits(P=0.915).CONCLUSION After gaining valuable experience recovering from the initial surgery,a patient’s perioperative outcomes are improved for their second TJA.This may be the result of increased confidence and decreased anxiety,and it supports the theory that enhanced patient education pre-operatively may improve outcomes.For the surgical team,the second procedure of a staged THA is more efficient,although this finding did not hold for TKA.

Academic productivity correlates with industry earnings in foot and ankle fellowship programs in the United States:A retrospective analysis

BACKGROUND The study investigates the connection between academic productivity and industry earnings in foot and ankle orthopedic surgery fellowships.Utilizing metrics like the H-index and Open Payments Database(OPD)data,it addresses a gap in understanding the relationship between scholarly achievements and financial outcomes,providing a basis for further exploration in this specialized medical field.AIM To elucidate the trends between academic productivity and industry earnings across foot and ankle orthopedic surgery fellowship programs in the United States.METHODS This study is a retrospective analysis of the relationship between academic productivity and industry earnings of foot and ankle orthopedic surgery fellowships at an individual faculty and fellowship level.Academic productivity was defined via H-index and recorded from the Scopus website.Industry earnings were recorded from the OPD.RESULTS Forty-eight foot and ankle orthopedic surgery fellowships(100%of fellowships)in the United States with a combined total of 165 physicians(95.9%of physicians)were included.Mean individual physician(n=165)total life-time earnings reported on the OPD website was United States Dollar(USD)451430.30±1851084.89(range:USD 25.16-21269249.85;median:USD 27839.80).Mean physician(n=165)H-index as reported on Scopus is 14.24±12.39(range:0-63;median:11).There was a significant but weak correlation between individual physician H-index and individual physician total life-time earnings(P<0.001;Spearman’s rho=0.334)and a significant and moderate positive correlation between combined fellowship H-index and total life-time earnings per fellowship(P=0.004,Spearman’s rho=0.409).CONCLUSION There is a significant and positive correlation between academic productivity and industry earnings at foot and ankle orthopedic surgery fellowships in the United States.This observation is true on an individual physician level as well as on a fellowship level.

Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy

AIM To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors.METHODS We performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013(n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariateanalyses were performed to describe variables associated with readmission.RESULTS One hundred thirty-two patients(59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit.CONCLUSION Readmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.

Impact of surgical volume and resident involvement on patency rates after vasectomy reversaldA 14-year experience in an open access system

Objective:Evaluate the influence of fellowship training,resident participation,reconstruction type,and patient factors on outcomes after vasectomy reversals in a high volume,open access system.Methods:Retrospective review of all vasectomy reversals performed at a single institution from January 1,2002 to December 31,2016 was conducted.Patient and spouse demographics,patient tobacco use and comorbidities,surgeon training and case volume,resident participation,reconstruction type,and postoperative patency were collected and analyzed.Results:Five hundred and twenty-six vasectomy reversals were performed during the study period.Follow-up was available in 80.6%of the cohort and overall patency,regardless of reconstruction type was 88.7%.The mean time to reversal was 7.87 years(range of 0-34 years).The majority of cases included resident participation.Case volume was high with faculty and residents logging a mean of 37.0 and 38.7(median 18 and 37)cases respectively.Bilateral vasovasostomy was the most common reconstruction type(83%)and demonstrated a significantly better patency rate(89%)than all other reconstructions(p=0.0008).Overall patency and patency by reconstruction type were not statistically different among faculty surgeons and were not impacted by fertility fellowship training,resident participation or postgraduate year.Multivariate analysis demonstrated that increased time to reversal and repeat reconstructions had a negative impact on patency(p=0.0023 and p=0.043,respectively).Conclusions:Surgeons with a high volume of vasectomy reversals have outcomes consistent with contemporary series regardless of fellowship training in fertility.Patency was better for bilateral vasovasostomies.Patency was not negatively impacted by tobacco use,comorbidities,resident participation,or post-graduate year.

