Experience of an Anatomic Femoral Stem in a United Kingdom Center - Excellent Survivorship and Negligible Periprosthetic Fracture Rates at Mean 12 Years Following Primary Total Hip Arthroplasty.

BACKGROUND: As the clinical burden of periprosthetic fractures (PPFs) continues to increase, it has been suggested that the use of anatomical femoral stems may help reduce PPF risk. The primary aim of this study was to determine the survivorship and PPF rate of an anatomical femoral stem in a single center at minimum 10-year follow-up. METHODS: A total of 1,000 consecutive total hip arthroplasties (THAs) performed using an anatomical femoral stem were identified from a prospectively collected arthroplasty database. Patient radiographs were reviewed finally at a mean of 12 years (range, 10 to 16 years) following surgery to identify any revision surgery, dislocations or PPFs. Mean patient age at surgery was 69 years (range, 24 to 93). There were 634 women (63%). Osteoarthritis was the operative indication in 946 patients (95%). RESULTS: All-cause THA survivorship was 99.1% (95% confidence interval (CI), 99.0-99.3%) at 10 years and 97.9% (CI, 97.8 - 98.0%) at 15 years. Stem survivorship at 10 years was 99.6% (CI, 99.5-99.7%) and at 15 years was 98.2% (CI, 98.1-98.3%). The 15-year stem survival for aseptic loosening was 100% with no cases of significant lysis found (lucent line >2mm). Implant survivorship was not significantly impacted by patient sex (P = .65), body mass index (P = .49), deprivation level (P = .284), operative indication (P = .33), or American Society of Anesthesiologists class (P = .374). There were 3 PPFs identified (0.3%) at mean 12-year follow-up and 15 dislocations (1.5%). CONCLUSION: This anatomical femoral stem demonstrated excellent survivorship and negligible PPF rates at mean 12-year follow-up following primary THA.

Telemedicine monitoring of high-risk coronavirus disease 2019 (COVID-19) patients by family medicine service after discharge from the emergency department.

BACKGROUND: Up to 25% of the total coronavirus disease 2019 (COVID-19) admissions comprise patients with comorbidities who present to the emergency department (ED) with only mild-to-moderate disease. It is unclear whether as an alternative to hospitalization, telemedicine can be used to monitor these "high-risk" comorbid patients. The aim of our study was to answer this question by comparing the outcome of such patients discharged under a family medicine service (FMS) telemonitoring program and those admitted to hospital. MATERIALS AND METHODS: Patients with three or more risk factors for progression to severe COVID-19 disease were designated as "high-risk" in our study. In the absence of acute indication for hospitalization, these high-risk patients with mild-to-moderate disease were discharged home under the supervision of FMS led telemonitoring between October 2020 and February 2021 and were labelled as "Telemedicine group." They were compared to similar patients who were admitted to hospital between March-August 2020 before the implementation of telemedicine service (TMS) and were taken as "Control group." Outcome measures included intubation, number of inpatient days, 28-day mortality and cost analysis for the two groups. RESULTS: Out of 572 COVID-19 patients who presented to the ED, 70 met the inclusion criteria for the "Telemedicine Group" and 35 were included in the "Control Group". In the Telemedicine group, 21 (30.0%) patients were brought back to ED for re-evaluation and 16 (22.9%) were eventually admitted to the hospital. There was no difference in terms of oxygen requirements, intubation, and intensive care unit admission (P > 0.74) between the groups, and none of the study patients died. The Family Medicine-led TMS saved 77% inpatient admissions and on average 4.4 hospital days and $3400 per patient (P < . 0001). CONCLUSION: Family medicine-led telemonitoring of high-risk COVID-19 patients presenting to the ED with mild-to-moderate disease is a feasible and cost-effective alternative to hospitalization.

Heparin for assisted reproduction.

