新型冠状病毒核酸检测在眼科医院疫情防控中的实践与有效性研究

目的:探索以系统化、标准化的新型冠状病毒核酸检测为核心和重要组成部分,建立适合于眼科医院新冠疫情精准防控切实可行的防控体系。方法:系列病例研究。自2020年2月24日至3月2日期间,以标准化病毒核酸检测联合血常规、C反应蛋白(CRP)、血清淀粉样蛋白A(SAA)等检测作为所有眼科手术患者术前筛查常规检测项目,同时也为返岗员工提供病毒核酸检测。设计调查问卷了解受检者对鼻咽拭子采样的接受度以及核酸检测结果对其心理状态的影响。结果:99例患者血液学检测结果有一定的异常比例,其中SAA检测结果增高13例,淋巴细胞计数减低12例、增高5例,白细胞计数增高11例、减低1例,CRP增高2例,新型冠状病毒核酸检测均阴性。33例本院职工新型冠状病毒核酸检测均阴性。12%的受访者对鼻咽拭子采样接受度评分较低。受检者在核酸检测前后思想压力评分较高的比例分别为46.7%和6.7%。结论:该项举措一方面为术前新冠病毒肺炎筛查及鉴别诊断提供了客观依据,很大程度上排除了隐性无症状感染者传播的可能,有利于减少二次传播的风险,降低院内交叉感染的概率;另一方面,核酸检测阴性结果有利于调整患者术前的心理状态并缓解医护人员在疫情防控期间的心理压力。     

Tadalafil for the treatment of benign prostatic hyperplasia

Introduction: In men, lower urinary tract symptoms (LUTS) are primarily attributed to benign prostatic hyperplasia (BPH). Therapeutic options are targeted to relax prostate smooth muscle and/or reduce prostate enlargement.

Areas covered: This article reviews the major preclinical and clinical data on PDE5 inhibitors with a specific focus on tadalafil. It includes details of the role of the nitric oxide (NO)-cyclic guanosine monophosphate (cGMP) – PDE5 pathway in the LUT organs (bladder and prostate) in addition to the available data on tadalafil in patients with LUTS secondary to BPH with or without erectile dysfunction (ED).

Expert opinion: Preclinical and clinical data have clearly demonstrated that PDE5 inhibitors induce bladder and prostate relaxation, which contributes to the improvement seen in storage symptoms in both animal models of bladder and prostate hypercontractility. Tadalafil is effective both as a monotherapy and add-on therapy in patients with LUTS secondary to BPH. Furthermore, as LUTS-BPH and ED are urological disorders that commonly coexist in aging men, tadalafil is more advantageous than α1-adrenoceptors and should be used as the first option. Tadalafil is a safe and tolerable therapy and unlike α1- adrenoceptors and 5-alpha reductase inhibitors, which can cause sexual dysfunctions, tadalafil improves sexual function.     

Efficacy and safety of pembrolizumab for the treatment of advanced biliary cancer: Results from the KEYNOTE-158 and KEYNOTE-028 studies

We present data from patients with advanced biliary tract cancer (BTC) receiving pembrolizumab in the KEYNOTE-158 (NCT02628067; phase 2) and KEYNOTE-028 (NCT02054806; phase 1b) studies. Eligible patients aged ≥18 years from both studies had histologically/cytologically confirmed incurable BTC that progressed after standard treatment regimen(s), measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, Eastern Cooperative Oncology Group performance status 0/1, and no prior immunotherapy. Programmed death ligand 1 (PD-L1)-positive tumors were required for eligibility in KEYNOTE-028 only. Patients received pembrolizumab 200 mg every three weeks (KEYNOTE-158) or 10 mg/kg every two weeks (KEYNOTE-028) for ≤2 years. Primary efficacy endpoint was objective response rate (ORR) by RECIST v1.1. Response assessed by independent central review is reported. KEYNOTE-158 enrolled 104 patients and KEYNOTE-028 enrolled 24 patients. Median (range) follow-up was 7.5 months (0.6-34.3) in KEYNOTE-158 and 5.7 months (0.6-55.4) in KEYNOTE-028. In KEYNOTE-158, ORR was 5.8% (6/104; 95% CI, 2.1%-12.1%); median duration of response (DOR) was not reached (NR) (range, 6.2-26.6+ months). Median (95% CI) OS and PFS were 7.4 (5.5-9.6) and 2.0 (1.9-2.1) months. Among PD-L1-expressers (n = 61) and PD-L1-nonexpressers (n = 34), respectively, ORR was 6.6% (4/61) and 2.9% (1/34). In KEYNOTE-028, ORR was 13.0% (3/23; 95% CI, 2.8%-33.6%); median DOR was NR (range, 21.5-53.2+ months). Median (95% CI) OS and PFS were 5.7 (3.1-9.8) and 1.8 (1.4-3.1) months. Grade 3 to 5 treatment-related adverse events occurred in 13.5% of patients in KEYNOTE-158 (no grade 4; grade 5 renal failure, n = 1) and 16.7% in KEYNOTE-028 (no grade 4/5). In summary, pembrolizumab provides durable antitumor activity in 6% to 13% of patients with advanced BTC, regardless of PD-L1 expression, and has manageable toxicity.     

