A nomogram for predicting the need for sciatic nerve block after total knee arthroplasty

Purpose

Sciatic nerve block (SNB) is commonly performed in combination with femoral nerve block (FNB) for postoperative analgesia following total knee arthroplasty (TKA). Despite the fact that 10–20 % of TKA patients require SNB for postoperative posterior knee pain, there are no existing studies that suggest a model to predict the need for SNB. The aim of our study was to develop a prediction tool to measure the likelihood of patients undergoing TKA surgery requiring a postoperative SNB.

Methods

With institutional review board approval, we obtained data from the electronic medical record of patients who underwent TKA at the Cleveland Clinic. A multivariable logistic regression was used to estimate the probability of requiring a postoperative SNB. Clinicians selected potential predictors to create a model, and the potential nonlinear association between continuous predictors and SNB was assessed using the restricted cubic spline model.

Results

In total 6279 TKA cases involving 2329 patients with complete datasets were used for building the prediction model, including 276 (12 %) patients who received a postoperative SNB and 2053 (88 %) patients who did not. The estimated C statistic of the prediction model was 0.64. The nomogram is used by first locating the patient position on each predictor variable scale, which has corresponding prognostic points. The cut-off of 11.6 % jointly maximizes the sensitivity and specificity.

Conclusion

This is the first study to be published on SNB prediction after TKA. Our nomogram may prove to be a useful tool for guiding physicians in terms of their decisions regarding SNB.

     

Is there an athlete’s artery? A comparison of brachial and femoral artery structure and function in male strength,power and endurance athletes

ObjectivesExercise places physiological demands upon the cardiovascular system, subsequently leading to adaptations in structure and function. Different exercise modalities (endurance, strength and power) lead to distinct hemodynamic demands and, possibly, different patterns of adaptation. Our aim was to assess and compare brachial and femoral artery function and structure in elite level athletes engaged in endurance, strength and power sports.Designcross sectional comparison.Methods30 male elite athletes (runners n = 10, powerlifters n = 11, weightlifters n = 9) and 23 healthy controls were recruited. Brachial and femoral arterial diameters were assessed using ultrasound. Arterial function (brachial and femoral arteries) was determined using the flow mediated dilation (FMD) technique and body composition using body mass index (BMI) and body surface area (BSA).ResultsWeightlifters had significantly larger brachial arterial diameters compared to controls (4.39 ± 0.34 vs 3.86 ± 0.42 mm, p < 0.01). As weightlifter and power athletes had significantly higher body mass, BMI and BSA, we adjusted diameter for BSA. BSA-correction ameliorated differences in brachial artery resting diameters between athletes and controls. However, BSA-corrected femoral artery diameter was significantly larger in runners compared to controls (3.51 ± 0.28 vs 3.25 ± 0.34 mm, p < 0.05). There were no differences in brachial FMD between groups. Femoral artery FMD was significantly higher in runners and weightlifters compared to controls (p < 0.05 for both groups).ConclusionsHeterogeneous, limb-specific structural and functional vascular adaptation is evident in athletes, which may be influenced by exercise modality. Further, vascular remodelling relates to differences in body shape, specifically body composition, which should be accounted for when comparing athletes.     

Proctalgia Fugax in Patients with the Irritable Bowel, Peptic Ulcer, or Inflammatory Bowel Disease

One hundred forty-eight patients with gastrointestinal disease, 50 patients with the irritable bowel syndrome (IBS) and 49 each with peptic ulcer and inflammatory bowel disease, were interviewed to determine if they had proctalgia fugax (PF) and if the symptom was associated with the IBS. One-third of the patients had PF. It occurred in 51% of females and 12% of males (p less than 0.001). When corrected for sex, PF was no more prevalent in IBS than in peptic ulcer or inflammatory bowel disease. Only two of six previously described IBS symptoms were more prevalent in the PF patients. Attacks occurred in the day in 94%, and one-third of sufferers related them to defecation. The pain was localized in the anus in 90%, occurred less than five times a year in 51%, and lasted less than 1 min in 57%. In most, activity was not interrupted by this pain and only 20% had ever reported it to a physician. PF is very common among patients with abdominal symptoms, but is not related to the IBS. Since it is infrequent, benign, and transient, PF is usually not mentioned to the physician.     

Antibody to human T-cell leukemia virus membrane antigens, beta 2-microglobulin levels, and thymosin alpha 1 levels in hemophiliacs and their spouses

Recently, antibodies to human T-cell leukemia virus membrane antigens (HTLV-MA) and elevated levels of beta 2-microglobulin and thymosin alpha 1 have been found with high frequency in patients with the acquired immunodeficiency syndrome. Prospective studies of asymptomatic persons at high risk for this syndrome will ascertain whether any of these findings is a predictive marker for the disease. In this study, antibodies to HTLV-MA, beta 2-microglobulin levels, and thymosin alpha 1 levels were determined for a group of asymptomatic adult hemophiliacs and their wives. Five of thirty-nine hemophiliacs had HTLV-MA antibody, compared with none of 21 wives tested. The mean beta 2-microglobulin level for hemophiliacs was significantly higher than the control value (p less than 0.001), whereas the wives had a normal mean value. The mean thymosin alpha 1 values were normal for hemophiliacs and their wives; however, 3 of 22 hemophiliacs and 1 of 16 wives had abnormally high levels. Whether any of these abnormalities correlate with subsequent development of the acquired immunodeficiency syndrome will be ascertained by longitudinal follow-up of this population.     

