Mortality After Revision Total Hip Arthroplasty

BackgroundIn counseling patients about the complications of revision total hip arthroplasty (revTHA), it is imperative that mortality be considered. The actual mortality rate by indication of revision is ill-defined. The purpose of this study is to determine the mortality rate after revTHA.MethodsAn institutional database identified 596 patients who had undergone revTHA between 2012 and 2018. Medical records, national, state, and local death indexes were queried for mortality status and indication for revTHA. For survivors, the last clinical visit date was used for censoring in the mortality analysis. Mortality rates were calculated for all clinical patients and then by specific indication for revision.ResultsThe overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 or 1 in 51 patients. Patients presenting with a periprosthetic fracture had a significantly higher 2-year mortality rate of 74.5 deaths per 1000 or 1 in 13 patients (P < .001), while an indication of dislocation or instability had a slightly higher 2-year mortality rate of 50.3 per 1000 (1 in 20) but this difference was not significant (P = .531). Other indications such as mechanical loosening or infection did not have a significantly different mortality rate.ConclusionThe overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 which was largely attributed to patients with a periprosthetic fracture (74.5 per 1000) with other indications not significantly impacting mortality. Mortality rates and specific rates by indication for revision should be considered when counseling patients prior to revTHA.     

Low-Dose ATG/GCSF in Established Type 1 Diabetes: A Five-Year Follow-up Report

Previously, we demonstrated low-dose antithymocyte globulin (ATG) and granulocyte colony-stimulating factor (GCSF) immunotherapy preserved C-peptide for 2 years in a pilot study of patients with established type 1 diabetes (n = 25). Here, we evaluated the long-term outcomes of ATG/GCSF in study participants with 5 years of available follow-up data (n = 15). The primary end point was area under the curve (AUC) C-peptide during a 2-h mixed-meal tolerance test. After 5 years, there were no statistically significant differences in AUC C-peptide when comparing those who received ATG/GCSF versus placebo (P = 0.41). A modeling framework based on mean trajectories in C-peptide AUC over 5 years, accounting for differing trends between groups, was applied to recategorize responders (n = 9) and nonresponders (n = 7). ATG/GCSF reponders demonstrated nearly unchanged HbA_1c over 5 years (mean [95% CI] adjusted change 0.29% [–0.69%, 1.27%]), but the study was not powered for comparisons against nonresponders 1.75% (–0.57%, 4.06%) or placebo recipients 1.44% (0.21%, 2.66%). These data underscore the importance of long-term follow-up in previous and ongoing phase 2 trials of low-dose ATG in recent-onset type 1 diabetes.     

Controlled studies of intranasal immunotherapy for ragweed pollenosis

During 1978 a double blind study compared the efficacy of preseasonal short ragweed (RW) extract intranasal immunotherapy with a histamine placebo; in 1979 more prolonged treatment with a larger dose of polymerized ragweed (PRW) was evaluated. In neither year did the placebo-treated patients show significantly more severe disease as assessed by daily symptom diaries, examination in season, comparison of overall symptom severity with previous years or changes in nasal challenge tests. Following treatment in 1979 there was a significantly greater amount of secretory IgA and IgG ragweed antibodies secreted by the nose of the PRW-treated group, but these titers did not correlate with clinical results.     

Costs of terminal care for people with AIDS

Despite the numerous studies on the costs of AIDS, little has been reported on the economic costs for terminal care. This study reports on the average monthly costs of care used in the last 6 months of life by a group of people with AIDS between 1984 and 1990. Hospital and outpatient visits, laboratory results, and medications were evaluated for all subjects. Standard costs (1990 dollars) were applied to all services. The 81 subjects received care in a large private medical practice located in northern California. The group was primarily male (98 percent), white (87 percent), and gay or bisexual (89 percent). Mean age at diagnosis of AIDS was 40.8 (SE = 1.1). Patients averaged a total of 2.9 (SE = 0.2) opportunistic infections (OIs) from the diagnosis of AIDS to death. Median survival was 13.2 months. The primary outcome measures were the components of the costs of terminal care: inpatient visits and outpatient costs. Covariates include location of death, year of death, and OIs. Average monthly terminal care resources included 8.3 days of in-hospital care, $8258 in costs for inpatients care, $840 in outpatient costs, and $9098 in total costs. Death at home increased in frequency (from 20 percent for 1984-1987 to 37 percent for 1987-1990). However, costs in the last 6 months of life did not change significantly as costs for patients who died in the hospital decreased and costs for patients who died at home increased over time. Policies that promote dying at home, while likely to affect patient quality of life, may not lower health care costs.     

A strategy for reducing maternal mortality

A confidential system of enquiry into maternal mortality was introduced in Malaysia in 1991. The methods used and the findings obtained up to 1994 are reported below and an outline is given of the resulting recommendations and actions.     

A large animal model of bladder exstrophy: observations of bladder smooth muscle and collagen content

PURPOSE: The development of adequate bladder capacity is not ensured in all patients with bladder exstrophy despite successful bladder closure and reconstruction. To determine the factors leading to the development and maturation of the exstrophic bladder we created a large animal model of exstrophy. We compared biopsies obtained from a cohort of experimentally induced exstrophic neonatal sheep bladders to those of normal control bladders and related the findings to a previously reported comparison of human neonatal normal and exstrophic bladders. MATERIALS AND METHODS: Bladder specimens of 7 newborn lambs with experimentally induced exstrophy were compared to specimens of 10 newborn control lamb bladders. All specimens were stained with Masson's trichrome as well as with specific monoclonal antibodies to types I and III collagen. Stained sections were then analyzed using a morphometric image analysis system to quantify the amounts of smooth muscle and collagen present. RESULTS: A significant increase in the ratio of collagen-to-smooth muscle was noted in exstrophic versus normal control bladders (p <0.05). This difference was similar to that in the previous study of neonatal human bladders. There was no significant difference in the ratios of types I and III collagen in the 2 groups of sheep bladders. This finding is different from that reported in the previous human studies. CONCLUSIONS: Overall changes in the ratio of smooth muscle-to-collagen in the sheep exstrophy model are similar to those in humans. However, the differences in collagen types I and III do not seem to be present.     

Paget disease of the male breast.

Twenty-two fully documented cases of Paget disease of the male breast are reviewed, and an additional patient is reported. The most common initial symptom was ulceration and excoriation, while a breast mass was palpable in the majority of patients. Nipple changes were surprisingly rare, in contrast to the female. The prognosis of the disease in the male appears to be worse than in the female, with the Paget carcinoma carrying a worse prognosis than the "ordinary" male breast cancer. The subareolar location and the meager volume of tissue interposed between the tumor and chest wall may be an important factor in this regard. Nipple changes or symptoms (ulceration, discharge, enlargement) are mroe apt to be due to cancer in the male than in the female. Therefore, prompt diagnosis is mandatory.