Bone Marrow Aspirate and Trephine Biopsy Procedure in a Teaching and Referral Hospital in Kenya

Introduction: Bone marrow aspiration and biopsies are carried out principally to permit cytological assessment of marrow. The procedure is also indicated for immunophenotypic, cytogenetic, molecular and other specialized investigations. The skill to perform bone marrow aspirate and biopsy is usually acquired by the medical personnel through apprenticeship during their training. The training includes performing the procedure, indications, contraindications, and associated hazards. Moi Teaching and Referral Hospital (MTRH) being a specialized Hospital in Western Kenya has several staff trained on performing the procedure. Objective: To assess the performance of bone marrow procedure by clinicians at a teaching and referral hospital. Materials and methods: A descriptive cross-sectional study was done involving 40 clinicians working in the hematology clinic and medical wards from June to December 2019. A structured questionnaire was used to collect the data and data analysis was done using frequency tables. Approval to carry out the study was sought from the institutional IRB. Results: Patients attended to were predominantly adults 33 (83%). The superior posterior iliac crest was the commonest site for the procedure and disposable needles were routinely used in 33 (83%) of the patients. Pain and excessive bleeding 18 (45%) were the commonest complications associated with the procedure. Conclusion: Most of the clinicians involved doing the procedure were residents/registrars. Most of the patients attended to were adults (83%) and majority of the clinicians performed the procedure on the posterior iliac site (96%) using disposable needles (83%). Local anesthesia was commonly used during the procedure (88%). The common complications associated with the bone marrow procedure were pain and excessive bleeding (45%).

Existing fixation modalities for Jones type fifth metatarsal fracture fixation pose high rates of complications and nonunion

Jones type fifth metatarsal fractures pose a challenge to the foot and ankle surgeon,given documented high nonunion rates as well as high complication rates including hardware prominence,nerve injury,and screw breakage for existing treatment modalities including screw and plantar plate fixation.We call for the design of innovative Jones-fracture specific implants which contour to the natural curve of the fifth metatarsal.Future research should aim to expand upon existing literature for Jones fracture fixation and evaluate efficacy of novel implants which are designed to address unacceptably high complication rates for existing treatment modalities.

The use of remifentanil in ex utero intrapartum treatment procedures

Purpose: We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia. Using remifentanil along with spinal anesthesia eliminates the fetal and maternal risks associated with inhalational general anesthesia, allows the mother to be awake, and obviates the need for and costs associated with general anesthesia and a second anesthesia team. Materials and Methods: We performed a retrospective review of all sequential patients undergoing ex utero intrapartum treatment procedure at our hospital from 1/1/2009 to 11/1/2010. All procedures were performed under regional neuraxial analgesia, using nitroglycerine as a tocolytic agent and remifentanil for analgesia. Variables included indication, time to secured fetal airway, complications, estimated blood loss, need for additional anesthetics, participating personnel, and survival. Results: All five of our ex utero intrapartum treatment procedures were successfully completed with combined spinal epidural remifentanil anesthetic. No patient was required additional alternative anesthetic. There were no complications with mother or fetus. Indications for procedure were arthyrogryposis (n = 3), fetal goiter, and micrognathia. Average time to secured airway was 10.25 minutes. Average estimated blood loss was 1010 ml. All five mothers were conscious during their procedure. Conclusions: We report the largest series of ex utero intrapartum treatment procedures performed with remifentanil regional anesthesia. We found that the combined use of nitroglycerin and regional remifentanil anesthesia is a safe alternative to the pediatric otolaryngologist for performing ex utero intrapartum treatment procedures without the risks of general anesthesia, allowing the mother to be awake for the delivery, and reducing the cost of providing care.

Torsades de Pointes Secondary to Excessive Loperamide Use

Abstract： Loperamide is a common, over-the-counter, antidiarrheal medication that has been implicated in cases of ventricular tachycardia. A 32 year-old female patient with a history of opioid abuse and no prior history of cardiovascular disease experienced Torsades de pointes. An electrocardiogram at the time of hospital presentation revealed a prolonged QT interval at 636 msec. Diagnostic evaluation was unremarkable for any underlying cardiovascular pathology. Further investigation revealed the patient had been taking 30-40 loperamide 2 mg tablets oral daily for 2 weeks prior to the onset of Torsades de pointes. At high doses, loperamide may prolong the QT interval through antagonism of the human ether-a-go-go potassium current, thus increasing the risk of ventricular arrhythmias. Clinicians should be cautious with administration of high doses of loperamide to all patients, especially patients at high risk for QT interval prolongation.