BACKGROUND: Heparin as an adjunct in assisted reproduction (peri-implantation heparin) is given at or after egg collection or at embryo transfer during assisted reproduction. Heparin has been advocated to improve embryo implantation and clinical outcomes.  It has been proposed that heparin enhances the intra-uterine environment by improving decidualisation with an associated activation of growth factors and a cytokine expression profile in the endometrium that is favourable to pregnancy. OBJECTIVES: To investigate whether the administration of heparin around the time of implantation (peri-implantation heparin) improves clinical outcomes in subfertile women undergoing assisted reproduction. SEARCH METHODS: A comprehensive and exhaustive search strategy was developed in consultation with the Trials Search Co-ordinator of the Cochrane Menstrual Disorders and Subfertility Group (MDSG). The strategy was used in an attempt to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress). Relevant trials were identified from both electronic databases and other resources (last search 6 May 2013). SELECTION CRITERIA: All randomised controlled trials (RCTs) were included where peri-implantation heparin was given during assisted reproduction. Peri-implantation low molecular weight heparin (LMWH) during IVF/ICSI was given at or after egg collection or at embryo transfer in the included studies. Live birth rate was the primary outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the eligibility and quality of trials and extracted relevant data. The quality of the evidence was evaluated using GRADE methods. MAIN RESULTS: Three RCTs (involving 386 women) were included in the review.Peri-implantation LMWH administration during assisted reproduction was associated with a significant improvement in live birth rate compared with placebo or no LMWH (odds ratio (OR) 1.77, 95% confidence interval (CI) 1.07 to 2.90, three studies, 386 women, I(2) = 51%, very low quality evidence with high heterogeneity). There was also a significant improvement in the clinical pregnancy rate with use of LMWH (OR 1.61, 95% CI 1.03 to 2.53, three studies, 386 women, I(2) = 29%, very low quality evidence with low heterogeneity).However these findings should be interpreted with extreme caution as they were dependent upon the choice of statistical method: they were no longer statistically significant when a random-effects model was used.Adverse events were poorly reported in all included studies, with no comparative data available. However, LMWH did cause adverse effects including bruising, ecchymosis, bleeding, thrombocytopenia and allergic reactions. It appeared that these adverse effects were increased if heparin therapy was used over a longer duration. AUTHORS' CONCLUSIONS: The results of this Cochrane review of three randomised controlled trials with a total of 386 women suggested that peri-implantation LMWH in assisted reproduction treatment (ART) cycles may improve the live birth rate in women undergoing assisted reproduction. However, these results were dependent on small low quality studies with substantial heterogeneity, and were sensitive to the choice of statistical model. There were side effects reported with use of heparin, including bruising and bleeding, and no reliable data on long-term effects. The results do not justify this use of heparin outside well-conducted research trials.These findings need to be further investigated with well-designed, adequately powered, double-blind, randomised, placebo-controlled, multicentre trials. Further investigations could also focus on the effects of the local (uterine) and not systemic application of heparin during ART.

Aspirin and heparin as adjuvants during IVF do not improve live birth rates in unexplained implantation failure.

This study tested the hypothesis that using aspirin and/or heparin as adjuvants in IVF improves the treatment outcome. This retrospective cohort-control study recruited 234 consecutive subjects aged ≤ 44 years who had previously had one or more unsuccessful IVF cycle. All underwent IVF using conventional protocols. The study group received aspirin and/or heparin post embryo transfer until the day of pregnancy test or until 12 weeks of pregnancy. The control group did not receive adjuvant treatment. The outcome measures were live birth, clinical pregnancy and miscarriage rates. The outcomes were compared by chi-squared test and relative-risk analysis. Analysis was performed in 206 subjects. There was no statistically significant difference in the live birth rate (35.0%, 36/103 versus 47.6%, 49/103), clinical pregnancy rate (40.8%, 42/103 versus 53.4%, 55/103) and miscarriage rate (14.3%, 6/42 versus 10.9%, 6/55) between the study group and the control group. The data in this study show that low-dose aspirin and/or heparin as adjuvant therapies during IVF do not improve live birth rates in an unselected group of subfertile women who have previously had one or more unexplained implantation failure following IVF.

Hepatic histopathology and clinical characteristics associated with antiretroviral therapy in HIV patients without viral hepatitis.

