Drivers of transfusion decision making and quality of the evidence in orthopedic surgery: a systematic review of the literature

Reasons for variation in transfusion practice in orthopedic surgery are not well understood. This systematic review identified and appraised the quality of the literature in this area to assess the impact of factors associated with the use of allogeneic red blood cell (RBC) transfusion in orthopedic procedures. MEDLINE and EMBASE databases were searched for relevant English language publications. Articles containing a range of MeSH and text terms regarding "blood transfusion," "predictors," and "multiple logistic regression" were retrieved. Articles that focused on patients undergoing orthopedic procedures and that met prespecified inclusion criteria were appraised in terms of potential bias and the appropriateness of statistical approach. A total of 3641 citations were retrieved, and 29 met the inclusion criteria for the review. Articles reported on a range of orthopedic procedures including total hip arthroplasty; total knee arthroplasty, total shoulder arthroplasty, and spinal surgery. Most studies were conducted in the United States (n = 12) or Canada (n = 5). Study quality was moderate; 50% or more of the quality criteria were assessed in 15 articles. Particular areas of concern were the lack of prospective studies, lack of clarity in defining the time interval between risk factor assessment and transfusion outcome, and lack of model validation. A narrative synthesis found that 2 factors consistently influenced the use of RBC transfusion-decreased hemoglobin (n = 25) and increased patient age (n = 18). Increased surgical complexity (n = 12), low body weight (n = 9), presence of additional comorbidities (n = 9), and female sex (n = 7) were also important factors. The general quality of the studies in the field is weak. However, low hemoglobin and increasing age were consistently identified as independent risk factors for RBC transfusion in orthopedic practice. Additional or alternative analytical approaches are required to obtain a more comprehensive, holistic understanding of the decision to transfuse RBCs to patients undergoing orthopedic surgery.     

Sexually transmitted infections among brothel-based sex workers in bangladesh: high prevalence of asymptomatic infection

OBJECTIVE AND GOAL: The goal of this study was to study the prevalence of sexually transmitted infections (STIs)/reproductive tract infections (RTIs) among brothel-based sex workers (SWs) in Bangladesh. STUDY: A cross-sectional study was conducted among SWs in 4 randomly selected brothels. A sociodemographic and behavioral survey and pelvic examination was conducted. Specimens including endocervical swab, high vaginal swab, and blood were collected and were examined for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, bacterial vaginosis candidiasis, and syphilis. RESULTS: A total of 439 SWs were enrolled and 49.6% had genital symptoms. Among all SWs, 17.5% were positive for N. gonorrhoeae; 15.5% for C. trachomatis; 7.5% for T. vaginalis, and 6.6% had active syphilis. A total of 67.4% SWs were positive for at least 1 cervical and/or vaginal infection. CONCLUSION: The prevalence of STIs/RTIs among SWs in brothels in Bangladesh is high. An intervention strategy addressing both symptomatic and asymptomatic infections and periodic screening of SWs for RTIs/STIs is essential for successful HIV and STIs prevention programs.     

A 4-year prospective study of septicemia in pediatric surgical patients at a tertiary care teaching hospital in Kuwait

Background

Critically ill children are at high risk for developing nosocomial infections that contributes to death in 4% of all pediatric intensive care unit admissions. This prospective study was undertaken to determine the prevalence of septicemia in the pediatric surgery department of a large tertiary care teaching hospital in Kuwait and to evaluate the risk factors, the microbial etiology, and the antimicrobial susceptibility pattern of the isolated microorganisms.

Methods

All patients admitted to the pediatric surgery department from January 2001 until December 2004 with the diagnosis of septicemia were included in the study, and the microbiologically proven cases were then analyzed. The patients' demographics and risk factors for sepsis were recorded. All positive blood cultures were subjected to identification and antimicrobial susceptibility testing by VITEK 2(bioMerieux, Marcy l'Etoile, France).