Positive Cultures Can Be Safely Ignored in Revision Arthroplasty Patients That Do Not Meet the 2018 International Consensus Meeting Criteria

BackgroundDuring aseptic revision total joint arthroplasty (TJA), one or more cultures may occasionally isolate an organism. The hypothesis of this study was that in a portion of patients undergoing revision arthroplasty for aseptic failure, culture may isolate an organism(s) that can be left untreated.MethodsAll patients undergoing revision TJA from 2000 to 2017 at two institutions were retrospectively reviewed. Patients were categorized as aseptic if they were appropriately investigated preoperatively and did not meet the 2018 International Consensus Meeting criteria. In the aseptic revision cohort, patients with a single positive culture or multiple cultures positive for different organisms (“organism-positive”) and patients who had negative intraoperative cultures (“organism-negative”) were compared based on demographics, comorbidities, operative details, subsequent reoperations, and periprosthetic joint infection (PJI).ResultsIn total, 3,234 International Consensus Meeting–negative aseptic revision TJAs were included, of which 215 patients (6.6%) were organism-positive, 196 (91.2%) had a single positive culture, and 19 (8.8%) were positive for 2 or more distinct organisms (ie, polymicrobial). The most prevalent organisms were coagulase-negative Staphylococci (37.5%), Staphylococcus epidermidis (9.6%), and Cutibacterium acnes (8.0%). Demographics and operative details were comparable between the groups. Using multiple regressions there was no association between culture positivity and the rate of reoperation or PJI.ConclusionIsolation of organisms by culture in patients undergoing revision for aseptic failure was not uncommon. As long as these patients were appropriately investigated preoperatively and PJI was excluded, these findings suggest that culture results may be ignored without subjecting patients to additional antimicrobial treatment.     

Surgical Helmets Used During Total Joint Arthroplasty Harbor Common Pathogens: A Cautionary Note

BackgroundThe use of personal-protection surgical helmet/hood systems is now a part of the standard surgical attire during arthroplasty in North America. There are no protocols for the disinfection of these helmets.MethodsThis is a prospective, single-center, observational study. Helmets worn by 44 members of the surgical team and foreheads of 44 corresponding surgical personnel were swabbed at three distinct time points. In addition, 16 helmets were treated with hypochlorite spray to determine if pathogens could be eliminated. Swabs obtained were processed for culture and next-generation sequencing (NGS).ResultsOf the 132 helmet samples, 97 (73%) yielded bacteria on culture and 94 (71%) had evidence of bacterial–deoxyribonucleic acid (DNA) on NGS. Of the swabs sent for bacterial identification at the three time points, at least one from each helmet was positive for a pathogen(s). Of the 132 forehead samples, 124 (93%) yielded bacteria on culture and 103 (78%) had evidence of bacterial-DNA on NGS. The most commonly identified organism from helmets was Cutibacterium acnes (86/132) on NGS and Staphylococcus epidermidis (47/132) on culture. The most commonly identified organism from the foreheads of surgical personnel was Cutibacterium acnes (100/132) on NGS and Staphylococcus epidermidis (70/132) on culture. Sanitization of helmets was totally effective; no swabs taken the following morning for culture and NGS identified any bacteria.ConclusionThis study demonstrates that surgical helmets worn during orthopedic procedures are contaminated with common pathogens that can potentially cause surgical site infections. The findings of this study should at the minimum compel us to develop protocols for the disinfection of these helmets.     

