The diagnostic utility of FIB-4 as a non-invasive tool for liver fibrosis scoring among NAFLD patients: a retrospective cross-sectional study.

OBJECTIVE: Liver biopsy is the gold standard method to evaluate patients with non-alcoholic fatty liver disease (NAFLD). However, due to its several limitations and complications, a reliable and non-invasive marker is required to assess liver fibrosis. In this study, we compared the performance of the FIB-4 index [based on age, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels and platelets count] with the Scheuer scoring system of liver biopsies to evaluate the diagnostic utility of FIB-4 among NAFLD patients with different liver fibrosis severities. PATIENTS AND METHODS: A cross-sectional study was conducted at An-Najah National University Hospital (NNUH) in Palestine. The FIB-4 index was calculated using laboratory data for 128 NAFLD patients who underwent liver biopsies between November 2014 and July 2022. The results of FIB-4 were compared with the Scheuer scoring system of liver biopsies (using F0, F1+F2, F3+F4) to determine the sensitivity and specificity of FIB-4 in detecting and staging liver fibrosis. RESULTS: Out of 128 patients involved in our study, 49 of them had advanced fibrosis according to liver biopsy (F3+F4), where their FIB-4 indices showed 87% sensitivity at 1.45 cut off point and 87% specificity at 3.25 cut off point. CONCLUSIONS: The FIB-4 index may be used as a screening tool in the primary care setting. To raise awareness of liver diseases, this non-invasive, inexpensive, simple, and quick marker could identify people in need of further liver fibrosis evaluation and diagnosis.

The estimated prevalence of osteoporosis in Bahrain: a multi-centered-based study.

OBJECTIVES: the primary aim of this study was to examine the prevalence and risk factors of low bone mineral density in Bahrain. METHODS: this was a retrospective study, which targeted a cohort of 4822 Bahraini subjects (mean age 59.36 years: 93% females). Demographic data and results of lumbar and femur DEXA scan for the targeted sample, over the period 2016-2018, were retrieved from four hospitals. RESULTS: The prevalence of low BMD was 62.3% (46.4% had osteopenia and 15.9% had osteoporosis). The highest rate of osteopenia was detected at the age group younger than 44 years. However, with increasing age, the rate of osteopenia declined, whereas osteoporosis increased (P < 0.001). Females were found to be at higher risk of developing both osteopenia (45.8%) and osteoporosis (18.1%) compared to males (39% and 12.4%, respectively) (P < 0.001). Postmenopausal women exhibited higher rates of low BMD (42.4% osteopenia, 22.3% osteoporosis) compared to elderly men (30.9% osteopenia, 9% osteoporosis). CONCLUSIONS: We reported high prevalence of osteopenia and osteoporosis in Bahrain. Low BMD was more common in females, especially in postmenopausal women. Highest prevalence of osteopenia happened at young age. Therefore, we advocate screening at younger age than previously recommended.

Robot-Assisted Pelvic Dissection for Enlarged Lymph Nodes in Melanoma Improves Recovery with Equivalent Oncological Outcomes to Open Pelvic Dissection.

BACKGROUND: Robot-assisted pelvic lymph node dissection (rPLND) has been reported in heterogenous groups of patients with melanoma, including macroscopic or at-high-risk-for microscopic metastasis. With changing indications for surgery in melanoma, and availability of effective systemic therapies, pelvic dissection is now performed for clinically detected bulky lymph node metastasis followed by adjuvant drug therapy. rPLND has not been compared with open pelvic lymph node dissection (oPLND) for modern practice. METHODS: All patients undergoing pelvic node dissection for macroscopic melanoma at a single institution were reviewed as a cohort, observational study. RESULTS: Twenty-two pelvic lymph node dissections were identified (8 oPLND; 14 rPLND). The number of pelvic lymph nodes removed was similar (median oPLND 6.5 (interquartile range [IQR] 6.0-12.5] versus rPLND 6.0 [3.75-9.0]), with frequent matted nodes (11/22, 50.0%). Operative time (median oPLND 130 min [IQR 95.5-182] versus rPLND 126 min [IQR 97.8-160]) and complications (Clavien-Dindo scale) were similar. Length of hospital stay (median 5.34 days (IQR 3.77-6.94) versus 1.98 days (IQR 1.39-3.50) and time to postoperative adjuvant therapy (median 11.6 weeks [IQR 10.6-18.5] versus 7.71 weeks [IQR 6.29-10.4]) were shorter in the rPLND group. No differences in pelvic lymph node recurrence (p = 0.984), distant metastatic recurrence (p = 0.678), or melanoma-specific survival (p = 0.655) were seen (median follow-up 21.1 months [rPLND] and 25.7 months [oPLND]). CONCLUSIONS: rPLND is an effective way to remove bulky pelvic lymph nodes in melanoma, with a shorter recovery and reduced interval to initiating adjuvant therapy compared with oPLND. This group of patients may especially benefit from neoadjuvant systemic approaches to management.

