A Comparison of Two Dosing Regimens of ASA Following Total Hip and Knee Arthroplasties.

BACKGROUND: The purpose of this study was to compare short-term side effects of aspirin (ASA) 325 mg vs ASA 81 mg orally twice daily (PO BID) when used as thromboembolic prophylaxis following primary total joint arthroplasty. METHODS: A 1-year prospective cohort study was performed on 643 primary unilateral total joint arthroplasty patients operated on by a single surgeon. Two hundred eighty-two patients were administered ASA 325 mg PO BID and 361 patients were administered ASA 81 mg PO BID for 1 month. A questionnaire assessing the side effects of ASA intake was administered 1 month postoperatively. RESULTS: The overall rate of gastrointestinal side effects (GI upset and nausea) was 1.9%, but ASA 325 mg had a higher rate 9/282 (3.2%) than ASA 81 mg 3/361 (0.8%), P = .04. Overall GI bleeding was 0.9%, with 2/282 (0.7%) in the ASA 325 mg group, vs 4/361 (1.1%) in the ASA 81 mg group, P = .70. One patient in the ASA 81 mg group (0.3%) developed a deep vein thrombosis. No patient developed pulmonary embolism, periprosthetic joint infection, tinnitus, wheezing and/or shortness of breath, chest pain, or headaches. In the ASA 325 mg group, 9/282 (3.2%) discontinued ASA and in the ASA 81 mg group, 8/361 (2.2%) discontinued ASA, P = .47. Four patients in the ASA 325 group (1.4%) changed to ASA 81 mg. CONCLUSION: ASA 81 mg is associated with significantly less GI distress and nausea compared with ASA 325 mg. GI bleeding was equally prevalent between the 2 dosing regimens, so patients need to be informed of this risk regardless of the ASA dose.

Prevalence of Poor Bone Quality in Women Undergoing Spinal Fusion Using Biomechanical-CT Analysis.

STUDY DESIGN: Retrospective, cross-sectional analysis of vertebral bone quality in spine-fusion patients at a single medical center. OBJECTIVE: To characterize the prevalence of osteoporosis and fragile bone strength in a spine-fusion population of women with an age range of 50 years to 70 years. Fragile bone strength is defined as the level of vertebral strength below which a patient is at as high a risk of future vertebral fracture as a patient having bone density-defined osteoporosis. SUMMARY OF BACKGROUND DATA: Poor bone quality--defined here as the presence of either osteoporosis or fragile bone strength--is a risk factor for spine-fusion patients that often goes undetected but can now be assessed preoperatively by additional postprocessing of computed tomography (CT) scans originally ordered for perioperative clinical assessment. METHODS: Utilizing such perioperative CT scans for a cohort of 98 women (age range: 51-70 yr) about to undergo spine fusion, we retrospectively used a phantomless calibration technique and biomechanical-CT postprocessing analysis to measure vertebral trabecular bone mineral density (BMD) (in mg/cm³) and by nonlinear finite element analysis, vertebral compressive strength (in Newtons, N) in the L1 or L2 vertebra. Preestablished validated threshold values were used to define the presence of osteoporosis (trabecular BMD of 80 mg/cm³ or lower) and fragile bone strength (vertebral strength of 4500 N or lower). RESULTS: Fourteen percent of the women tested positive for osteoporosis, 27% tested positive for fragile bone strength, and 29% were classified as having poor bone quality (either osteoporosis or fragile bone strength). Over this narrow age range, neither BMD nor vertebral strength were significantly correlated with age, weight, height, or body mass index (P values 0.14-0.97 for BMD; 0.13-0.51 for strength). CONCLUSION: Poor bone quality appears to be common in women between ages 50 years and 70 years undergoing spinal fusion surgery. LEVEL OF EVIDENCE: 3.

Smoking cessation and bone healing: optimal cessation timing.

Smoking is a worldwide epidemic. Complications related to smoking behavior generate an economic loss around $193 billion annually. In addition to impacting chronic health conditions, smoking is linked to increased perioperative complications in those with current or previous smoking history. Numerous studies have demonstrated more frequent surgical complications including higher rates of infection, poor wound healing, heightened pain complaints, and increased pulmonary morbidities in patients with a smoking history. Longer preoperative cessation periods also seem to correlate with reduced rates. At roughly 4 weeks of cessation prior to surgery, complication rates more closely reflect individuals without a smoking history in comparison with those that smoke within 4 weeks of surgery. In the musculoskeletal system, a similar trend has been observed in smokers with higher rates of fractures, nonunions, malunions, infections, osteomyelitis, and lower functional scores compared to non-smoking patients. Unfortunately, the present literature lacks robust data suggesting a temporal relationship between smoking cessation and bone healing. In our review, we analyze pseudoarthrosis rates following spinal fusion to suggest that bone healing in the context of smoking behavior follows a similar time sequence as observed in wound healing. We also discuss the implications for further clarity on bone healing and smoking cessation within orthopedics including improved risk stratification and better identification of circumstances where adjunct therapy is appropriate.

Evaluation of a novel technique for wound closure using a barbed suture.

