Preoperative Risk Factors for Postoperative Urinary Tract Infection After Primary Total Hip and Knee Arthroplasties

BackgroundEstablishing clear risk factors for complications such as urinary tract infection (UTI) after arthroplasty procedures helps guide clinical practice and provides more information to both surgeons and patients. This study aims to assess selected preoperative patient characteristics as risk factors for postoperative UTI after primary total hip and knee arthroplasties (THA and TKA).MethodsThis was a retrospective analysis using current procedural terminology codes to investigate the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified for UTI by NSQIP guidelines. Patient samples with all possible covariates were included for multivariate logistic regression analysis and assessed for independent associations.ResultsIn a cohort of 983 identified patients (983 of 119,096; 0.83%): ages 57+ years, preoperative red blood cell (RBC) transfusion, perioperative RBC transfusion, bleeding disorders, operative time 110+ minutes, preoperative steroid use, diabetes, pulmonary comorbidities, body mass index 30+ kg/m² were independent risk factors for postoperative UTI after THA. In a cohort of 1503 identified patients (1503 of 189,327; 0.8%): ages 60+ years, preoperative RBC transfusion, perioperative RBC transfusion, anemia, platelets less than 150k, preoperative steroid use, diabetes, and body mass index 30+ kg/m² were independent risk factors for postoperative UTI after TKA. Male sex was associated with a decreased risk of UTI in both THA and TKA.ConclusionThis study provides novel evidence on risk factors associated with the development of UTI after THA or TKA. Clinicians should be aware of risk factors in the manifestation of postoperative UTI after primary THA or TKA procedures.     

Factors Associated With Early Return to Driving Following Total Joint Arthroplasty

BackgroundPatients often ask when they can safely return to driving a car following total joint arthroplasty (TJA). Most prior research has relied on driving simulators. Our study sought to learn more about real-world patient experiences in returning to driving after total knee arthroplasty (TKA) or total hip arthroplasty (THA).MethodsOur institutional total joint registry was used to identify living patients aged 18-85 who underwent primary TKA or primary THA for a primary diagnosis of osteoarthritis between January 1, 2019 and December 31, 2019. Patients who had undergone multiple TJA operations in 2019 or had a primary mailing address outside of the United States were excluded. Ultimately 2508 eligible TJA patients received a survey by mail.ResultsA total of 1128 of 2508 eligible patients (45%) completed surveys and returned them by mail. After 121 surveys were discarded for incompletion, inconsistency, or limited preoperative driving volume, 1007 patients were included in our study. Among these patients, 99% returned to driving postoperatively, with 23% returning within 2 weeks, and 88% returning within 6 weeks. Factors associated with the odds of a patient returning to driving within 2 weeks included laterality, gender, postoperative confidence, postoperative comfort, and surgeon advice. Ten patients (1%) have been involved in a car accident postoperatively.ConclusionAlmost all patients returned to driving postoperatively without being involved in a car accident. Gender, laterality, patient confidence, and comfort as well as surgeon advice were significantly associated with the odds of a patient returning to driving within 2 weeks postoperatively.     

A comparison of postoperative respiratory complications associated with the use of desflurane and sevoflurane: a single-centre cohort study

Sevoflurane and desflurane are the most commonly used volatile anaesthetics for maintenance of anaesthesia. In this study, we aimed to evaluate the relationship between choice of volatile anaesthetic and early postoperative respiratory complications, and to address a critical knowledge gap in safety outcomes between these two commonly used agents. We performed a retrospective analysis of adult (non-cardiac surgery) patients who received sevoflurane or desflurane for the maintenance of general anaesthesia at our institution between 2005 and 2018. We evaluated the association between desflurane exposure (when compared with sevoflurane) and the primary outcome of postoperative respiratory complications, defined by early post-extubation desaturation (S_pO₂ < 90%) or re-intubation within 7 days postoperatively. Multivariable regression analyses were performed and adjusted for confounding factors, including patient, anaesthetic and surgical factors. Propensity matched, interaction and sub-group analyses were performed to assess outcomes in high-risk groups: morbidly obese (BMI > 35 kg.m⁻²); elderly (age > 65 years); and high risk of respiratory complications as well as the primary outcome at 24 h. Desflurane was used for 23,830 patients and sevoflurane for 84,608 patients. Patients exposed to desflurane did not demonstrate a reduced risk of postoperative respiratory complications when compared with sevoflurane (adjusted odds ratio 0.99, 95%CI 0.94–1.04, p = 0.598). These findings were consistent across all sub-groups of high-risk patients and in the propensity score matched cohort. In summary, desflurane use was not associated with reduced postoperative respiratory complications when compared with sevoflurane. In the context of environmental and cost concerns with volatile anaesthetic agents, our study provides important data to support organisational decisions regarding the use of desflurane.     

Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis

Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side-effects. We undertook a systematic review, meta-analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0–10) at 8–12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty-nine trials including 1814 patients were identified. Rest pain score at 8–12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of −1.7 (−2.0 to −1.3), p < 0.0001 (19 trials; 1420 patients; high-quality evidence), without sub-group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3–1.6), p < 0.0001 (24 trials; 1603 patients; high-quality evidence). However, a sub-group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub-group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5–1.7), p = 0.78 (16 trials; 1173 patients; high-quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a ‘ceiling’ dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting.     

Value of preoperative urine white blood cell and nitrite in predicting postoperative infection following percutaneous nephrolithotomy: a meta-analysis

BackgroundTo evaluate to what degree preoperative urine white blood cell (WBC) and urine nitrite (NIT) values are predictive of postoperative infections following percutaneous nephrolithotomy (PCNL).MethodsA systematic literature search was performed of the PubMed, Embase, Cochrane Library, Wanfang Data, National Knowledge Infrastructure (CNKI), and China Science and Technology Journal Database (CSTJ or VIP) online databases to identify relevant studies that examined the predictive value of urine WBC or NIT as risk factors for post-PCNL infection, and the search was finished on February 28, 2020. Two independent reviewers screened the relevant studies, extracted necessary data from the eligible case-control studies (CCS), and assessed the quality of included studies through the Newcastle-Ottawa scale (NOS). RevMan 5.3 software and the Stata 16.0 software were used to complete the statistical analysis of data. Results are expressed as odds ratio (OR) with 95% confidence intervals (CIs).ResultsAccording to the statistical analysis of 12 eligible studies involving 6113 patients, positive urine WBC (WBC+: OR =3.86, 95% CI: 3.03–4.91, P<0.001) and positive NIT (NIT⁺: OR =7.81, 95% CI: 5.44–11.21, P<0.001) in preoperative tests were identified as independent risk factors for postoperative infections following PCNL.ConclusionsIn summary, as risk factors for postoperative infections, the presence of preoperative urine WBC+ and NIT+ should be evaluated as part of clinical procedure, in order to reduce infections of PCNL.     

Clinical pharmacokinetics of intravenous and oral 9-amino-1,2,3,4-tetrahydroacridine,tacrine

Summary The pharmacokinetics of 9-amino-1,2,3,4-tetrahydroacridine; tacrine, THA, was studied after intravenous administration and following the first and last oral doses of a seven week clinical trial involving 8 patients with amyotrophic lateral sclerosis, ALS. Two surgical patients given intravenous THA for reversal of postoperative sedation were also included. Plasma concentration of THA and in some cases the metabolite, 1-hydroxy-THA, were assayed using a selective and sensitive method with high performance liquid chromatography.After an intravenous dose of 30 mg THA, the plasma concentrations were fitted to a two-compartment model. Plasma clearance showed a threefold interindividual variation with a mean of 2.42 l·h^–1. Volume of distribution, V varied 100–680 l with a mean of 349 l. The plasma half-lives of distribution and elimination were 1.8 and 98.2 min, respectively. Oral bioavailability showed large interindividual differences and ranged 6–36% in the four subjects studied.After seven weeks treatment with oral THA, plasma concentrations immediately prior to medication were below 10 ng/ml in three patients and above 100 ng/ml in two patients. At the same occasion the plasma metabolite concentrations considerably exceeded those of THA. THA medication was associated with side effects in the majority of the patients.     

颅咽管瘤切除术后常见并发症的处理

目的：研究颅咽管瘤术后的常见并发症及其相应的防治措施。方法：分析110例颅咽管瘤手术后所出现的各种并发症,探讨其产生的原因并总结临床处理过程中的体会。结果：颅咽管瘤切除术后并发症的发生与肿瘤切除程度和术中垂体柄、下丘脑等的受损状况有关。尿崩、高热、水电解质平衡失调和癫痫是颅咽管瘤术后最常见的并发症,其发生率分别为79.1%、47.3%、88.2%和17.3%。结论;耐心细致的术中显微外科操作和严格规范化的术后管理对降低颅咽管瘤术后病残率,提高其术后生存率具有十分重要的临床意义。