Lifestyle and Dietary Patterns during the COVID-19 Lockdown in Bahrain: A Web-Based Cross-Sectional Study.

Lifestyle factors such as dietary habits, perceived weight, sleep, and physical activity worsened during the COVID-19 pandemic. Through this study, we aimed to understand the impact of COVID-19 on these lifestyle factors in Bahrain. A cross-sectional study was conducted among 1005 adult Bahrainis. Data were collected online using a structured and validated questionnaire for the assessment of eating habits, physical activity, and lifestyle during the COVID-19 pandemic. Participants were snowballed through those who agreed to answer the online questionnaire. There was a higher consumption of fast food, and a higher dependence on takeaways during the COVID-19 pandemic. About 63.5% of the participants consumed >4 meals per day, compared to 36.5% before the COVID-19. About 30% reported consumption of sugar sweetened beverages from two to three times a day. Weight loss was predominantly observed in persons exercising 1-3 times a week. The consumption of sugar-sweetened beverages was also high, with about 19% reporting drinking sweet beverages once every day, 10.6% from two to three times a day, and 40.4% from one to four times a week. A higher proportion of the participants reported poor sleep quality during the pandemic (31.2%) compared to before (12.2%), and 39.7% of the participants reported feeling lazy. Screen time use also doubled during the pandemic, with participants spending more than five hours per day on screens for entertainment, which went from 22.4% before to 51.9% during the pandemic. The lifestyle and dietary habits changed drastically for our study participants during the pandemic. The increased reliance on processed fast food instead of healthier options is a challenge to be tackled in any future pandemic situation. Future research needs to focus on strategies to promote healthier lifestyle modifications during situations such as the COVID-19 pandemic.

Perceptions of Medical Students on Distance Learning During the COVID-19 Pandemic: A Cross-Sectional Study from Bahrain.

Purpose: The COVID-19 pandemic resulted in a sudden shift from face-to-face to distance learning. We explored medical students' views of online learning during this pandemic at the Arabian Gulf University in Bahrain. Methods: This was a cross-sectional study of students in years two, three and four (n= 559) using an electronic questionnaire. Data were collected from April 10 to May 5, 2021. The survey included three domains: behavioral, affective, and cognitive. We also analyzed the association between students' perceptions and certain demographic and institutional factors. Results: The number of respondents was 311 (response rate: 55.6%; 27.7% males, 72.3% females). Participants were generally satisfied with distance learning (54.6%), although they had less motivation (46.3%) and required more effort (32.2%). Most students preferred distance learning for theoretical parts, and face-to-face approach for practical components (73.3%). Participants reported that distance learning, improved interaction with instructors and classmates (45.6% and 48.9%, respectively), small group learning (47.6%), independent learning (75.3%) and problem-solving skills (44.7%). The students were comfortable with online assessment (60.1%), and reported improved achievement in written (42.1%) and practical examinations (46%), but not in professional skills grades (21.6%). There was no association between students' perceptions and gender (p= 0.079), year of study (p= 0.28) or attendance of live or recorded sessions (p= 0.904), but there was a positive association with the availability of WiFi (p< 0.01) and attendance of college-organized activities (p< 0.0001). Conclusion: Distance learning was successfully implemented during the COVID-19 pandemic. Students were generally satisfied with distance learning and online assessment, but they had concerns about the clinical skills learning. After the pandemic is over, theoretical components of the curriculum can be delivered using distance learning, whereas hands on elements should be offered face-to-face. However, those curricular reforms will likely need investing in the information technology infrastructure.