“Bull’s eye”appearance of hepatocellular adenomas in patients with glycogen storage disease type I-atypical magnetic resonance imaging findings:Two case reports

BACKGROUND Hepatocellular adenomas are rare tumors that can occur in patients with glycogen storage disease type I.CASE SUMMARY We herein report two cases of histologically proven hepatocellular adenomas in patients with glycogen storage disease type I.Magnetic resonance imaging(MRI)was performed after bolus injection of gadoxetate disodium,a liver-specific gadolinium-based MRI contrast agent.In the present cases,some of the hepatocellular adenomas showed unexpectedly a“bull’s eye”appearance on T2-weighted and post-contrast images,which was not previously described as imaging findings of hepatocellular adenomas in glycogen storage disease.A bull’s eye appearance on T2-weighted images can be encountered in both benign(i.e.,abscess)or malignant(i.e.,epithelioid hemangioendothelioma,cholangiocarcinoma,and metastases)hepatic lesions.CONCLUSION We present two cases of hepatocellular adenomas in patients with glycogen storage disease type 1,in which gadoxetate disodium-MRI showed atypical imaging findings for hepatocellular adenomas.At present there is no systematic study evaluating MRI findings of hepatocellular adenomas in patients with glycogen storage disease,further studies are needed to specifically investigate this issue.

The sound of blood:photoacoustic imaging in blood analysis

Blood analysis is a ubiquitous and critical aspect of modern medicine.Analyzing blood samples requires invasive techniques,various testing systems,and samples are limited to relatively small volumes.Photoacoustic imaging(PAI)is a novel imaging modality that utilizes non-ionizing energy that shows promise as an alternative to current methods.This paper seeks to review current applications of PAI in blood analysis for clinical use.Furthermore,we discuss obstacles to implementation and future directions to overcome these challenges.Firstly,we discuss three applications to cellular analysis of blood:sickle cell,bacteria,and circulating tumor cell detection.We then discuss applications to the analysis of blood plasma,including glucose detection and anticoagulation quantification.As such,we hope this article will serve as inspiration for PAI's potential application in blood analysis and prompt further studies to ultimately implement PAI into clinical practice.

Progressive multifocal leukoencephalitis in a patient with sarcoidosis on hydroxychloroquine with negative cerebrospinal fluid testing for the John Cunningham virus

Progressive multifocal leukoencephalopathy (PML) is a severe demyelinating disease of the central nervous system caused by the John Cunningham (JC) virus typically seen in immuno-compromised patients. Several drugs that suppress that immune system have already been known to cause PML such as natalizumab and rituximab. We present a patient with sarcoidosis who develops PML in the rare setting of minimal immunosuppression with only hydroxychloroquine. There was significant delay in the diagnosis due to negative cerebrospinal fluid testing for JC virus and concern for neuro-sarcoidosis, but eventually a diagnosis of PML was made via brain biopsy.

Anxiety disorders in patients with cardiopulmonary diseases:A brief review

This manuscript reviews the current literature involving clinical anxiety and cardiopulmonary disease,considers the hypothesized physiological mechanisms for anxiety,and discusses the use of exercise as a treatment for both anxiety and cardiopulmonary diseases.The literature summary consists of original investigations,meta-analysis,commentaries,and review publications in order to better understand the biological and psychological mechanisms for using exercise as treatment and to provide details specific to cardiopulmonary disease and anxiety management.A gap in the literature exists concerning the anxiolytic effects of exercise as a psychological and physical treatment in cardiopulmonary populations.The findings from this review support further investigation into the use of exercise to ameliorate the burden of anxiety in cardiopulmonary disease patients.This review evaluates the current literature surrounding cardiopulmonary disease and anxiety.A systematic literature search identified articles discussing the prevalence,association,and risk of anxiety in cardiopulmonary patients.Though depression is often studied in this population,recent investigation supports a need for further research regarding anxiety in cardiopulmonary patients.Treatment to manage patients’psychological profile can reduce exacerbations of known disease,reduce hospital readmission,and improve functional capacity,and overall quality of life.