BACKGROUND: All available ARV (antiretroviral) agents can cause hepatotoxicity. Many case reports of ARV-induced hepatotoxicity have been described in patients with confounding viral hepatitis. This case series is comprised 23 HIV-positive patients with hepatic enzyme abnormalities but without the evidence of viral hepatitis. The data available for these 23 patients were assessed with an effort to establish any correlation between ARV therapy and abnormal liver function tests (LFTs) as well as the histologic findings on liver biopsies. METHODS: The 23 participants included in this study were referred to a hepatology/gastrointestinal clinic that catered specifically to HIV patients. The patients were referred by their HIV providers for evaluation of elevated LFTs, gastrointestinal symptoms or cirrhosis. The data surveyed included variables associated with hepatotoxicity and HIV infection. RESULTS: Liver biopsies were obtained in 21 out of 23 participants. The remaining two participants had evidence of cirrhosis based on imaging studies. The LFT elevations were definitely or possibly attributed to ARV therapy in 17 out of 23 participants. Specifically, the biochemical hepatotoxicity was definitely related to ARV therapy in six and possibly related to ARV medications in 11 participants. Nine out of 17 participants had evidence of nonalcoholic steatohepatitis, whereas four out of 17 had clinical features of lipodystrophy. Six participants had elevated LFTs before starting ARV therapy. The participants with nonalcoholic fatty liver diseases had normal LFTs for many years after which a steep rise was noted. All participants with nonalcoholic fatty liver diseases were exposed to nucleoside reverse transcriptase inhibitors. CONCLUSION: ARV medications, particularly the nucleoside reverse transcriptase inhibitors, can cause a dose-dependent hepatotoxicity that occurs after several months of exposure and possibly result in increasing the adverse effects of alcohol and obesity. Owing to the overlap of ARV medications, the contribution of each class of drugs toward the observed hepatotoxicity is not entirely clear. Liver biopsies should be considered in patients receiving ARV therapy with elevated LFTs and/or evidence of fatty liver.

Metal-Based Antibacterial and Antifungal Agents: Synthesis, Characterization, and In Vitro Biological Evaluation of Co(II), Cu(II), Ni(II), and Zn(II) Complexes With Amino Acid-Derived Compounds.

A series of antibacterial and antifungal amino acid-derived compounds and their cobalt(II), copper(II), nickel(II), and zinc(II) metal complexes have been synthesized and characterized by their elemental analyses, molar conductances, magnetic moments, and IR, and electronic spectral measurements. Ligands (L(1))-(L(5)) were derived by condensation of beta-diketones with glycine, phenylalanine, valine, and histidine and act as bidentate towards metal ions (cobalt, copper, nickel, and zinc) via the azomethine-N and deprotonated-O of the respective amino acid. The stoichiometric reaction between the metal(II) ion and synthesized ligands in molar ratio of M : L (1 : 1) resulted in the formation of the metal complexes of type [M(L)(H(2)O)(4)]Cl (where M = Co(II), Cu(II), and Zn(II)) and of M : L (1 : 2) of type [M(L)(2)(H(2)O)(2)] (where M = Co(II), Cu(II), Ni(II), and Zn(II)). The magnetic moment data suggested for the complexes to have an octahedral geometry around the central metal atom. The electronic spectral data also supported the same octahedral geometry of the complexes. Elemental analyses and NMR spectral data of the ligands and their metal(II) complexes agree with their proposed structures. The synthesized ligands, along with their metal(II) complexes, were screened for their in vitro antibacterial activity against four Gram-negative (Escherichia coli, Shigella flexeneri, Pseudomonas aeruginosa, and Salmonella typhi) and two Gram-positive (Bacillus subtilis and Staphylococcus aureus) bacterial strains and for in vitro antifungal activity against Trichophyton longifusus, Candida albicans, Aspergillus flavus, Microsporum canis, Fusarium solani, and Candida glaberata. The results of these studies show the metal(II) complexes to be more antibacterial/antifungal against one or more species as compared to the uncomplexed ligands. The brine shrimp bioassay was also carried out to study their in vitro cytotoxic properties. Five compounds, (3), (7), (10), (11), and (22), displayed potent cytotoxic activity as LD(50) = 8.974 x 10(-4), 7.022 x 10(-4), 8.839 x 10(-4), 7.133 x 10(-4), and 9.725 x 10(-4) M/mL, respectively, against Artemia salina.