Failed prior rotator cuff repair is associated with worse clinical outcomes after reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to determine the comparative risk profile and clinical outcomes for patients undergoing reverse total shoulder arthroplasty (RTSA) for cuff tear arthropathy (CTA) without failed prior rotator cuff repair (RCR) compared with RTSA for CTA with prior RCR.MethodsFrom 2006 to 2014, all patients who underwent RTSA by two surgeons after failed RCR with minimum 2-year follow-up were identified. Patients who underwent RTSA with failed prior RCR were matched in a 1:1 ratio to patients undergoing primary RTSA, while controlling for demographic factors, prosthesis design, and surgeon. Postoperative active forward elevation and active external rotation were recorded. Outcome measures included American Shoulder and Elbow Surgeons score, Visual Analog Scale (VAS), and Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were noted, and comparative multivariate analysis was performed.ResultsOf 262 patients, 192 (73.3%) were available at minimum 2-year follow-up. The prior RCR group had a significantly higher complication rate (17.4%, n = 15) than the primary RTSA group (3.8%, n = 4) (P = .001), although no significant difference in periprosthetic infection (P = .469) or secondary revision rate (P = .136) was observed. At mean 36.3 ± 26.1-month follow-up, the prior RCR group had statistically worse American Shoulder and Elbow Surgeons score (P < .001), VAS (P = .001), Simple Shoulder Test (P < .001), and active forward elevation (P = .006). Patients with multiple failed RCR attempts (n = 38) before RTSA demonstrated no significant differences versus isolated failed RCR (n = 48; P > .05).ConclusionThis study demonstrated that patients with RTSA after prior failed RCR have significantly worse patient-reported outcomes and greater rate of perioperative complications than patients undergoing primary RTSA for CTA.     

Joint Recommendations for Reporting Carotid Ultrasound Investigations in the United Kingdom

At present in the United Kingdom a number of different criteria are used to grade disease in carotid ultrasound investigations. One main cause of this has been the difference in the method of grading angiograms used in the NASCET and ECST large carotid surgery trials. It is desirable that all centres reporting carotid ultrasound investigations report to the same standard. This paper presents recommendations for the reporting of ultrasound investigations of the extra cranial arteries produced by a Joint Working Group formed between the Vascular Society of Great Britain and Ireland, and the Society for Vascular Technology of Great Britain and Ireland. The recommended criteria are based on the NASCET method of grading carotid bulb disease. Key recommendations include recording peak systolic velocity (PSV) and end-diastolic velocity (EDV) in both internal and distal common carotid arteries; measuring all velocities at a Doppler angle of 45–60°; the use of internal carotid PSV of >1.25 ms^?1 and >2.3 ms^?1 and a Peak Systolic Velocity Ratio of >2 and >4 to indicate >50% and >70% stenosis respectively; and the use of the St Mary's Ratio to grade >50% stenoses in deciles. General recommendations are also given for the acquisition, interpretation and reporting of the data.     

Identifying the High-risk Patient with Clinically Relevant Embolisation After Carotid Endarterectomy

ObjectivesSustained embolisation after carotid endarterectomy (CEA) predicts an increased risk of stroke due to post-operative carotid thrombosis (POCT). Progression towards stroke can be prevented by transcranial Doppler (TCD) directed intravenous Dextran therapy. However, TCD monitoring is extremely labour intensive. The aim of this study was to see whether a small cohort of high-risk patients could be identified following a 30-min period of monitoring in the Recovery Area of the operating theatre so as to reduce the overall burden of monitoring for the majority of patients.MethodsRetrospective audit of prospectively acquired data in 821 patients with an accessible temporal window who had undergone 3 h of TCD monitoring after CEA. Patients with >25 emboli in any 10 min period or large emboli distorting the waveform received Dextran.ResultsGroup 1: 694 patients (85%) with ≤10 emboli detected within the first 30 min in the Recovery Area of the operating theatre. Recovery: None required Dextran, none suffered a proven ischaemic stroke and none were re-explored. Group 2: 127 patients (15%) with 11+ emboli detected. Overall, 26 (20%) required Dextran (54% had the dose increased to control excessive embolisation), none suffered a stroke due to POCT, but 2 suffered embolic strokes despite Dextran. Both, however, had mitigating reasons why optimal Dextran doses could not be administered.ConclusionsTCD directed Dextran has abolished stroke due to POCT. A high-risk cohort of patients requiring Dextran can be identified by measuring the magnitude of embolisation in the first 30 min in Theatre Recovery. The vast majority of patients (85%) require no further monitoring.     

Performance of colposcopy in five sub-Saharan African countries

Objective  The performance of colposcopy provided in a screening study in five African countries was evaluated.
Design  Cross-sectional study.
Setting  Burkina Faso, Congo Brazzaville, Guinea Conakry, Mali and Niger.
Population  Women aged 25–59 years.
Methods  A total of 29 294 women participated in a cervical screening study in the five study sites, and newly trained local doctors performed colposcopy and directed biopsies as indicated. Using meta-analytical tools, four measures of colposcopy performance at different thresholds of colposcopic abnormalities were assessed. Sources of heterogeneity were also assessed.
Main outcome measures  Proportions of women receiving biopsies, adequate biopsies and women diagnosed with cervical intraepithelial neoplasia (CIN).
Results  Among 28 553 women with satisfactory colposcopy, 3101 had a colposcopic diagnosis of probable low-grade or worse lesions and 1128 probable high-grade or worse lesions. Overall, the measures that reached the set standards were proportion of biopsy taken at colposcopy threshold of probable high-grade or worse lesions (95%, 95% CI 90–100%) and proportion of adequate biopsy samples. The set standards were not met for the proportions of women diagnosed with CIN at different colposcopic abnormality thresholds. Detection of CIN2 or worse lesions increased with increasing colposcopic abnormality.
Conclusions  The performance of colposcopy in some of the African sites studied was comparable to that previously observed in other studies. With appropriate training, monitoring, continuing practice and quality assurance, adequate standards of colposcopy can be attained in sub-Saharan Africa.