Phosphaturic Mesenchymal Tumor of the Ankle: A Case Report and Review of the Literature.

We report the case of a phosphaturic mesenchymal tumor of the ankle; an extremely rare lesion that causes osteomalacia via paraneoplastic renal phosphate wasting. A 41-year-old man was referred to plastic surgery with a swelling over the anterior ankle, which had been increasing in size for 1 year. Focused ultrasound assessment was inconclusive, but excision biopsy demonstrated features in keeping with a phosphaturic mesenchymal tumor. Evidence of tumor-induced osteomalacia was subsequently identified on review of historical biochemistry. The patient was followed-up for 1 year with normalization of serum phosphate. In this case report, we present a discussion of the differential diagnosis for foot and ankle soft tissue lesions, and a review of the literature regarding the diagnosis and management of these tumors. Accurate identification of any soft tissue lesion on clinical examination alone is extremely challenging and excision biopsy should be considered in cases of diagnostic uncertainty.

Lymph node dissections in cutaneous malignancy: Where are we now? A review of 10 years' experience at a tertiary centre.

The surgical management of cutaneous malignancies has evolved over recent years with the introduction of novel medical therapies and an increasing emphasis upon early adjuvant systemic therapy. As such, completion lymph node dissection (cLND) is now no longer recommended following a positive sentinel lymph node biopsy (SLNB) in melanoma. We evaluated our ten-year practice at a regional tertiary centre, assessing the change in lymph node dissection (LND) caseload volume, anatomical distribution, and indication for the procedure. A retrospective search was carried out of all LNDs performed by the Plastic Surgery department at Cambridge University Hospitals NHS Trust, UK from 1 January 2010 to 31 December 2019. Case notes were retrospectively analysed for each procedure, with the site and pathology recorded. A total of 491 LNDs were performed over the 10-year period. Surgical volume peaked in 2015 with 67 cases, followed by a decline to 41 cases in 2019. The number of neck dissections increased over the decade, as well as the proportion of cases due to macroscopic nodal disease. We sub-analysed the number of LNDs in three contiguous 18-month intervals, corresponding to changes in practice due to evidence from the DeCOG and MSLT-II Trials. We found a 41.67% reduction in LNDs caseload between July 2018-Dec 2019, compared to a similar period prior to trial evidence (July 2015-Dec 2016) (p=0.0.14). In summary, the surgical volume of LNDs has decreased significantly since 2018, reflecting emerging evidence and changes to national guidelines. This will require ongoing monitoring for workforce planning and surgical training.

Does Resident Participation in the Surgical Fixation of Hip Fractures Increase Operative Time or Affect Outcomes?

BACKGROUND: Surgical fixation of hip fractures is a common procedure at teaching hospitals with resident support and in community hospitals. OBJECTIVE: We evaluated to what extent participation by residents in hip fracture fixation affects operative times or outcomes. SETTING: Operations were performed by three surgeons who operate at a teaching hospital with resident support, and at a community hospital without residents in the same metropolitan area. PARTICIPANTS: We performed a retrospective analysis of operative time and early post-operative outcomes on a series of 314 patients with hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association A1-3, B1-3) treated with surgical fixation between April 2012 and March 2015; 177 patients at the community hospital, and 137 at the teaching hospital. METHODS: Multivariate regression assessed the effect of hospital type, adjusting for age, gender, American Society of Anesthesiologist classification, and Charlson comorbidity index. RESULTS: We found lower median operative time at the community hospital than the teaching hospital (46 minutes, 95% confidence interval [CI] = [43, 52] versus 75 minutes, 95% CI = [70, 81]) and lower estimated blood loss (177.3 mL, 95% CI=[158.6, 195.1] versus 234.8 mL, 95% CI = [196.4, 273.6]), but no differences in transfusion requirement, length of stay, or discharge to skilled nursing facility. Adjusted odds ratio for thirty-day mortality at the teaching hospital was 5.44 (95% CI = [1.22, 24.1]). CONCLUSION: We found longer operative times and elevated estimated blood loss with resident involvement in surgical fixation of hip fractures. There was a difference in 30-day mortality between the groups, although this cannot simply be attributed to resident involvement as there are many other factors related to mortality.

