Long-term rates of bladder dysfunction after decompression in patients with cauda equina syndrome

BACKGROUND CONTEXTCauda equina syndrome (CES) occurs due to compression of the lumbar and sacral nerve roots and is considered a surgical emergency. Although the condition is relatively rare, the associated morbidity can be devastating to patients. While substantial research has been conducted on the timing of treatment, the literature regarding long-term rates of bladder dysfunction in CES patients is scarce.PURPOSEThe aim of this study was to identify long-term rates of bladder dysfunction in CES patients and to compare those rates to non-CES patients who underwent similar spinal decompression.STUDY DESIGN/SETTINGRetrospective database study.PATIENT SAMPLEThe CES cohort was comprised of 2,362 patients who underwent decompression surgery following CES diagnosis with a 5-year follow-up. These patients were matched to 9,448 non-CES control patients who underwent spinal decompression without a diagnosis of CES.OUTCOME MEASURESDiagnosis of bladder dysfunction, surgical procedure to address bladder dysfunctionMETHODSUsing the national insurance claims database, PearlDiver, CES patients who underwent decompression surgery were identified and 1:4 matched to non-CES patients who underwent similar spinal decompression surgery. The 1-year, 3-year, and 5-year rates of progression to a bladder dysfunction diagnosis and surgical intervention to manage bladder dysfunction were recorded. The CES and non-CES groups were compared with univariate testing, and an analysis of risk factors for bladder dysfunction was performed with multivariate logistic regression analysis.RESULTSA total of 2,362 CES patients who underwent decompression surgery were identified and matched to 9,448 non-CES control patients. After 5 years, CES patients had a 10%–12% increased absolute risk of continued bladder dysfunction and a 0.7%–0.9% increased absolute risk of undergoing a surgical procedure for bladder dysfunction, as compared to matched non-CES patients. Multivariate analysis controlling for age, sex, obesity, tobacco use, and diabetes, identified CES as independently associated with increased 5-year risk for bladder dysfunction diagnosis (odds ratio [OR]: 1.72; 95% confidence interaval [CI] 1.56–1.89; p<.001) and procedure (OR: 1.40; 95% CI 1.07–1.81; p=.012).CONCLUSIONSUnderstanding the long-term risk for bladder dysfunction in CES patients is important for the future care and counseling of patients. Compared to non-CES patients who underwent similar spinal decompression, CES patients were observed to have a significantly higher long-term likelihood for both bladder dysfunction diagnosis and urologic surgical procedure.     

Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass

BackgroundHiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease–related complications.ObjectivesTo examine the association between concurrent hiatal hernia repair (HHR) and bariatric outcomes.SettingA 2010–2017 U.S. commercial insurance claims data set.MethodsWe conducted a retrospective cohort study. We identified adults who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) alone or had bariatric surgery concurrently with HHR. We matched patients with and without HHR and followed patients up to 3 years for incident abdominal operative interventions, bariatric revisions/conversions, and endoscopy. Time to first event for each outcome was compared using multivariable Cox proportional hazards modeling.ResultsWe matched 1546 SG patients with HHR to 3170 SG patients without HHR, and we matched 457 RYGB patients with HHR to 1156 RYGB patients without HHR. A total of 73% had a full year of postoperative enrollment. Patients who underwent concurrent SG and HHR were more likely to have additional abdominal operations (adjusted hazard ratio [aHR], 2.1; 95% CI, 1.5–3.1) and endoscopies (aHR, 1.5; 95% CI, 1.2–1.8) but not bariatric revisions/conversions (aHR, 1.7; 95% CI, .6–4.6) by 1 year after surgery, a pattern maintained at 3 years of follow-up. Among RYGB patients, concurrent HHR was associated only with an increased risk of endoscopy (aHR, 1.4; 95% CI, 1.1–1.8)) at 1 year of follow-up, persisting at 3 years.ConclusionsConcurrent SG/HHR was associated with increased risk of some subsequent operative and nonoperative interventions, a pattern that was not consistently observed for RYGB. Additional studies could examine whether changes to concurrent HHR technique could reduce risk.     

