Surgical Treatment of Chronic Periprosthetic Joint Infection: Fate of Spacer Exchanges

BackgroundPatients with periprosthetic joint infection (PJI) undergoing 2-stage exchange arthroplasty may undergo an interim spacer exchange for a variety of reasons including mechanical failure of spacer or persistence of infection. The objective of this study is to understand the risk factors and outcomes of patients who undergo spacer exchange during the course of a planned 2-stage exchange arthroplasty.MethodsOur institutional database was used to identify 533 patients who underwent a 2-stage exchange arthroplasty for PJI, including 90 patients with a spacer exchange, from 2000 to 2017. A retrospective review was performed to extract relevant clinical information. Treatment outcomes included (1) progression to reimplantation and (2) treatment success as defined by a Delphi-based criterion. Both univariate and multivariate Cox regression models were performed to investigate whether spacer exchange was associated with failure. Additionally, a propensity score analysis was performed based on a 1:2 match.ResultsA spacer exchange was required in 16.9%. Patients who underwent spacer exchanges had a higher body mass index (P < .001), rheumatoid arthritis (P = .018), and were more likely to have PJI caused by resistant (0.048) and polymicrobial organisms (P = .007). Patients undergoing a spacer exchange demonstrated lower survivorship and an increased risk of failure in the multivariate and propensity score matched analysis compared to patients who did not require a spacer exchange.DiscussionDespite an additional load of local antibiotics and repeat debridement, patients who underwent a spacer exchange demonstrated poor outcomes, including failure to undergo reimplantation and twice the failure rate. The findings of this study may need to be borne in mind when managing patients who require spacer exchange.     

Urological complications of live related donor renal transplantation: 13 years' experience at a single center

BACKGROUND: This study is a retrospective analysis of urological complications and their treatment in our series of live-donor renal transplantation. MATERIAL AND METHODS: The series comprised of 500 patients. All underwent extravesical ureteroneocystostomy and all except a few initial patients were stented. RESULTS: There were 92 complications in 82 patients (18.4%). Urinary leakage occurred in 1.2%. There were no intrinsic ureteric obstructions. Extrinsic ureteric obstruction occurred in 0.8% of cases. The incidence of UTI was 15.4% and of urethral strictures 1%. CONCLUSION: The technique of stented extravesical ureteroneocystomy has led to an extremely low rate of urological complications in our series, over a long time and in a substantial number of patients.     

Antecolic laparoscopic Roux-en-Y gastric bypass is not associated with higher complication rates

Since its introduction in 1994, laparoscopic Roux-en-Y gastric bypass (LRYGB) has rapidly gained popularity for the treatment of morbid obesity. Historically, the operation is performed in a retrocolic fashion; however antecolic LRYGB has been advocated as a safe alternative. We reviewed our experience with both techniques. From January 2003 to November 2004, the new UCLA Laparoscopic Bariatric Surgery Program performed 341 LRYGBs. In March 2004, our program transitioned from a retrocolic to an antecolic approach for all gastric bypass procedures. Institutional review board approval was obtained, and the data for all patients was collected into a prospective database. The patient characteristics for the two groups were similar. The significant differences between the two groups were average body mass index and the percentage of patients with diabetes and sleep apnea. The complication profiles for the two groups were also similar. There were significant differences between the two groups in the reoperation rate, antecolic 2.0 per cent versus retrocolic 7.8 per cent, and length of stay, antecolic 2.57 versus retrocolic 2.89 days. There were no anastomotic leaks or deaths in either group. Antecolic LRYGB is safe and may be associated with fewer complications. Only long-term weight loss results and complication rates will provide a definitive answer.     

Effects of pain and audiovisual stimulation on the opioid-induced depression of the hypoxic ventilatory response

