Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty

Background

Whether prolonged operative time is an independent risk factor for subsequent surgical site infection (SSI) and periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant and underexplored issue. The aim of this study is to investigate the association between operative time and the risk of subsequent SSI and PJI in patients undergoing primary TJA.

Blood Biochemical Profiles of Thai Indigenous and Simmental × Brahman Crossbred Cattle in the Central Thailand

Plasma biochemical profiles were studied in 112 mature (3 to 5‐year‐old) healthy cattle comprised of 61 Thai indigenous and 51 Simmental × Brahman crossbred male and cyclic female cattle at Nongkwang (Central Thailand) Livestock Research and Breeding Center, Thailand. Data were analysed for the effect of breed and sex. The results showed that the plasma glucose and gamma‐glutamyl transferase (GGT) in the two breeds were significantly (P < 0.05) different. Furthermore, the urea, creatinine, albumin, total protein, aspartate amino transferase (AST), alanine amino transferase (ALT) and alkaline phosphatase (ALP) levels in Thai indigenous were significantly (P < 0.01) higher than in crossbred cattle. However, creatine kinase did not significantly differ in crossbred and indigenous animals. A sex difference was found in glucose level with male Thai indigenous having significantly higher levels (P < 0.05) than the other three groups. Plasma urea concentration in male crossbred cattle was lower than in the other groups (P < 0.05). Female crossbred cattle had significantly (P < 0.05) lower plasma creatinine levels than the other animals. Furthermore, levels of albumin in male and total protein in female crossbred were the lowest (P < 0.05) among the groups. The AST, ALT, ALP and GGT levels were significantly (P < 0.05) different between male and female. Female crossbred cattle had the lowest (P < 0.05) AST and GGT levels, whereas lowest (P < 0.05) ALT and ALP concentration was determined in male individuals of these breeds.     

Pathological laughter and crying in patients with multiple system atrophy-cerebellar type.

In the cerebellar type of multiple system atrophy (MSA-C), the burden of pathological changes involves the cerebellum and its associated brainstem structures in the basis pontis and the inferior olivary nucleus, and as a result, the clinical phenotype is dominated early on by the cerebellar dysfunction. We report our clinical and post mortem findings in a patient with MSA-C who exhibited pathological laughter in the absence of any congruent changes of mood. A review of the clinical notes of 27 other patients with MSA-C revealed a problem with pathological laughter, or crying, or both in 9 more patients. Our finding of about 36% occurrence suggests that the problem of dysregulation of emotional expression is more prevalent in MSA-C than the paucity of reports in the literature suggests. Our findings are consistent with the view that the cerebellum and its interconnected structures may be involved in the regulation of emotional expression.     

Ontogenetic development of proenkephalin A and proenkephalin B messenger RNA in fetal pigs

Summary Using solution hybridization analysis and Northern blotting with complementary RNA probes labelled to high specific activity, levels of proenkephalin A and B mRNA were analyzed throughout prenatal development in the hippocampus and striatum of fetal pigs. A differential time course for the appearance of these opioid precursor mRNAs was observed: in hippocampus, both mRNAs increased linearly throughout development with proenkephalin B mRNA increasing faster than proenkephalin A mRNA. In striatum, both mRNAs behaved similarly, increasing to a maximum level around mid-gestation and declining thereafter. The differences might be attributed to differential localization of the two precursor systems in the tissues and might be of functional relevance.Abberviations PENK A, PENK B Proenkephalin A, B - mRNA Messenger Ribonucleic Acid - cRNA Complementary RNA     

