Patient Characteristics, Length of Stay, Cost of Care, and Complications in Super-Obese Patients Undergoing Total Hip Arthroplasty: A National Database Study

Background@#The purpose of this study was to compare postoperative complication rates in super-obese (SO) patients with a body mass index (BMI) ≥ 50 kg/m 2 undergoing total hip arthroplasty (THA) versus non-super-obese (NSO) patients undergoing THA. @*Methods@#In this retrospective study using the National Inpatient Sample (NIS) database, 1,646 cases of THA in SO (BMI ≥ 50 kg/m 2 ) patients were reviewed. We used International Classification of Diseases (ICD)-10 codes to assess postoperative variables including length of stay, cost of care (cost of inpatient hospitalization), and medical and surgical complications among SO patients undergoing THA compared to NSO patients before being discharged. @*Results@#A comparison of demographic variables showed there were more women in both groups and nearly 17.2% of SO patients were diabetic patients, 11.1% of SO patients were tobacco users, and 74.8% of the SO patients were whites (African American, 15.1%; Hispanic, 2.9%). The mean length of stay was 3.43 days in the SO group and 2.32 days in the NSO group, and this difference was statistically significant. The cost of care was $79,784.64 for the SO group, which was significantly higher than $66,821.75 for the NSO group. The SO group also showed higher odds of developing medical complications such as anemia (odds ratio [OR], 1.555; 95% confidence interval [CI], 1.395–1.734; p < 0.001), acute renal failure (OR, 3.375; 95% CI, 2.816–4.045; p < 0.001), pneumonia (OR, 2.319; 95% CI, 1.241–4.331; p = 0.014), and need for blood transfusion (OR, 1.596; 95% CI, 1.289–1.975;p < 0.001). The SO patients also showed a higher risk of several postoperative surgical complications such as periprosthetic fractures, infection, and wound dehiscence. @*Conclusions@#Postoperative complication rates in SO patients were higher than those in the NSO group. Length of stay and cost of care were higher, whereas the mean age was lower for the SO group. Therefore, THA in SO patients should be undertaken only after careful consideration and preferably in a tertiary facility capable of handling all medical and surgical in-hospital complications.

Intra-operative fractures in primary total knee arthroplasty - a systematic review

Background@#One of the rare complications of primary total knee arthroplasty is intra-operative fracture. Intraoperative fracture during revision knee arthroplasty has been well-documented but there is limited literature on fractures occurring during primary knee arthroplasty. We conducted a systematic review of the literature to compare and contrast the various studies to clearly define the predisposing factors, incidence, and characteristics of the fracture itself and to arrive at a consensus on the management and prevention of intra-operative fractures during primary knee arthroplasty. @*Methods@#The PubMed/Medline, Cochrane, Scopus and Embase databases were searched using keywords “intraoperative fracture”, “distal femoral fracture”, “tibial fracture”, “patella fracture” and “primary total knee arthroplasty”. A total of 158 articles were retrieved and after further filtration and exclusion processing, 10 articles that evaluated intra-operative fractures in primary total knee arthroplasty were included for the review. @*Results@#The reported incidence of intra-operative fractures varied from 0.2% to 4.4%. A higher incidence in female patients with a male to female ratio of 0.4 was reported. Posterior stabilized (PS) total knee arthroplasty was associated with higher risk of intra-operative femoral fractures by many authors in this review. Timing of occurrence and location of the intra-operative fractures can vary widely, with femoral fractures occurring more commonly during bone preparation, trialing and impaction of the final implant and tibial fractures occurring during preparation for the tibial keel and impaction of the tibial component. @*Conclusions@#Intra-operative fractures during primary total knee arthroplasty are rare with higher risk associated with osteoporosis, rheumatoid arthritis, advanced age, female gender, chronic steroid use, metabolic bone disorders, PS type of femoral implant and difficult surgical exposure of the knee joint due to severe deformities. A plethora of management options have been utilized according to surgeon preference. Standard principles of fracture fixation and arthroplasty principles should be followed to achieve stable internal fixation and any unstable fracture site should be bypassed with the utilization of stemmed components. Satisfactory radiographic and functional outcome can be expected with appropriate treatment.

Does Second-Generation Suspensory Implant Negate Tunnel Widening of First-Generation Implant Following Anterior Cruciate Ligament Reconstruction?

