24 hours stay after hip replacement

Background and purpose — The length of stay after total hip arthroplasty has been reduced to 2–4 days after implementing fast-track surgery. We investigated whether a new time-based patient-centered primary direct anterior approach (DAA) total hip arthroplasty (THA) treatment protocol in a specialized clinic, with a planned length of stay of about 24?hours, could be achieved in all patients or only in a selected group of patients.

Patients and methods — We analyzed prospectively collected data in a cohort of 378 consecutive patients who underwent a primary direct anterior THA as a patient-centered time-based procedure between March 1, 2012 and December 31, 2015. Patients with complicated medical comorbidity and those over the age of 85 were excluded from the study. The average length of stay was recorded and all complications, re-admissions, and reoperations were registered and analyzed. The primary outcome measures were length of stay and complication rate, at discharge and 90 days postoperatively.

Results — The average length of stay for all patients was 26?hours. All patients were discharged from the clinic on the day after the operation and were able to continue their recovery at home or in a rehabilitation facility. The overall complication rate within 3 months of surgery was 6%. The 3-month re-admission rate and the 3-month reoperation rate were both 2%.

Interpretation — Performing a time-based, patient-centered fast-track program for DAA total hip arthroplasty can result in a standardized length of stay of about 24?hours and a high level of patient satisfaction with few complications, re-admissions, and reoperations.     

Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up

Purpose

Patients with an upper brachial plexus lesion can suffer from dysfunction, joint deformities and instability of the shoulder. The goal of this study was to determine pain, shoulder function, patient satisfaction and muscle strength in shoulder arthrodesis in patients with an upper brachial plexus lesion more than 15 years after surgery.

Methods

We retrospectively studied 12 patients with a brachial plexus lesion of mean age 46 years (27–61). At a mean of 19.8 years (15.4–30.3) after shoulder arthrodesis, patient-reported outcome measures (PROMs), range of motion (e.g., active and passive), patient satisfaction, strength of the affected and non-affected side (e.g., maximum isometric strength in Newton in forward and retroflexion, ab- and adduction, internal and external rotation) and position of fusion were obtained. PROMS consisted of the Visual Analogue Scale (VAS; 0–100, 0 being painless) for pain and the Disabilities of the Arm, Shoulder and Hand Score (DASH; 0–100, 0 being the best score) for function.

Results

At latest follow-up, the median VAS pain score was 49 (0–96) and 0 for, respectively, the affected and unaffected side. The DASH was 15 (8–46), meaning a reasonable to good function of the upper extremity. Active and passive retroflexion was significantly different (p = 0.028). All subjects stated that in the same situation they would undergo a shoulder arthrodesis again. The unaffected side was significantly stronger in every direction. Arthrodesis showed position of fusion of 31° (12–70) abduction, 20° (10–50) forward flexion and 22° (? 14 to 58) internal rotation. The unaffected side was significantly (p ≤ 0.05) stronger in every movement direction.

Conclusion

At a mean of 20 years after shoulder arthrodesis, patients with an upper brachial plexus lesion are still satisfied with a good to moderate functional improvement.

Level of evidence III

A retrospective cohort study.

     

Inflammation and oxidation: do they improve after kidney transplantation? Relationship with mortality after transplantation

Summary

Patients with chronic kidney disease (CKD) are characterized by a state of inflammation and oxidative stress that seems to improve after kidney transplantation (KT). Nevertheless, there is controversy regarding what is the best marker that better define inflammation and specially oxidative stress.

Objective

To evaluate the biomarkers which are associated with improvements in inflammation and lipid peroxidation in patients who have undergone KT. To evaluate the relationship between inflammation, lipid peroxidation and mortality in KT.

Patients

196 KT (between 2003 and 2008). 67.9% men; median age: 51.9 years. Inflammation markers analyzed previous KT and 3 months after KT: c-reactive protein(CRP), interleukin 6(IL-6), tumor necrosis factor alpha(TNFα), soluble tumor necrosis factor receptor alpha(sTNFRα), soluble interleukin-2 receptor (sIL-2R). Lipid peroxidation markers analyzed: oxidized low-density lipoprotein (oxLDL) and anti-oxLDL antibodies. Calculation of glomerular filtration rate after KT: MDRD equation.

Results

Following KT, there is a significant decrease in CRP (p = 0.006), IL-6 (p = 0.0037), TNFα (p < 0.0001), sTNFRα (p < 0.0001) and sIL-2R (p < 0.0001), while levels of oxLDL increase after KT (p < 0.0001) and there is not a significantly difference in anti-oxLDL. 12.8% of the patients had died in 2012. These patients had higher levels of IL-6 (p = 0.011) and sTNFRα (p < 0.006) after KT and a lower MDRD (p < 0.0001), hemoglobin (p = 0.012) and albumin (p = 0.007). We observed no statistically differences in the levels of markers previous KT. Of the patients who died, the 43.5% of them had anti-oxLDL antibody levels greater than 75th percentile (P₇₅: 3781 UI/ml, p = 0.028). In the multivariate analysis, age (OR:1.12; p = 0.0129), MDRD (OR:0.92; p = 0.013) and P₇₅ of anti-oxLDL(OR: 5.19; p = 0.026) were independent risk factors for mortality. Independent risk factors for survival were: P₇₅ of IL-6 (HR: 2.45; p = 0.027), oxLDL (HR:19.85; p = 0.002) and anti-oxLDL (HR: 9.55; p = 0.003).