Pleuropulmonary Recurrence Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion for Appendiceal Pseudomyxoma Peritonei.

BACKGROUND: The aim of this study was to identify factors associated with pleuropulmonary disease recurrence following cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) for appendiceal pseudomyxoma peritonei (PMP) and to evaluate the oncologic impact of pleuropulmonary disease recurrence compared with isolated peritoneal recurrence. METHODS: From a prospective database, we identified patients who developed pleuropulmonary recurrence, isolated peritoneal recurrence, or no recurrence following CRS/HIPEC for appendiceal PMP. Clinicopathologic, perioperative, and oncologic data associated with the index CRS/HIPEC procedure were reviewed. The Kaplan-Meier method was used to estimate survival. Multivariate analyses identified associations with recurrence and survival. RESULTS: Of 382 patients undergoing CRS/HIPEC, 61 (16%) developed pleuropulmonary recurrence. Patients who developed a pleuropulmonary recurrence were more likely to have high-grade (American Joint Committee on Cancer [AJCC] grade 2/3) tumors (74% vs. 56%, p = 0.02) and increased operative blood loss (1651 vs. 1201 ml, p = 0.05) and were more likely to have undergone diaphragm stripping/resection (79% vs. 48%, p < 0.01) compared with patients with an abdominal recurrence. In a multivariate analysis, pleuropulmonary recurrence after CRS/HIPEC was associated with diaphragm stripping/resection, incomplete cytoreduction, and higher AJCC tumor grade. There was a trend towards reduced survival in patients with pleuropulmonary recurrence compared with patients with isolated peritoneal recurrence (median overall survival 45 vs. 53 months, p = 0.87). CONCLUSION: Pleuropulmonary recurrence of appendiceal PMP following CRS/HIPEC is common and may negatively impact survival. Formal protocols for surveillance and therapeutic intervention need to be studied and implemented to improve oncologic outcomes.

Free Flap Selection and Outcomes of Soft Tissue Reconstruction Following Resection of Intra-oral Malignancy.

Introduction: Surgery to resect intra-oral malignancy is a well-established mode of primary treatment. The tissue requirement in this area is for a thin, pliable flap with minimal bulk and this has historically been provided by free tissue transfer with a radial forearm free flap (RFFF). More recently, a role for the anterolateral thigh free flap (ALTFF) has been described, although in populations with a westernized diet, body habitus may preclude use of an ALTFF due to flap thickness, relative to a radial forearm free flap. Methods: An analysis of data was performed retrospectively for 90 consecutive patients with intra-oral malignancy, requiring immediate soft tissue reconstruction by the senior author, at Addenbrooke's Hospital between July 2008 and April 2016. Cases requiring bony reconstruction were excluded. Data on patient age, sex, indication for surgery, tumor location and defect type, complications, success rates, and length of stay were recorded. Results: The majority of patients received an ALTFF (n = 56) with 38% receiving a RFFF (n = 34). Surgical resection took place in the floor of the mouth most frequently. These were closed with ALTFF and RFFF in 41 and 28 occasions, respectively. A success rate of 97% was observed in the RFFF group; 1 flap developed partial necrosis and required complete revision. In the ALTFF group, there was a 100% flap success rate. ALTFF usage resulted in a reduction in the number of intraoperative (p = 0.021) in addition a reduction in the number of days in ITU (p = 0.01) and post-operative clinic visits (p = 0.025). Conclusion: We present a series that used predominately the ALTFF to reconstruct intra-oral defects following resection of squamous cell carcinoma in a Western population. The results demonstrate that this treatment can produce at least as comparable results as to the use of a RFFF repair in this population, whilst avoiding the donor site morbidity and aesthetic compromise of a RFFF.

