Fresh Osteochondral Allograft Transplantation for Treatment of Large Cartilage Defects of the Femoral Head: A Minimum Two-Year Follow-Up Study of Twenty-Two Patients

Background

Controversy remains over the surgical management of large osteochondral lesions of the femoral head in young, active patients. The purpose of this study is to assess midterm clinical and radiographic outcomes after fresh osteochondral allograft transplantation (OAT) for large femoral head lesions at minimum 2-year follow-up.

Evolving trends in aortic valve replacement: A statewide experience

Background

Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for the treatment of aortic stenosis in patients at intermediate, high, and extreme risk for mortality from SAVR. We examined recent trends in aortic valve replacement (AVR) in Michigan.

Methods

The Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS‐QC) database was used to determine the number of SAVR and TAVR cases performed from January 2012 through June 2017. Patients were divided into low, intermediate, high, and extreme risk groups based on STS predicted risk of mortality (PROM). TAVR patients in the MSTCVS‐QC database were also matched with those in the Transcatheter Valve Therapy Registry to determine their Heart Team‐designated risk category.

Results

During the study period 9517 SAVR and 4470 TAVR cases were performed. Total annual AVR volume increased by 40.0% (from 2086 to 2920), with a 13.3% decrease in number of SAVR cases (from 1892 to 1640) and a 560% increase in number of TAVR cases (from 194 to 1280). Greater than 90% of SAVR patients had PROM ≤8%. While >70% of TAVR patients had PROM ≤ 8%, they were mostly designated as high or extreme risk by a Heart Team.

Conclusions

During the study period, SAVR volume gradually declined and TAVR volume dramatically increased. This was mostly due to a new group of patients with lower STS PROM who were designated as higher risk by a Heart Team due to characteristics not completely captured by the STS PROM score.     

Traumatic respiratory insufficiency: comparison of conventional mechanical ventilation to high-frequency positive pressure with low-rate ventilation

Eleven patients suffering severe traumatic respiratory insufficiency were mechanically ventilated using a new system which combined high-frequency positive-pressure ventilation (HFPPV) with low-rate conventional mechanical ventilation (LRCMV). Ten similar patients were ventilated by conventional mechanical ventilation (CMV) with PEEP. HFPPV patients were fully conscious and cooperative during ventilation and did not need sedatives or muscle relaxants. Arterial oxygenation was significantly (p less than .005) better in HFPPV than CMV patients (89.91 +/- 10.24 vs. 78.43 +/- 11.13 torr, respectively), and pulmonary shunt was also better in the HFPPV group (13.1 +/- 4.7% vs. 20.4 +/- 6.4%, p less than .01). Moreover, inspired oxygen concentrations were lower (PaO2/FIO2 197.8 +/- 51.3 in the HFPPV group vs. 130 +/- 46.6 in the CMV group, p less than .005) and the time required for mechanical ventilation was shorter (4.2 +/- 0.91 vs. 6.1 +/- 0.8 days, p less than .1). All HFPPV patients immediately began breathing spontaneously when they were disconnected from the ventilator. We suggest this method as a better ventilatory mode for patients suffering traumatic respiratory insufficiency.     

Differences in Reported Outcomes in Industry-Funded vs Nonfunded Studies Assessing Thromboprophylaxis After Total Joint Arthroplasty

Background

There are numerous studies discussing thromboprophylaxis after total joint arthroplasty (TJA), with varying conclusions. Patient inclusion criteria may be different for each study, which may lead to selection bias and misrepresentation of data. This study aimed to investigate if industry funding impacted patient demographics and overall reported outcomes of studies analyzing venous thromboembolism (VTE) prevention after TJA.

A novel method for prediction of stone composition: the average and difference of Hounsfield units and their cut-off values

Purpose

The purpose of the study was to investigate the predictive value of stone measurements by including a novel method on non-contrast computed tomography (NCCT) images for stone composition.

Methods

We retrospectively evaluated patients who had stone analysis, NCCT images, and underwent percutaneous nephrolithotomy between 2013 and 2016. Patient characteristics, stone measurements on NCCT images, and stone analysis results were evaluated. Hounsfield unit (HU) values (maximum (HU_max), minimum (HU_min), and average (HU_ave) of HU values) were investigated on NCCT images. HU_diff was calculated as the difference between the HU_max and the HU_min values. Patients were divided into seven stone groups and data were compared. Then patients were separately divided into two groups according to mineral complexity (mono-mineral and multi-mineral groups) and calcium-based (calcium and other stone groups) evaluation.

