Suture Catheter for Rescue Perineural Catheter Placement When Unable to Position a Conventional Through-the-Needle Catheter: A Case Report.

The main purported benefit of suture-style catheters is the ability to secure the catheter at 2 sites, thereby decreasing the likelihood of catheter dislodgement. An additional benefit is the ability to precisely control the placement of the orifice to infuse local anesthetic. Here we present the case of a patient undergoing open ankle surgery for whom placement of a conventional through-the-needle popliteal sciatic perineural catheter for postoperative analgesia was attempted. Despite multiple attempts, the catheter repeatedly advanced beyond the nerve. Placement of a suture catheter was then attempted, and the catheter was successfully placed on the first attempt.

A Predictive Model for Determining Patients Not Requiring Prolonged Hospital Length of Stay After Elective Primary Total Hip Arthroplasty.

BACKGROUND: Hospital length of stay (LOS) is an important quality metric for total hip arthroplasty. Accurately predicting LOS is important to expectantly manage bed utilization and other hospital resources. We aimed to develop a predictive model for determining patients who do not require prolonged LOS. METHODS: This was a retrospective single-institution study analyzing patients undergoing elective unilateral primary total hip arthroplasty from 2014 to 2016. The primary outcome of interest was LOS less than or equal to the expected duration, defined as ≤3 days. Multivariable logistic regression was performed to generate a model for this outcome, and a point-based calculator was designed. The model was built on a training set, and performance was assessed on a validation set. The area under the receiver operating characteristic curve and the Hosmer-Lemeshow test were calculated to determine discriminatory ability and goodness-of-fit, respectively. Predictive models using other machine learning techniques (ridge regression, Lasso, and random forest) were created, and model performances were compared. RESULTS: The point-based score calculator included 9 variables: age, opioid use, metabolic equivalents score, sex, anemia, chronic obstructive pulmonary disease, hypertension, obesity, and primary anesthesia type. The area under the receiver operating characteristic curve of the calculator on the validation set was 0.735 (95% confidence interval, 0.675-0.787) and demonstrated adequate goodness-of-fit (Hosmer-Lemeshow test, P = .37). When using a score of 12 as a threshold for predicting outcome, the positive predictive value was 86.1%. CONCLUSIONS: A predictive model that can help identify patients at higher odds for not requiring a prolonged hospital LOS was developed and may aid hospital administrators in strategically planning bed availability to reduce both overcrowding and underutilization when coordinating with surgical volume.

Predicting patients requiring discharge to post-acute care facilities following primary total hip replacement: Does anesthesia type play a role?

STUDY OBJECTIVE: We sought to develop a predictive model for discharge to post-acute care facilities in patients undergoing unilateral total hip replacement (THR). Furthermore, we sought to determine if the use of neuraxial anesthesia was an important covariate for the predictive model. DESIGN: Retrospective observational study. SETTING: Preoperative care and operating room at a single institution. PATIENTS: Patients (n = 960) who underwent an elective primary THR between 2014 and 2016. INTERVENTIONS: No intervention was performed. MEASUREMENTS: We collected variables that were known preoperatively including age, sex, body mass index (BMI), preoperative opioid use, functional status based on metabolic equivalents (METS), preoperative anemia, thrombocytopenia, osteoarthritis and contralateral osteoarthritis grade, anesthesia type, comorbidities and surgical approach. We then performed multivariable logistic regression to develop a predictive model. MAIN RESULTS: Female sex, preoperative opioid use, older age, general anesthesia, anemia, hypertension, a psychiatric diagnosis, use of dialysis, metabolic equivalents <4 and obesity are all risk factors for a post-acute facility discharge. The use of general anesthesia compared to neuraxial anesthesia was associated with increased odds (odds ratio 1.98, 95% confidence interval 1.31-3.00, p = 0.001) for post-acute facility discharge. Model performance was assessed using ten-fold cross-validation - the average area under the receiver operating characteristic curve calculated was 0.794. CONCLUSIONS: We developed a predictive model for post-acute care facility discharge following THR. The use of neuraxial anesthesia was associated with decreased odds for post-acute care facility discharge.

Transcriptional corepressors HIPK1 and HIPK2 control angiogenesis via TGF-ß-TAK1-dependent mechanism.

Several critical events dictate the successful establishment of nascent vasculature in yolk sac and in the developing embryos. These include aggregation of angioblasts to form the primitive vascular plexus, followed by the proliferation, differentiation, migration, and coalescence of endothelial cells. Although transforming growth factor-ß (TGF-ß) is known to regulate various aspects of vascular development, the signaling mechanism of TGF-ß remains unclear. Here we show that homeodomain interacting protein kinases, HIPK1 and HIPK2, are transcriptional corepressors that regulate TGF-ß-dependent angiogenesis during embryonic development. Loss of HIPK1 and HIPK2 leads to marked up-regulations of several potent angiogenic genes, including Mmp10 and Vegf, which result in excessive endothelial proliferation and poor adherens junction formation. This robust phenotype can be recapitulated by siRNA knockdown of Hipk1 and Hipk2 in human umbilical vein endothelial cells, as well as in endothelial cell-specific TGF-ß type II receptor (TßRII) conditional mutants. The effects of HIPK proteins are mediated through its interaction with MEF2C, and this interaction can be further enhanced by TGF-ß in a TAK1-dependent manner. Remarkably, TGF-ß-TAK1 signaling activates HIPK2 by phosphorylating a highly conserved tyrosine residue Y-361 within the kinase domain. Point mutation in this tyrosine completely eliminates the effect of HIPK2 as a transcriptional corepressor in luciferase assays. Our results reveal a previously unrecognized role of HIPK proteins in connecting TGF-ß signaling pathway with the transcriptional programs critical for angiogenesis in early embryonic development.