Prior Pelvic Osteotomy Affects the Outcome of Subsequent Total Hip Arthroplasty

BackgroundAlthough pelvic osteotomy (PO) is an important surgical procedure that can alleviate symptoms and potentially slow progression of osteoarthritis in patients with development dysplasia of the hip, some patients eventually require conversion to total hip arthroplasty (THA). This study aimed to determine the outcome of conversion THA in patients with prior PO.MethodsForty nine patients with a history of prior PO who underwent conversion THA at a single institution were matched at a 1:3 ratio based on the date of surgery, age, gender, and body mass index with 147 developmental dysplasia of the hip patients who underwent primary THA without prior PO. A retrospective chart review was performed to compare outcomes at a minimum follow-up of 2 years.ResultsPatients with prior PO required more supplemental screw fixation for the acetabular component (59.2% vs 38.1%, P = .016), more autologous bone grafting (24.5% vs 11.6%, P = .048), had a longer mean operative time (106.0 vs 79.8 minutes, P < .001), and greater estimated blood loss (350.0 vs 206.8 mL, P = .015). Patients with prior PO had smaller cup version angle (26.0° vs 29.0°, P = .012) and greater discrepancy in the limb length (10.3 vs 7.26 mm, P = .041). Eight hips (16.3%) with prior PO and 6 (4.1%) without osteotomy required reoperation (P = .008). There was no difference in outcome scores at the latest follow-up.Conclusion: THA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.ConclusionTHA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.     

Risk of Gastrointestinal Bleeding With Extended Use of Nonsteroidal Anti-Inflammatory Drug Analgesia After Joint Arthroplasty

BackgroundChronic nonsteroidal anti-inflammatory drug (NSAID) use is associated with gastrointestinal bleeding via inhibition of endogenous mucosal protection and platelet aggregation. This study aimed to determine whether extended NSAIDs after joint arthroplasty is associated with increased risk of gastrointestinal bleeding.MethodsThis was a retrospective study examining 28,794 adults who underwent joint arthroplasty by one of 50 surgeons from 2016 to 2018. Episodes of gastrointestinal bleeding within 90 days postoperatively were identified prospectively. Postoperative medications were reported directly by patients with electronic questionnaires. The primary analysis was performed using binary logistic regression.ResultsA total of 74 (0.26%) episodes of gastrointestinal bleeding occurred within 90 days (median 8 days) postoperatively. Of 5086 patients with complete data included in the primary analysis, 59.6% had used NSAIDs with median duration of 2 weeks (interquartile range, 0-6 weeks). Patients with gastrointestinal bleeding were significantly older (71.3 vs 67.0 years), required longer hospitalizations (2.1 vs 1.5 days), and more commonly had a history of peptic ulcers (10.8% vs 0.9%). However, there was no positive association between NSAID use and gastrointestinal bleeding. In fact, the odds of gastrointestinal bleeding were lower in patients taking NSAIDs. Gastrointestinal bleeding was associated with anticoagulants, antiplatelet agents, and, to a lesser extent, aspirin.ConclusionNSAIDs were not associated with gastrointestinal bleeding and may be prescribed safely for a majority of patients after joint arthroplasty. The greatest odds of gastrointestinal bleeding occurred in patients with peptic ulcer disease and those who received antiplatelet and anticoagulation agents. Increasing age and bilateral surgery were also associated with gastrointestinal bleeding.Level of EvidenceLevel III.     