Cognitive, language and social-cognitive skills of individuals with fragile X syndrome with and without autism

Background It is not known whether those with co‐morbid fragile X syndrome (FXS) and autism represent a distinct subtype of FXS; whether the especially severe cognitive delays seen in studies of young children with co‐morbid FXS and autism compared with those with only FXS continue into adolescence and young adulthood; and whether autism in those with FXS is ‘true autism’, i.e. reflects the same underlying problems as idiopathic autism. Method We compared the non‐verbal IQ of adolescents and young adults with co‐morbid FXS and autism (n = 10) with those with only FXS (n = 44). We then created a subsample of those with FXS only, matched on non‐verbal IQ, mental age and gender (n = 21) to the subsample of those with co‐morbid FXS and autism. We compared the two groups on measures of expressive language, receptive language (lexical, grammatical morphology and syntactic patterns), and a theory of mind task. Results Those with co‐morbid FXS and autism had lower non‐verbal IQs than those with only FXS. The participants with co‐morbid FXS and autism did not perform as well as the cognitive ability‐ and gender‐matched participants with only FXS on the three measures of receptive language or the theory of mind task; there were no differences on the expressive language measure. Conclusions Our findings support the notion that those with co‐morbid FXS and autism represent a distinct subtype of FXS, with more impairment in receptive language and theory of mind even when controlling for their lower non‐verbal IQ relative to those with only FXS. The greater cognitive impairments observed in those with co‐morbid FXS and autism continues into adolescence and young adulthood; and the autism seen in those with FXS appears to be the same as idiopathic autism.     

Estrogen–BDNF interactions: Implications for neurodegenerative diseases

Since its’ discovery over 20 years ago, BDNF has been shown to play a key role in neuronal survival, in promoting neuronal regeneration following injury, regulating transmitter systems and attenuating neural-immune responses. Estrogen’s actions in the young and mature brain, and its role in neurodegenerative diseases in many cases overlaps with those observed for BDNF. Reduced estrogen and BDNF are observed in patients with Parkinson’s disease and Alzheimer’s disease, while high estrogen levels are a risk factor for development of multiple sclerosis. Estrogen receptors, which transduce the actions of estrogen, colocalize to cells that express BDNF and its receptor trkB, and estrogen further regulates the expression of this neurotrophin system. This review describes the distribution of BDNF and trkB expressing cells in the forebrain, and the roles of estrogen and the BDNF–trkB neurotrophin system in Parkinson’s disease, Alzheimer’s disease and multiple sclerosis.     

Knee arthroscopy and driving. Results of a prospective questionnaire survey and review of the literature

Orthopaedic surgeons routinely advise patients when to drive after surgical procedures. There are however very few guidelines concerning the return to driving after an orthopaedic operation. We performed a literature search and found very limited studies or research regarding this topic and in particular following arthroscopic surgery. We subsequently conducted a prospective questionnaire survey from one hundred knee arthroscopy patients attending outpatient follow-up clinics. Results showed the advice given to patients was delivered by doctors of differing levels of experience, but interestingly the majority of patients did not know the grade of doctor they were being consented by. Our study has highlighted that the advice given to patients was inconsistent. Patients returned to driving over a variety of time frames from one day to greater than three weeks. No adverse events were reported but 14% chose not to answer this question. We have illustrated the need for thorough consenting, further research in this area, and the development of universal guidelines surrounding the return to driving after surgery.     

Risk Factors for Infection after 46,113 Intramedullary Nail Operations in Low- and Middle-income Countries

Background

The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.

Methods

The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis.

Results

The overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country.

Conclusions

The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.     