Determination and risk assessment of naturally occurring genotoxic and carcinogenic alkenylbenzenes in basil-containing sauce of pesto.

A risk assessment of basil-based pesto sauces containing methyleugenol and related alkenylbenzenes was performed based on their levels detected in a series of pesto sauces available on the Dutch market. The estimated daily intake (EDI) values of alkenylbenzenes as a result of consumption of the different pesto sauces amounted to 1.2-44.3 µg/kg bw for individual alkenylbenzenes, 14.3-43.5 µg/kg bw when adding up the alkenylbenzene levels assuming equal potency, and 17.3-62.9 µg/kg bw when expressed in methyleugenol equivalents using alkenylbenzenes defined toxic equivalency factors (TEF). The margin of exposure approach (MOE), used to evaluate the potential risks, resulted in MOE values that were generally lower than 10000 indicating a priority for risk management when assuming daily consumption. The levels of methyleugenol detected in the pesto sauces would allow consumption of 1.1-29.8, 7.5-208, 15.1-416.5, and 32.4-892.5 g of pesto sauce on a daily basis, once a week, once every two weeks, and once a month, respectively, to achieve MOE values above the 10000 limit indicating low priority for risk management. It is concluded that consumption of pesto sauces would only be of concern if consumed on a daily basis over longer periods of time.

Vismodegib for Locally Advanced Periocular and Orbital Basal Cell Carcinoma: A Review of 15 Consecutive Cases.

Basal cell carcinoma (BCC) is the most common periocular skin cancer and can lead to significant morbidity. We assess the effectiveness of vismodegib, a first-in-class Hedgehog signaling pathway inhibitor, in the management of periocular and orbital BCCs based on clinical response, tolerability, and orbital content preservation. All patients with periocular or orbital BCCs who met criteria for vismodegib treatment were recruited prospectively between May 2012 and 2014 from 2 hospitals. Patients received oral vismodegib (150 mg daily) until disease progression, unacceptable toxicity, or withdrawal. All patients were followed up monthly. Patient demographics, tumor size, treatment duration including dosing regimen, adverse events, response rate, duration of response, progression-free survival, and disease-free survival were analyzed. All 15 patients had biopsy-proven BCCs with no metastatic disease at presentation. The mean age was 74 years and 10 patients (67%) had orbital involvement. The mean lesion longest dimension was 51 mm and 7 cases (47%) represented recurrence following previous surgery and/or radiotherapy. The mean treatment duration was 13 months and mean follow-up duration 36 months. Ten patients (67%) had a complete response, 3 (20%) had a partial response, and 2 had progressive disease following an initial partial response (13%). The partial response of 55% in 1 patient allowed subsequent surgical resection with clear margins. Vismodegib is effective for treating periocular and orbital BCCs with orbital salvage of patients who otherwise would have required exenteration. There is a neoadjuvant role for vismodegib but further studies are required.

Risk assessment of combined exposure to alkenylbenzenes through consumption of plant food supplements containing parsley and dill.

A risk assessment was performed of parsley- and dill-based plant food supplements (PFS) containing apiol and related alkenylbenzenes. First, the levels of the alkenylbenzenes in the PFS and the resulting estimated daily intake (EDI) resulting from use of the PFS were quantified. Since most PFS appeared to contain more than one alkenylbenzene, a combined risk assessment was performed based on equal potency or using a so-called toxic equivalency (TEQ) approach based on toxic equivalency factors (TEFs) for the different alkenylbenzenes. The EDIs resulting from daily PFS consumption amount to 0.74-125 µg kg-1 bw for the individual alkenylbenzenes, 0.74-160 µg kg-1 bw for the sum of the alkenylbenzenes, and 0.47-64 µg kg-1 bw for the sum of alkenylbenzenes when expressed in safrole equivalents. The margins of exposure (MOEs) obtained were generally below 10,000, indicating a priority for risk management if the PFS were to be consumed on a daily basis. Considering short-term use of the PFS, MOEs would increase above 10,000, indicating low priority for risk management. It is concluded that alkenylbenzene intake through consumption of parsley- and dill-based PFS is only of concern when these PFS are used for long periods of time.