BACKGROUND: Normoxic and hypoxic ventilation are influenced by chemoreceptor and nonchemoreceptor drives. Although inhalational anesthetics blunt hypoxic ventilation, this effect is reversed by audiovisual stimulation but not by pain. Opioids reduce both normoxic and hypoxic ventilation, but their interaction with pain and audiovisual stimulation has not been fully reported. METHODS: Isocapnic, acute hypoxic ventilatory responses (AHRs) were measured in 11 volunteers. AHR and normoxic ventilation were measured under the following conditions: (1) eyes closed, no audio stimulation (low wakefulness); (2) low wakefulness conditions plus painful thermal stimulation; and (3) playing a computer game (high wakefulness), each with and without remifentanil infusion. RESULTS: The average (+/- sd) remifentanil dose was 0.035 +/- 0.012 microg x kg x min(-1). Both normoxic and hypoxic ventilation were significantly reduced by the remifentanil infusion under all three conditions. The AHR values under low wakefulness conditions were 0.33 +/- 0.19 and 0.89 +/- 0.49 l x min(-1) x sat(-1) with and without remifentanil, respectively (P < 0.05). High wakefulness significantly increased AHR with and without remifentanil, whereas low wakefulness with pain did not. However, high wakefulness with remifentanil did not increase the AHR back to what was observed during low wakefulness without remifentanil. CONCLUSIONS: The computer game was a more potent stimulus than pain in countering the depressant effect of remifentanil on AHR. Although the effect of high wakefulness was more attenuated than was previously observed with respect to inhalational anesthetics, the significance of these findings is underlined by the more clinically relevant scenario of what is experienced in the face of opioid administration.     

Role of platelet activating factor in triazolobenzodiazepines-induced retrograde amnesia

Benzodiazepine (diazepam), triazolobenzodiazepines (brotizolam, triazolam) and platelet activating factor (PAF) antagonist (BN 52021) are administered to mice before acquisition and retrieval trials conducted using Morris water maze. Benzodiazepine has produced only anterograde amnesia and it has not produced retrograde amnesia. Triazolobenzodiazepines have produced both anterograde and retrograde amnesia. PAF antagonist (BN 52021) has only produced retrograde amnesia and it has not produced anterograde amnesia. The anterograde amnesia produced by benzodiazepine and triazolobenzodiazepines, has been prevented by benzodiazepine receptor antagonist (flumazenil). It suggests that benzodiazepine- and triazolobenzodiazepines-induced anterograde amnesia may be mediated through benzodiazepine receptors. On the other hand, retrograde amnesia produced by PAF antagonist (BN 52021) and triazolobenzodiazepines has been attenuated by PAF and PAF acetyl hydrolase inhibitors such as cigarette smoke extract (CSE) and phenylmethanesulfonylflouride. It suggests that triazolobenzodiazepine-induced retrograde amnesia may be mediated through blockade of PAF receptors.     

A novel mutation in the ELOVL4 gene causes autosomal dominant Stargardt-like macular dystrophy

PURPOSE: To conduct clinical and genetic studies in a European family with autosomal dominant Stargardt-like macular dystrophy (adSTGD-like MD) and to investigate the functional consequences of a novel ELOVL4 mutation. METHODS: Ophthalmic examination and mutation screening by direct sequencing of the ELOVL4 gene was performed in two affected individuals. Wild-type and mutant ELOVL4 genes were expressed as enhanced green fluorescent protein (EGFP) fusion proteins in transient transfection in NIH-3T3 and HEK293 cells. To determine the subcellular localization of ELOVL4, an endoplasmic-reticulum (ER)-specific marker for pDsRed2-ER was cotransfected with ELOVL4 constructs. Transfected cells were viewed by confocal microscopy. Western blot analysis was performed to assess protein expression using an anti-GFP antibody. RESULTS: Affected patients exhibited macular atrophy with surrounding flecks characteristic of adSTGD-like MD. A novel ELOVL4 p.Tyr270X mutation was detected in affected individuals. In cell-transfection studies, wild-type ELOVL4 localized preferentially to the ER. In contrast, the mutant protein appeared to be mislocalized within transfected cells. CONCLUSIONS: In a European family with adSTGD-like MD, a novel ELOVL4 mutation was found to underlie the disorder. Transfection studies indicated that, unlike wild-type ELOVL4, the mutant protein does not localize to the ER but rather appears to be sequestered elsewhere in an aggregated pattern in the cytoplasm. Further analysis of the function of normal and mutant ELOVL4 will provide insight into the mechanism of macular degeneration.     

Hypolipidemic activity of seeds of Cassia tora Linn

Ethanolic extract of seeds of Cassia tora L. and its fractions were investigated for hypolipidemic activity on triton induced hyperlipidemic profile. Ethanolic extract and its ether soluble and water soluble fraction decreased serum level of total cholesterol by 42.07, 40.77 and 71.25%, respectively. On the other hand ethanolic extract, ether soluble fraction and water soluble fraction increased the serum HDL-cholesterol level by 6.72, 17.20 and 19.18%, respectively. Ethanolic extract, ether fraction and water fraction decreased triglyceride level by 26.84, 35.74 and 38.46%, respectively. The reduction in LDL-cholesterol level by ethanolic extract, ether soluble fraction and water soluble fraction were 69.25, 72.06 and 76.12%, respectively.