Conclusions

KT improved inflammation but not lipid oxidative state. KT patients who died had a higher inflammatory state (with higher levels of IL-6 and sTNFRα), a worse lipid oxidative state and a worse renal function 3 months after KT. Age, anti-oxLDL and renal function at 3 months after KT were independent risk factors for mortality.

     

Inflammatory thromboembolic complication after craniopharyngioma surgery?

Summary Aside from endocrine or visual disturbances an appearance of other complications after craniopharyngioma surgery is rare. We report a case of delayed brain infarction in the postoperative period of craniopharyngioma resection. A 30-year-old man presented with visual impairment and diabetes insipidus. Imaging revealed a partly cystic, partly contrast enhancing intra-/suprasellar mass lesion. The patient underwent craniotomy with resection of the tumour. Histological examination revealed an adamantinomatous craniopharyngioma. Early postoperative an aseptic meningitis, which was diagnosed clinically as well as by laboratory and CSF analysis, resolved spontaneously. One week later a cerebral incident with infarction in the peripheral territory of MCA on the left side occurred. For this unusual event with a review of the literature a thromboembolic origin is suggested on the basis of inflammatory vascular involvement after an attack of aseptic meningitis.     

Wernicke’s Syndrome after Sleeve Gastrectomy

We report a case of Wernicke’s encephalopathy after sleeve gastrectomy, which had been complicated by stomach wall edema and aggravated by dietary noncompliance. Despite intense parenteral nutrition, thiamine deficiency became clinically evident. It suggests that nutritional preparations used were unable to cover the increased thiamine requirement. After intense thiamine supplementation, gradual improvement occurred during the 6 months after the diagnosis, without permanent cognitive impairment. Clinicians involved in postoperative management of bariatric surgery patients must consider Wernicke’s syndrome in hyper-emetic patients, who show unclear neurological deterioration. Early diagnosis and treatment can instantly improve the patient’s condition without permanent sequelae.     

What influences reconvalescence after lung resection?

INTRODUCTION: Reconvalescence after lung resections underlies several influences. The aim of this study was to outline the effect of patient and operative factors. METHODS: Between 1/97 and 6/98 a cross sectional prospective study was undertaken at the University of Ulm. 125 patients with lung resections for various reasons via anterolateral thoracotomy were included. Variants thought to affect postoperative recovery were statistically analysed using uni- and multivariate analysis. A "good postoperative recovery" (GPR) was seen as at least two of the following criteria were fulfilled on the second postoperative day: Spitzer Index >/=6, FEV1 >40% of preoperative measurement, pain on LASA scale 相似文献   

Guillain-Barré syndrome after solid organ transplantation

BACKGROUND: Neurological complications occur frequently in solid organ transplant recipients. However, the peripheral nerves are usually spared significant toxicity. Guillain Barré syndrome (GBS) is the most common cause of acute neuropathy in adults. Despite numerous reports of GBS in recipients of bone marrow transplants, GBS has rarely been reported in recipients of solid organ transplants. Recent evidence supports the role of the immune system in initiating and perpetuating the ongoing neural damage in this entity. Infectious agents may initiate the immune attack, and the association of GBS with cytomegalovirus (CMV) infection has been studied extensively. METHODS: To alert clinicians to the occurrence of GBS in the latter setting, we report five new cases of GBS after solid organ transplant and summarize five other cases previously reported in the literature. RESULTS: The GBS cases (published and unpublished) have much in common: all the patients were men, most had evidence of active CMV infection at or before the onset of GBS, and all but one developed GBS within 1 year after transplantation (range 1-26 months). CONCLUSION: The association of GBS with cytomegalovirus (CMV) infection in the nontransplant population and evidence of CMV infection in almost all reported cases of GBS in solid organ transplant recipients suggest that CMV may have a role in triggering this illness.     

Corticosteroids for fat embolism after multiple fractures

Fat embolism is a common complication of multiple fractures. Corticosteroids are usually prescribed in prophylactic and treatment of fat embolism. A case of fat embolism followed multiple fractures was hospitalized, and we searched best evidences about corticosteroids for fat embolism so as to provide best therapeutics for the patient.     

Ureterolithiasis after Cohen re-implantation – case report

Background  

In the past decades, the widespread use of cross-trigonal ureteral reimplants for the treatment of children with vesicoureteral reflux has resulted in a large population of patients with transversely lying ureters. As this population gets older they will consequently be entering an age group at higher risk for stone and urothelial cancer formation. If ureteroscopy becomes necessary, the transverse position of the ureter makes ureteric access often impossible.