BACKGROUND: Suture knots present several disadvantages in wound closure, because they are tedious to tie and place ischemic demands on tissue. Bulky knots may be a nidus for infection, and they may extrude through skin weeks after surgery. Needle manipulations during knot-tying predispose the surgeon to glove perforation. A barbed suture was developed that is self-anchoring, requiring no knots or slack management for wound closure. The elimination of knot tying may have advantages over conventional wound closure methods. METHODS: This prospective, randomized, controlled trial was designed to show that the use of barbed suture in dermal closure of the Pfannenstiel incision during nonemergent cesarean delivery surgery produces scar cosmesis at 5 weeks that is no worse than that observed with conventional closure using 3-0 polydioxanone suture. Cosmesis was assessed by review of postoperative photographs by a blinded, independent plastic surgeon using the modified Hollander cosmesis score. Secondary endpoints included infection, dehiscence, pain, closure time, and other adverse events. RESULTS: The study enrolled 195 patients, of whom 188 were eligible for analysis. Cosmesis scores did not significantly differ between the barbed suture group and the control group. Rates of infection, dehiscence, and other adverse events did not significantly differ between the two groups. Closure time and pain scores were comparable between the groups. CONCLUSIONS: The barbed suture represents an innovative option for wound closure. With a cosmesis and safety profile that is similar to that of conventional suture technique, it avoids the drawbacks inherent to suture knots.

Intramuscular neuromuscular electric stimulation for poststroke shoulder pain: a multicenter randomized clinical trial.

OBJECTIVE: To assess the effectiveness of intramuscular neuromuscular electric stimulation (NMES) in reducing poststroke shoulder pain. DESIGN: Multicenter, single-blinded, randomized clinical trial. SETTING: Ambulatory centers of 7 academic rehabilitation centers in the United States. PARTICIPANTS: Volunteer sample of 61 chronic stroke survivors with shoulder pain and subluxation. INTERVENTION: Treatment subjects received intramuscular NMES to the supraspinatus, posterior deltoid, middle deltoid, and trapezius for 6 hours a day for 6 weeks. Control subjects were treated with a cuff-type sling for 6 weeks. Main outcome measure Brief Pain Inventory question 12 (BPI 12), an 11-point numeric rating scale administered in a blinded manner at the end of treatment, and at 3 and 6 months posttreatment. RESULTS: The NMES group exhibited significantly higher proportions of success based on the 3-point or more reduction in BPI 12 success criterion at the end of treatment (65.6% vs 24.1%, P<.01), at 3 months (59.4% vs 20.7%, P<.01), and at 6 months (59.4% vs 27.6%, P<.05). By using the most stringent "no pain" criterion, the NMES group also exhibited significantly higher proportions of success at the end of treatment (34.4% vs 3.4%, P<.01), at 3 months (34.4% vs 0.0%, P<.001), and at 6 months (34.4% vs 10.3%, P<.05). CONCLUSIONS: Intramuscular NMES reduces poststroke shoulder pain among those with shoulder subluxation and the effect is maintained for at least 6 months posttreatment.

Biaxial failure behavior of bovine tibial trabecular bone.

Multiaxial failure properties of trabecular bone are important for modeling of whole bone fracture and can provide insight into structure-function relationships. There is currently no consensus on the most appropriate form of multiaxial yield criterion for trabecular bone. Using experimentally validated, high-resolution, non-linear finite element models, biaxial plain strain boundary conditions were applied to seven bovine tibial specimens. The dependence of multiaxial yield properties on volume fraction was investigated to quantify the interspecimen heterogeneity in yield stresses and strains. Two specimens were further analyzed to determine the yield properties for a wide range of biaxial strain loading conditions. The locations and quantities of tissue level yielding were compared for on-axis, transverse, and biaxial apparent level yielding to elucidate the micromechanical failure mechanisms. As reported for uniaxial loading of trabecular bone, the yield strains in multiaxial loading did not depend on volume fraction, whereas the yield stresses did. Micromechanical analysis indicated that the failure mechanisms in the on-axis and transverse loading directions were mostly independent. Consistent with this, the biaxial yield properties were best described by independent curves for on-axis and transverse loading. These findings establish that the multiaxial failure of trabecular bone is predominantly governed by the strain along the loading direction, requiring separate analytical expressions for each orthotropic axis to capture the apparent level yield behavior.

Measuring children's coping.

Using a transactional model of stress and coping, a measure of children's coping is offered and applied in a semi-structured interview in which specific coping styles are assessed. Data from 176 school-age children yielded findings on age and gender differences along with other preliminary suggestions of the validity of the instrument.

Temperament as a moderator of children's stressful experiences.

Data on 158 children, six and nine years old, are analyzed for the relationship between stress and behavior. Undesirable life events and intense "hassles" were particularly correlated with behavioral symptoms. Statistically, temperament appears to moderate this influence but, lacking appreciable variance of symptoms in the models including these interaction effects, the more parsimonious main-effects concept may be more useful.

Reporting practices of psychiatrists who knew of sexual misconduct by colleagues.

Of 1423 psychiatrists responding to a national survey, 65% reported treating patients who had been sexually involved with previous therapists. Respondents saw these prior involvements as harmful in 87% of cases but reported the sexual abuse in only 8% of cases. The majority, however, favored mandatory reporting of such incidents. The problem of underreporting and the need for effective management of sexual abuse cases are discussed.