PURPOSE: Tunnel widening following anterior cruciate ligament (ACL) reconstruction is commonly observed. Graft micromotion is an important contributing factor. Unlike fixed-loop devices that require a turning space, adjustable-loop devices fit the graft snugly in the tunnel. The purpose of this study is to compare tunnel widening between these devices. Our hypothesis is that the adjustable-loop device will create lesser tunnel widening. MATERIALS AND METHODS: Ninety-eight patients underwent ACL reconstruction from January 2013 to December 2014. An adjustable-loop device was used in 54 patients (group 1) and a fixed-loop device was used in 44 patients (group 2). Maximum tunnel widening at 1 year was measured by the L’Insalata’s method. Functional outcome was measured at 2-year follow-up. RESULTS: The mean widening was 4.37 mm (standard deviation [SD], 2.01) in group 1 and 4.09 mm (SD, 1.98) in group 2 (p=0.511). The average International Knee Documentation Committee score was 78.40 (SD, 9.99) in group 1 and 77.11 (SD, 12.31) in group 2 (p=0.563). The average Tegner-Lysholm score was 87.25 (SD, 3.97) in group 1 and 87.29 in group 2 (SD, 4.36) (p=0.987). There was no significant difference in tunnel widening and functional outcome between the groups. CONCLUSIONS: The adjustable-loop device did not decrease the amount of tunnel widening when compared to the fixed-loop device. There was no significant difference in outcome between the two fixation devices. LEVEL OF EVIDENCE: Level 3, Retrospective Cohort

Characterization of coal fly ash nanoparticles and their induced in vitro cellular toxicity and oxidative DNA damage in different cell lines.

Coal combustion generates considerable amount of ultrafine particles and exposure to such particulate matter is a major health concern in the developing countries. In this study, we collected nano sized coal fly ash (CFA) and characterized them by scanning electron microscope-energy dispersive X-ray analysis (SEM-EDX), particle size analyzer (PSA) and transmission electron microscope (TEM), and investigated its toxicity in vitro using different cell lines. The imaging techniques showed that the coal fly ash nanoparticles (CFA-NPs) are predominately spherical shaped. The analyses have revealed that the CFA-NPs are 7-50 nm in diameter and contain several heavy metals associated with CFA particles. The studies showed significant amount of toxicity in all cell lines on treatment with CFA-NPs. The cytotoxicity and oxidative DNA damage caused by CFA-NPs were determined by inhibition of cellular metabolism (MTT), total intracellular glutathione (GSH), reactive oxygen species (ROS) and DNA fragmentation in cultured cell lines (Chang liver, HS294T and LL29). The cellular metabolism was inhibited in a dose-dependent manner in CFA-NPs treated cell lines. The CFA-NPs induced ROS and decreased the total intracellular glutathione with increased dose. Further, the CFA-NPs treated cells showed severe DNA laddering as a result of DNA fragmentation.

Isolation and antibiotic susceptibility of bacteria from foot infections in the patients with diabetes mellitus type I and type II in the district of Kancheepuram, Tamil Nadu, India.

Background: Diabetic foot infections are important cause of morbidity and mortality among persons with diabetes mellitus. The reported prevalence rates in India range from 0.9–8.3%. Diabetes foot lesions are the leading cause of non-traumatic amputations worldwide. A study has been conducted to isolate and find the antibiotic susceptibility pattern of the bacteria from diabetic foot infections from the patients of Kancheepuram district, Tamil Nadu, India. Methods: Sixty patients previously diagnosed or newly diagnosed as diabetic, presented with lower extremity infection attending Tagore medical college and hospital and its peripheral centres were selected for the study. Various specimens (pus, wound exudates, or tissues biopsy) for microbiological studies were obtained from the infected region. The specimens were cultured on blood agar and MacConkey agar for aerobic / facultative anaerobic organisms and on Neomycin Blood Agar for anaerobic organism. The plates were then incubated at 37°C. For anaerobic culture the plates were incubated in the McIntosh anaerobic jar. Isolates obtained are identified by standard laboratory techniques. Results: The result showed that Pseudomonas aeruginosa (48.3%) is the predominant bacterium followed by Staphylococcus aureus (38%) and other bacteria. The anaerobic bacteria are also isolated from the diabetic foot ulcers. The Peptostreptococcus species (26.7%) are the predominant bacteria followed by other bacteria. Further the results showed that 22 patients (37%) showed the multi-bacterial infection and remaining 38 patients (63%) showed mono bacterial infection. The drugs like amikacin, cefepine, ciprofloxacin, cotrimoxazole and roxythromycin are sensitive to many gram positive bacterial isolates. Conclusion: The present study has given the data of various bacteria encountered in the diabetic foot ulcer in the district of Kancheepuram, Tamil Nadu, India and its antibiotic sensitivity pattern. The results clearly reveal that there is no definite aetiology in diabetic foot infections. Many patients presented the infection with the involvement of many bacteria. Further it is evident that many bacteria are multi drug resistant and thus complicating the management of diabetic foot infections.