Minimum depths to essential structures in a UK military population using computed tomography: application to stab-resistant body armour

International Journal of Legal Medicine - Edged weapons are a known domestic threat to the police forces of the UK. This threat is mitigated by wearing stab-resistant body armour that is either...     

Variation and trends in reasons for knee replacement revision: a multi-registry study of revision burden

Background and purpose — Studies describing time-related change in reasons for knee replacement revision have been limited to single regions or institutions, commonly analyze only 1st revisions, and may not reflect true caseloads or findings from other areas. We used revision procedure data from 3 arthroplasty registries to determine trends and differences in knee replacement revision diagnoses.Patients and methods — We obtained aggregated data for 78,151 revision knee replacement procedures recorded by the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) for the period 2003–2017. Equivalent diagnosis groups were created. We calculated the annual proportions of the most common reasons for revision.Results — Infection, loosening, and instability were among the 5 most common reasons for revision but magnitude and ranking varied between registries. Over time there were increases in proportions of revisions for infection and decreases in revisions for wear. There were inconsistent proportions and trends for the other reasons for revision. The incidence of revision for infection showed a uniform increase.Interpretation — Despite some differences in terminology, comparison of registry-recorded revision diagnoses is possible, but defining a single reason for revision is not always clear-cut. There were common increases in revision for infection and decreases in revision for wear, but variable changes in other categories. This may reflect regional practice differences and therefore generalizability of studies regarding reasons for revision is unwise.

Although the survivorship of knee arthroplasty has improved over the last 15 years, the increased volume of primary knee replacement has led to growing numbers of revision procedures (Kumar et al. 2015, Patel et al. 2015). A prior study we undertook outlined changes in the volume and incidence of revision rates in Sweden, Australia, and the Kaiser Permanente registry from the USA (Lewis et al. 2020b).Factors influencing revision change with time. Patient factors may affect the rate of primary procedures, such as rising patient and surgeon acceptance of knee replacement (Hamilton et al. 2015), increasing rates of osteoarthritis (Hunter and Bierma-Zeinstra 2019), growing use in younger patients (Leyland et al. 2016, Karas et al. 2019), and also survivorship, such as longer life expectancy, increasing obesity, and higher physical activity of those receiving a replacement (Hamilton et al. 2015). In addition, prosthesis designs change to improve perceived shortcomings such as wear, instability, and patellofemoral pain and tracking (Lewis et al. 2020a). Methods to improve surgical precision, such as computer navigation (Jones and Jerabek 2018), image-derived instrumentation (Kizaki et al. 2019), and robotic assistance (Jacofsky et al. 2016) may decrease revision requirements (Price et al. 2018)These changing factors alter the reasons for revision. Previous studies observed a decrease in revisions for wear and loosening (Sharkey et al. 2014, Thiele et al. 2015), and related this to improved prosthesis design and materials. Other studies note infection is now the most common reason for revision (Koh et al. 2017, Postler et al. 2018). Studies of changing knee replacement failure modes are limited by being derived from single institutions or regions and may not accurately reflect what is occurring elsewhere (Sharkey et al. 2014, Thiele et al. 2015, Dyrhovden et al. 2017, Koh et al. 2017, Lum et al. 2018, Postler et al. 2018). Additionally, these studies do not show the true revision burden as they are restricted to 1st revision procedures, or only revisions of previous total knee replacements (TKR), and do not include revisions of partial knee replacement procedures.Combining registry data can be difficult due to inconsistency in the definition of revision (Liebs et al. 2015), and lack of consensus in defining modes of failure, with different terminologies used (Niinimaki 2015, Siqueira et al. 2015). Some have attempted to overcome this by defining equivalent diagnoses (Havelin et al. 2011, Paxton et al. 2011, Rasmussen et al. 2016).We determined variations and trends in reasons for knee replacement revision using data on all knee arthroplasty revision procedures from the national registries of Sweden and Australia and the institutional registry of Kaiser Permanente in the USA by using equivalent diagnosis groups (Table 1, see Supplementary data).