The Fate and Relevance of the Patella in Two-Stage Revision Total Knee Arthroplasty for Periprosthetic Joint Infection

BackgroundIt remains unclear whether reimplantation of a patellar component during a two-stage revision for periprosthetic total knee arthroplasty infection (PJI) affects patient reported outcome measures (PROMs) or implant survivorship. The purpose of this study was to evaluate whether patellar resurfacing during reimplantation confers a functional benefit or increases implant survivorship after two-stage treatment for PJI.MethodsTwo-stage revisions for knee PJI performed by three surgeons at a single tertiary care center were reviewed retrospectively. All original patellar components and cement were removed during resection and the patella was resurfaced whenever feasible during reimplantation. PROMs, implant survivorship, and radiographic measurements (patellar tilt and displacement) were compared between knees reimplanted with a patellar component versus those without a patellar component.ResultsA total of 103 patients met the inclusion criteria. Forty-three patients (41.7%) underwent reimplantation with, and 60 patients (58.3%) without a patellar component. At a mean follow-up of 33.5 months, there were no significant differences in patient demographics or PROMs between groups (P ≥ .156). No significant differences were found in the estimated Kaplan-Meier all-cause, aseptic, or septic survivorship between groups (P ≥ .342) at a maximum of 75 months follow-up. There was no significant difference in the change (pre-resection to post-reimplant) of patellar tilt (P = .504) or displacement (P = .097) between the groups.ConclusionPatellar resurfacing during knee reimplantation does not appear to meaningfully impact postoperative PROMs or survivorship. Given the risk of potential extensor mechanism complications with patellar resurfacing, surgeons may choose to leave the patella without an implant during total knee reimplantation and expect similar clinical outcomes.Level of EvidenceLevel III.     

Emerging Viral Infections Causing Anterior Uveitis

Purpose: To review the systemic and ocular manifestations of specific emergent viral infectious diseases relevant to the ophthalmologist with particular emphasis on anterior uveitis

Methods: Review of literature.

Results: Arboviral diseases are among the most important emergent and resurgent human infections, occurring mostly in tropical and subtropical zones, but appearing in virtually all regions of the world as a result of climate change, travel, and globalization. Arboviral infections are transmitted to humans by the bite of hematophagous arthropods, mainly mosquitoes. Systemic disease may range from asymptomatic to life-threatening. A wide variety of ocular manifestations, including uveitis, has been reported in association with these emerging viral diseases. Numerous viruses other than arboviruses also have been recently recognized as a potential cause of uveitis.

Conclusions: Proper clinical diagnosis of any emerging infectious disease is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is usually confirmed by detection of virus-specific DNA or antivirus antibodies in serum.     

Cementless Total Hip Arthroplasty for Adult Patients With Sequelae From Childhood Hip Infection: A Medium-Term Follow-Up Study

BackgroundThe aim of this study is to evaluate midterm clinical and radiographic results of total hip arthroplasties (THAs) with cementless implants for adult patients with sequelae from childhood hip infection.MethodsBetween 2002 and 2016, 165 patients (165 hips) who had a hip infection during childhood were treated with THAs with cementless implants. The average duration of follow-up was 93.5 months (range 26-206). Clinical results were evaluated via the Harris Hip Score and radiographic results were analyzed with postoperative serial X-rays.ResultsThe average Harris Hip Score increased from 27 (range 8-53) before surgery to 91 (range 45-100) at the latest follow-up examination (P < .001). At the latest follow-up evaluation, 9 cementless acetabular components demonstrated partial, nonprogressive radiolucencies. No subsidence of more than 2 mm or evidence of a radiolucent line was observed around the femoral components. Intraoperative periprosthetic fractures occurred in 11 hips, including 3 acetabular fractures, 2 fractures of greater trochanter, 1 femoral shaft fracture, and 5 fractures of femoral calcar. Postoperative complications included 3 cases of periprosthetic infection, 1 episode of dislocation, 1 case of a femoral periprosthetic fracture, 5 cases of sciatic nerve injury, 1 case of femoral nerve injury, and 1 case of squeaking from a ceramic bearing surface.ConclusionCementless THA for adult patients with sequelae from childhood hip infection presents significant technical challenges and a relatively high complication rate. With meticulous surgical planning and anticipation for the key technical challenges frequently encountered, the medium-term clinical and radiographic results of THA in this setting were good with high implant survivorship and patient satisfaction.