A novel method of removal of a broken drill bit in the femoral medullary canal during internal fixation of a type C distal femoral fracture: a case report / 中华创伤杂志(英文版)

Breakage of surgical instruments and implants during operative procedures is not uncommon in any surgical discipline. The need for removal and the outcome of leaving the broken instruments and implants in the surgical area have not been described in detail. Few studies have suggested removal if they are lying loosely in the tissues or joint, close to neurovascular structures. Challenges and the amount of time spent in the retrieval of broken instruments and implants are well known among surgeons, so most choose to leave them in situ. We reported a novel method of retrieval of a broken drill bit in the femoral medullary canal during internal fixation of a type C distal femoral fracture.

Assessment Of Basic Practical Skills In An Undergraduate Medical Curriculum

Introduction: Health educators and accrediting bodies have defined objectives and competencies that medical students need to acquire to become a safe doctor. There is no report in Malaysia, about the ability of medical students to perform some of the basic surgical skills before entering the houseman ship. The aim of this study is to determine whether the teaching/ learning methods of practical skills in our undergraduate program have been effective in imparting the desired level of competencies in these skills. Methods: A list of basic practical skills that students should be competent has been identified. These skills are taught in a structured way and assessed as part of the composite end- of- semester examination. Practical skills stations form part of an Objective structured practical examination (OSPE). Results: The results of 244 students who participated in three ends of semester examinations were analyzed. The mean score for the practical skills stations were higher than the mean OSPE (of all 18 stations) and overall score (of the written, practical and clinical examination). However the failure rate in the practical skills stations is higher in most of the stations (7 out of 8 stations) compared to overall failure rates. Conclusions: In spite of the formal skills training many students failed to demonstrate the desired level of competencies in these stations. Assessment of practical skills as part of overall composite examination may not be effective in ensuring that all students have achieved the required level of competency. Practical skills should be assessed through dedicated formative assessments to make sure that all the students acquire the required competencies.

Acute plastic bronchitis.

Plastic bronchitis is a rare disorder characterized by the formation of bronchial cast. The etiology is obscure, though usually associated with conditions like asthma, aspergillosis, pneumonia, cystic fibrosis and cardiac problems.

Double blind, placebo controlled trial on the cytoprotective effect of misoprostol in subjects with rheumatoid arthritis, osteoarthritis and seronegative spondarthropathy on NSAIDs.

Ninety arthritic patients were randomly allotted to receive misoprostol 200 micrograms thrice daily or placebo, for 4 weeks, while they were started on various NSAIDs. While upper gastrointestinal symptoms occurred equally in both groups, patients on placebo had significantly more post-therapy abnormal endoscopy findings. Misoprostol was well tolerated without any adverse side effects; it did not interfere with the therapeutic efficacy of the NSAIDs. Arthritic patients requiring long term NSAID therapy appear to benefit from misoprostol because of its cytoprotective effect on the gastrointestinal mucosa.

A clinical study of adult leukaemias.

The incidence of adult leukaemias, their response to therapy and the complications of therapy were studied in 121 cases over seven years (1981-1987). All cases were followed up till recovery or death for periods ranging from seven days to seven years. Adult leukaemias accounted for 2.56% of all admissions due to malignancies. There were 21 cases of acute lymphoblastic leukaemia, 61 of acute myelogenous leukaemia, 36 of chronic myelocytic leukaemia and 3 chronic lymphocytic leukaemia. All received aggressive combination chemotherapy. Remission could be achieved in 57% to 60% of cases. Infection (34%), bleeding (34%), and central nervous system involvement (25%) were the complications during therapy. The cause of death was ascertained in 87 of 90 deaths by a detailed postmortem. Haemorrhage (34.5%), infection (31%) and uncontrolled leukaemia (22%) were the leading causes, either singly or in combination. Some of the uncommon causes of death were fulminant hepatic failure, coronary artery disease, gangrene of the colon and disseminated tuberculosis.