The Frank Stinchfield Award. Sudden death during primary hip arthroplasty

The records of 23 patients who died intraoperatively during hip arthroplasty at the authors' institution were reviewed. Of the 38,488 hip arthroplasties in 29,431 patients performed between 1969 and 1997, there were 23 deaths during surgery. There were 15 women and eight men with a mean age of 80.9 years. Preoperative diagnoses were acute hip fracture (13 patients), pathologic fracture (four patients), femoral neck nonunion (one patient), osteoarthritis (four patients), and rheumatoid arthritis (one patient). Eleven patients undergoing cemented total hip arthroplasty died and 12 patients undergoing cemented hemiarthroplasty died. All deaths occurred because of irreversible cardiorespiratory disturbances that were initiated during cementing. There were no deaths among 12,551 patients receiving 15,411 uncemented hip arthroplasties during the 28-year period under review. Autopsy was performed in 13 patients. Bone marrow microemboli were seen in the lungs of 11 of 13 patients in whom an autopsy was performed and methylmethacrylate particles were seen in the lungs of three of 13 patients. These data suggest that elderly patients with preexisting cardiovascular conditions undergoing cemented arthroplasty, especially for fracture diagnosis, are at increased risk for intraoperative death compared with patients undergoing elective hip arthroplasty. In the latter years of the current study, modifications of the operative techniques designed to minimize intramedullary hypertension were associated with a reduction greater than three-fold in overall intraoperative mortality rate. These changes in surgical technique should be considered when cement fixation is used in patients thought to be at risk for having cardiopulmonary disturbances develop from venous embolization of marrow contents.     

High infection frequency,low diversity of Leishmania major and first detection of Leishmania turanica in human in northern Iran

Smears of suspected patients infected with zoonotic cutaneous leishmaniasis (ZCL) were stained and examined under a light microscopic observation. DNA of parasites within human ulcers was extracted directly from their smears. Nested PCR was used to amplify a fragment containing the internal transcribed spacers of the ribosomal RNA genes (ITS-rDNA) of Lesihmania parasites in human from Turkemen Sahara located in the northeastern part of Iran. Based on RFLP method by digesting BsuRI restriction enzyme and more precisely sequencing of DNA ITS-rDNA was shown to be species-specific. The infection rates of Leishmania parasites were high with 154 (93.9%) infections out of 164 suspected patients using microscopic observations. Only from 128 suspected patients out of 164, ITS-rDNA fragments were amplified and 125 samples had enough DNA to digest BsuRI restriction enzyme and do DNA sequencing. The Nested PCR assays detected not only Leishmania major but also Leishmania turanica for the first time, another parasite of the great gerbil in human. The density of L. major was high but the diversity was low with only 2 haplotypes. The overall ratio of L. major (123 infections) to L. turanica (2 infections) was significantly higher (Chi-squared test: p < 0.05). Infections of L. turanica are not reported only and/or not known to cause human disease. Our analytical framework conveys a clear understanding of both L. major and L. turanica which can only be approved as causative agents of ZCL by more extensive sampling and followed by standardized molecular diagnosis.     

Leukocyte Esterase Versus ICM 2018 Criteria in the Diagnosis of Periprosthetic Joint Infection

BackgroundA leukocyte esterase (LE) test is inexpensive and provides real-time information about patients suspected of periprosthetic joint infections (PJIs). The 2018 International Consensus Meeting (ICM) recommends it as a diagnostic tool with a 2+ cutoff. There is still a lack of data revealing LE utility versus the ICM 2018 criteria for PJI.MethodsThis is a retrospective study of patients who underwent revision total hip and total knee arthroplasty at a single institution between March 2009 and December 2019. All patients underwent joint aspiration before the arthrotomy, and the LE strip test was performed on aspirated joint fluid. PJI was defined using the 2018 ICM criteria.ResultsAs per the 2018 ICM criteria, 78 patients were diagnosed with chronic PJI and 181 were not infected. An LE test with a cutoff of $\ge$1+ had a sensitivity of 0.744, a specificity of 0.906, a positive predictive value of 0.773, an accuracy of 0.825 (95% confidence interval 0.772-0.878), and a negative predictive value of 0.891. The positive likelihood ratio (LR+) was 7.917. Using an LE cutoff of 2 + had a sensitivity of 0.513, a specificity of 1.000, and an accuracy of 0.756 (95% confidence interval—0.812).ConclusionLE is a rapid and inexpensive test which can be performed at the bedside. Its performance is valuable as per ICM criteria. Based on the findings of this study and the given cohort, we suggest using the cutoff of LE1+ (result = negative or trace) as a point of care test to exclude infection, whereas LE at 2 + threshold has near absolute specificity for the diagnosis.