Determination and risk assessment of naturally occurring genotoxic and carcinogenic alkenylbenzenes in nutmeg-based plant food supplements.

A risk assessment of nutmeg-based plant food supplements (PFS) containing different alkenylbenzenes was performed based on the alkenylbenzene levels quantified in a series of PFS collected via the online market. The estimated daily intake (EDI) of the alkenylbenzenes amounted to 0.3 to 312 µg kg-1 body weight (bw) for individual alkenylbenzenes, to 1.5 to 631 µg kg-1 bw when adding up the alkenylbenzene levels assuming equal potency, and to 0.4 to 295 µg kg-1 bw when expressed in safrole equivalents using toxic equivalency factors (TEFs). The margin of exposure approach (MOE) was used to evaluate the potential risks. Independent of the method used for the intake estimate, the MOE values obtained were generally lower than 10000 indicating a priority for risk management. When taking into account that PFS may be used for shorter periods of time and using Haber's rule to correct for shorter than lifetime exposure it was shown that limiting exposure to only 1 or 2 weeks would result in MOE values that would be, with the presently determined levels of alkenylbenzenes and proposed uses of the PFS, of low priority for risk management (MOE > 10000). It is concluded that the results of the present paper reveal that nutmeg-based PFS consumption following recommendations for daily intake especially for longer periods of time raise a concern. Copyright © 2017 John Wiley & Sons, Ltd.

Physiologically based kinetic modeling of the bioactivation of myristicin.

The present study describes physiologically based kinetic (PBK) models for the alkenylbenzene myristicin that were developed by extension of the PBK models for the structurally related alkenylbenzene safrole in rat and human. The newly developed myristicin models revealed that the formation of the proximate carcinogenic metabolite 1'-hydroxymyristicin in liver is at most 1.8 fold higher in rat than in human and limited for the ultimate carcinogenic metabolite 1'-sulfoxymyristicin to (2.8-4.0)-fold higher in human. In addition, a comparison was made between the relative importance of bioactivation for myristicin and safrole. Model predictions indicate that for these related compounds, the formation of the 1'-sulfoxy metabolites in rat and human liver is comparable with a difference of <2.2-fold over a wide dose range. The results from this PBK analysis support that risk assessment of myristicin may be based on the BMDL10 derived for safrole of 1.9-5.1 mg/kg bw per day. Using an estimated daily intake of myristicin of 0.0019 mg/kg bw per day resulting from the use of herbs and spices, this results in MOE values for myristicin that amount to 1000-2700, indicating a priority for risk management. The results obtained illustrate that PBK modeling provides insight into possible species differences in the metabolic activation of myristicin. Moreover, they provide an example of how PBK modeling can facilitate a read-across in risk assessment from a compound for which in vivo toxicity studies are available to a related compound for which tumor data are not reported, thus contributing to alternatives in animal testing.

Level of Alkenylbenzenes in Parsley and Dill Based Teas and Associated Risk Assessment Using the Margin of Exposure Approach.

Risk assessment of parsley and dill based teas that contain alkenylbenzenes was performed. To this end the estimated daily intake (EDI) of alkenylbenzenes resulting from use of the teas was quantified. Since most teas appeared to contain more than one alkenylbenzene, a combined risk assessment was performed based on equal potency of all alkenylbenzenes or using a so-called toxic equivalency (TEQ) approach through defining toxic equivalency factors (TEFs) for the different alkenylbenzenes. The EDI values resulting from consuming one cup of tea a day were 0.2-10.1 µg/kg bw for the individual alkenylbenzenes, 0.6-13.1 µg/kg bw for the sum of the alkenylbenzenes, and 0.3-10.7 µg safrole equiv/kg bw for the sum of alkenylbenzenes when expressed in safrole equivalents. The margin of exposure (MOE) values obtained were generally <10000, indicating a concern if the teas would be consumed on a daily basis over longer periods of time.