Results

In the study, 115 patients were evaluated. Age, gender, HU_min, HU_max, and HU_ave were significantly different between the stone groups. HU_diff and HU_ave were found to be 341.5 HU (AUC?=?0.719, p?=?0.017) and 1051.5 HU (AUC?=?0.701, p?=?0.029) as cut-off, respectively. Seventy of 72?>?341.5 HU_diff patients and 64 of 67?>?1051.5 HU_ave patients had multi-mineral stones (p?=?0.001, OR 9.26, and p?=?0.028, OR 4.27), respectively. In multivariate analysis, >?341.5 HU_diff rate was significantly higher in multi-mineral and calcium stone groups; HU_ave was also significantly higher in the calcium stone group.

Conclusions

HU_diff and HU_ave were significant predictors of mineral complexity. HU_diff of <?341.5 HU showed 81.8% sensitivity and 67.2% specificity for identification of mono-mineral stones.

     

Mitral valve surgery for acute papillary muscle rupture

Background

Papillary muscle rupture (PMR) is a rare complication of a myocardial infarction. The aim of this study was to review our results of mitral valve surgery for acute PMR.

Methods

Data from patients undergoing emergent mitral valve surgery for acute PMR between 2011 and 2017 at our institution were reviewed. Outcomes included operative morbidity and mortality, mitral valve reoperation, and hospital readmission.

Results

A total of 2479 patients underwent mitral valve surgery during the study period including 24 (1.0%) for PMR. Mean age was 62 years, and two (8.3%) patients had prior open‐heart surgery. Overall Society of Thoracic Surgeons predicted risk of mortality was 17.5%. Operative mortality was 12.5% (n = 3) with an observed‐to‐expected mortality ratio of 0.71. There were no strokes, and new onset dialysis was required in two (8.3%) patients. Mean follow‐up was 2.40 ± 1.96 years. Three‐year mortality, mitral valve reoperation, and readmission rates were 21.1%, 5.0%, and 45.4%.

Conclusions

Expeditious operative intervention for PMR can be associated with acceptable operative and longer‐term outcomes.     

A predictive model for survival after in-hospital cardiopulmonary arrest

BACKGROUND: In-hospital cardiopulmonary resuscitation (CPR) has seen a steady increase in the application of technology and techniques since the introduction of closed cardiac massage in 1960. Despite this progress, there has not been a demonstrated improvement in survival rates after in-hospital cardiac arrest over the last 40 years. Identification of prognostic factors associated with survival after a resuscitation attempt can help physician decisions and patients' end-of-life choices in a pre-arrest situation. METHODS: Using an Utstein-based template we analyzed 219 consecutive adult attempted resuscitations in a large urban teaching hospital over a 3-year period. The main outcome measures were survival to discharge, 1 and 3 months. Backwards stepwise logistic regression was used to select baseline variables that predict survival at discharge, 1 and 3 months. RESULTS: Survival rates at discharge, 1 and 3 months were 15.1, 13.3, and 11.5%. Meaningful neurological status (cerebral performance score of 1) at discharge was achieved in 61% of survivors. Independent predictors of survival were: higher body-mass index (BMI), presence of chronic renal insufficiency (CRI), respiratory arrest, ventricular tachycardia/fibrillation (VT/VF) as initial rhythm and arrest early during the hospital stay. A risk model based on these variables demonstrated a significant fit between predicted and observed survival at discharge with goodness of fit test P-value of 0.87. CONCLUSIONS: Survival after in-hospital cardiopulmonary arrest is poor and can be estimated by using clinical variables. If validated in a large prospective trial, this score could help physicians in attempting resuscitation, patients and families in making end-of-life decisions and hospitals in resource allocation.     

Geographic variations in clinical presentation and outcomes of decompressive surgery in patients with symptomatic degenerative cervical myelopathy: analysis of a prospective,international multicenter cohort study of 757 patients

Background Context

Degenerative cervical myelopathy (DCM) is a progressive degenerative spine disease and the most common cause of spinal cord impairment in adults worldwide. Few studies have reported on regional variations in demographics, clinical presentation, disease causation, and surgical effectiveness.