Results

Of 3408 patients suspected to have septicemia, 78 (2.3%) patients developed microbiologically documented septicemias, 26% of those were low-birth weight patients, and 82% were patients with congenital anomalies; 87% of those needed surgical intervention. More than 50% were admitted to the intensive care unit, and 80.5% needed ventilatory support. Fifty-seven percent had early onset septicemia. Gram-positive and gram-negative bacteria accounted for 54% and 39% of the septicemia cases, respectively, whereas Candida spp was responsible for 7%. More than 50% of the staphylococci were resistant to cloxacillin, and all gram-positives were uniformly susceptible to glycopeptides and linezolid. Gram-negative bacteria showed variable resistance to cephalosporins (65%), piperacillin/tazobactam (29%), and carbapenems (11%). The attributable mortality rate for these septic episodes was 19% mainly because of gram-negative bacteria and Candida.

Conclusion

The main etiologic agents of neonatal septicemia were coagulase-negative Staphylococcus, Pseudomonas aeruginosa, and members of the family Enterobacteriaceae. Empirical therapy with piperacillin/tazobactam or carbapenems for gram-negative septicemia and glycopeptides for gram-positive septicemia was effective.     

Surgical treatment of dysphagia

The role of surgery in the management of dysphagia is clear in some areas and controversial in others. Evaluation for the causes of dysphagia can elucidate conditions in which surgery can improve safety, quality of life, or both. Surgical therapy, when indicated, is safe and effective for many causes of dysphagia. This article includes a general overview of the causes of dysphagia that can be addressed successfully with surgery as well as a discussion of why surgery may be less appropriate for other conditions associated with dysphagia.     

An HPLC method for the simultaneous determination of neurotoxic dipyridyl isomers in human plasma

Several studies on dipyridyl isomers have suggested that they are neurotoxic and that chronic exposure to these compounds could be a potential human health hazard. A reversed phase HPLC method was developed for the simultaneous quantitation of 2,2'-dipyridyl and its four positional isomers, 2,3'-, 2,4'-, 3,4'- and 4,4'-dipyridyl in human plasma. Plasma samples were basified, extracted with 1-chlorobutane, evaporated, the residue reconstituted in mobile phase, and an aliquot part was analyzed by HPLC. Chromatographic separations were performed on a C(18) reversed phase Sunfire column eluted with a mobile phase composed of potassium phosphate (pH 3.5; 25 mM)-acetonitrile (80:20, v/v). Isomers were separated with good resolution, and quantification was determined utilizing an internal standard of quinoxaline. The method has been validated over a range from 30 to 2000 ng/ml with correlation coefficients higher than 0.995. Extraction recoveries for the dipyridyl isomers averaged from 65 to 92%. Limit of detection and limit of quantitation for the dipyridyl isomers ranged from 15 to 70 ng/ml and 30 to 90 ng/ml, respectively. The inter- and intra-day variation did not exceed 7% with an accuracy range of 96-102%. The described analytical method was successfully utilized for the determination of dipyridyl isomers in human plasma and suggested the need for more routine monitoring of tobacco smokers and other individuals who are involuntarily exposed to environmental source of dipyridyl isomers.     

TP53 codon 72 polymorphisms in favorable histology Wilms tumors

In Wilms tumor (WT), mutations in the gene encoding p53, TP53, are correlated with anaplasia; however TP53 variants have not been studied in favorable histology (FH) WTs. A single nucleotide polymorphism of TP53 encoding either arginine or proline at codon 72 is suggested to alter in vitro p53 behavior. Therefore, we analyzed tissue from 23 consecutive patients with FHWT to determine allelic and genotypic frequencies of Pro72 and Arg72 variants and correlate this with clinical outcomes. Interestingly, our cohort showed a statistically significant over-representation of the Arg allele and Arg/Arg genotype. However, the genotypic and allelic frequencies showed no significant correlation with age, stage, or disease recurrence.     

Hydronephrosis: a view from the inside

Unilateral ureteropelvic junction obstruction (UPJO) is the most common prenatally detected disease leading to hydronephrosis. The obstructive anatomic lesion leads to varying degrees of hydronephrosis, ranging from no apparent effect on renal function to atrophy. Furthermore, the natural course of hydronephrosis varies from spontaneous resolution to progressive deterioration and may take upwards of 3 years for a kidney to declare itself. The objectives of this article are to update our knowledge regarding the evaluation and management of UPJO in depth and to discuss the emerging value of urinary proteome analysis to the clinical arena.