Frequency and Treatment Trends for Periprosthetic Fractures About Total Hip Arthroplasty in the United States.

BACKGROUND: Periprosthetic hip fractures (PPHFx) are challenging complications that have become increasingly more prevalent. Wide variability exists in the quality and size of prior studies pertaining to hospital stay information. This study used the largest publicly available database in the United States to evaluate perioperative hospital data of PPHFx. METHODS: The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample was used to analyze trends related to the frequency, fracture type, mortality, treatment, patient demographics, time to surgery, length of stay (LOS), and hospital charges associated with PPHFx from 2006-2010. RESULTS: From 2006-2010, average patient age (76.7 years), hospital characteristics, rate of PPHFx, treatment choice, LOS (8.03 days), mortality (2.6%), disposition (78.1% to skilled nursing facility or inpatient rehab), and time to procedure (1.98 days) all remained relatively stable. The southern United States had the highest frequency of PPHFx and females had nearly twice the rate of PPHFx each year at an average of 67%. Despite these consistencies, hospital charges increased by an average of 8.3% per year over the study period ($27,683 over 5 years, P < .0001). CONCLUSION: In the era of containing cost while improving quality of care, this study demonstrates that despite consistent treatment trends of PPHFx, hospital charges are increasing independently. Regardless, surgeons can work to reduce LOS and charge to post acute care facilities to lessen spending. Refining our understanding of these relationships will be fundamental to further improving quality of care and cutting cost associated with these fractures.

Risk of Periprosthetic Fractures With Direct Anterior Primary Total Hip Arthroplasty.

BACKGROUND: Despite increasing interest in the anterior approach for cementless, primary total hip arthroplasty (THA), studies examining the incidence of periprosthetic fractures with this approach are lacking. The purpose of this study was to (1) investigate the incidence of early periprosthetic fractures associated with primary THA performed through an anterior supine intermuscular (ASI) approach without the use of a specialized table and (2) identify potential risk factors for these fractures. METHODS: We identified 2869 primary THAs performed via the ASI approach using a single cementless, tapered titanium femoral component with short and standard length options between February 2007 and April 2014. Fifty-two percent of THAs were in female patients, whereas 48% were in males. Short stems were used in 59% vs standard length in 41%. RESULTS: There were 26 (0.9%) early periprosthetic femoral fractures, with 23 requiring revision. When looking at the potential risk factors of age, gender, body mass index, and stem length, the only significant finding was that increased age was associated with increased risk of femoral fracture. Logistic regression analysis revealed a significant age-fracture association for female gender only, which remained when controlled for body mass index, stem length, or both. CONCLUSION: The muscle-sparing ASI approach appears to be a safe technique for performing primary THA when used in a suitable patient population. The early periprosthetic femoral fracture rate in our series may warrant consideration of using a different design or different approach in elderly female patients.

Mode of action based risk assessment of the botanical food-borne alkenylbenzene apiol from parsley using physiologically based kinetic (PBK) modelling and read-across from safrole.

The present study developed physiologically-based kinetic (PBK) models for the alkenylbenzene apiol in order to facilitate risk assessment based on read-across from the related alkenylbenzene safrole. Model predictions indicate that in rat liver the formation of the 1'-sulfoxy metabolite is about 3 times lower for apiol than for safrole. These data support that the lower confidence limit of the benchmark dose resulting in a 10% extra cancer incidence (BMDL10) that would be obtained in a rodent carcinogenicity study with apiol may be 3-fold higher for apiol than for safrole. These results enable a preliminary risk assessment for apiol, for which tumor data are not available, using a BMDL10 value of 3 times the BMDL10 for safrole. Based on an estimated BMDL10 for apiol of 5.7-15.3 mg/kg body wt per day and an estimated daily intake of 4 × 10(-5) mg/kg body wt per day, the margin of exposure (MOE) would amount to 140,000-385,000. This indicates a low priority for risk management. The present study shows how PBK modelling can contribute to the development of alternatives for animal testing, facilitating read-across from compounds for which in vivo toxicity studies on tumor formation are available to compounds for which these data are unavailable.