Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery

OBJECTIVE: To evaluate whether hospital volume and surgeon volume of total hip replacements (THRs) are associated with patient-reported functional status and satisfaction with surgery 3 years postoperatively. METHODS: We performed a population-based cohort study of a stratified random sample of Medicare beneficiaries who underwent elective primary or revision THR in Ohio, Pennsylvania, or Colorado in 1995. The primary outcomes were the self-reported Harris hip score and a validated scale measuring satisfaction with the results of surgery. Both outcomes were assessed 3 years postoperatively. Hospital volume was defined as the aggregate number of elective primary and revision THRs performed on Medicare beneficiaries in the hospital in 1995. High-volume hospitals were defined as those in which >100 such procedures are performed annually, and low-volume centers were defined as those in which 12 procedures per year. CONCLUSION: Hospital volume and surgeon volume have little effect on 3-year functional outcome following THR, after adjusting for patient sociodemographic and select clinical characteristics. However, satisfaction with primary THR is greater among patients who underwent surgery in high-volume centers, and satisfaction with revisions is greater among patients whose operations were performed by higher-volume surgeons. Referring clinicians should incorporate these findings into their discussion of referral choices with patients considering THR. Conclusions regarding the effect of volume on longevity of the implants must await longer-term followup studies. Finally, further research is warranted to better understand the association between hospital and surgeon procedure volume and patient satisfaction with surgery.     

Site‐Specific Labeling of Proteins and Peptides with Trans‐cyclooctene Containing Handles Capable of Tetrazine Ligation

There is a growing library of functionalized non‐natural substrates for the enzyme protein farnesyltransferase (PFTase). PFTase covalently attaches these functionalized non‐natural substrates to proteins ending in the sequence CAAX, where C is a cysteine that becomes alkylated, A represents an aliphatic amino acid, and X is Ser, Met, Ala, or Gln. Reported substrates include a variety of functionalities that allow modified proteins to undergo subsequent bioconjugation reactions. To date the most common strategy used in this approach has been copper catalyzed azide‐alkyne cycloaddition (CuAAC). While being fast and bioorthogonal CuAAC has limited use in live cell experiments due to copper's toxicity.¹ Here, we report the synthesis of trans‐cyclooctene geranyl diphosphate. This substrate can be synthesized from geraniol in six steps and be enzymatically transferred to peptides and proteins that end in a CAAX sequence. Proteins and peptides site‐specially modified with trans‐cyclooctene geranyl diphosphate were subsequently targeted for further modification via tetrazine ligation. As tetrazine ligation is bioorthogonal, fast, and is contingent on ring strain rather than the addition of a copper catalyst, this labeling strategy should prove useful for labeling proteins where the presence of copper may hinder solubility or biological reactivity.     

Prolonged intravenous remifentanil infusion for labor analgesia

IMPLICATIONS: A 34-h remifentanil infusion was administered for labor analgesia in a patient with thrombocytopenia and renal insufficiency. Compared with other opioids, remifentanil may produce fewer cumulative effects during prolonged infusion because of its unique metabolism.     

Pediatric emergency preparedness in the office

Pediatric office emergencies occur more commonly than is usually perceived by family physicians, and most offices are not optimally prepared to deal with these situations. Obtaining specific training in pediatric emergencies and performing mock "codes" to check office readiness can improve the proper handling of pediatric emergencies. Common airway emergencies include foreign-body aspiration and croup. Cool mist, racemic epinephrine nebulization and dexamethasone are typical treatment measures for croup. Asthma and bronchiolitis are common causes of respiratory distress. Hypovolemic shock is the most common cause of circulatory failure in children. Intraosseous access is a simple and underutilized route for vascular access in a critically ill child. Status epilepticus is the most common neurologic emergency. Avoidance of iatrogenic respiratory depression and hypotension can be optimized by taking an algorithmic approach to the use of anticonvulsant medications. Transport of patients after initial stabilization of an emergency should always be done in a manner that provides adequate safety and monitoring.     

The Abortion and Sterilization Act in 1975--experience of the Johannesburg Hospital Pregnancy Advisory Clinic

The experience of a Pregnancy Advisory Service operating in terms of the Abortion and Sterilization Act of 1975 is reviewed. A total of 454 applications for abortion were considered, of which 198 (44%) were accepted and the abortions performed. The urgent need for sex education at schools, colleges and universities is stressed, in view of the large number of scholars and students under the age of 17 who seek an abortion. There are also patients who discontinue contraception for a variety of reasons, on medical advice or otherwise, without an alternative being suggested or sought. Motivation of patient, nurse and doctor needs urgent improvement.     

Patient-reported outcome and survivorship after Kinemax total knee arthroplasty

BACKGROUND: We examined the long-term survivorship and patient-reported outcomes at a minimum of ten years following primary total knee arthroplasty. We hypothesized (1) that the survival rate would be at least 90% at ten years; (2) that age, gender, body-mass index, and primary diagnosis would not affect the survival rate; and (3) that the functional status of patients would be comparable with that of an age and gender-matched normal population. METHODS: A total of 407 patients (523 knees) who had had primary total knee arthroplasty between January 1988 and April 1991 were identified. The mean age of the patients at the time of surgery was sixty-nine years, and 68% of the patients were women. At ten years, 165 patients (211 knees) had died; seven of these 211 knees had been revised before the time of death. Of the remaining 242 patients, 208 (86%) completed a questionnaire, which included the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), the Short Form-36 (SF-36), and questions regarding patient satisfaction and revision surgery. In the group of patients who participated in the study, ten patients (eleven knees) had had a revision before the review. RESULTS: A total of eighteen knees were revised. Twelve knees were revised because of aseptic failure and, of these, nine were revised because of polyethylene wear. The probability of survival at ten years was 96.1% with revision for any reason as the end point (and 97.2% when only aseptic failures were considered). Because of the small number of failures, we were unable to draw conclusions about associations between failure and age, gender, diagnosis, and body-mass index. The mean WOMAC scores (and standard deviation) at the time of the evaluation were 88 +/- 17 for pain and 79 +/- 20 for function. The SF-36 scores were similar to those for an age and gender-matched normal population, with only the physical functioning score being significantly lower (p < 0.001) and with the general health score being significantly higher (p < 0.001). Patients generally were very satisfied with all aspects of the outcome. CONCLUSIONS: At ten years, the survival of the prosthesis was excellent and the majority of patients were functionally independent, had very little knee pain, and were very satisfied with the result. The health benefits of this total knee arthroplasty were maintained after a minimum duration of follow-up of ten years.