Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis.

Background: This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis. Methods: We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery. Results: Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/µL [standard deviation, 52 576.3/µL] vs 92 162.7/µL [59 330.6/µL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/µL [95% confidence interval, -65 355/µL to -20 213.90/µL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/µL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02). Conclusions: The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

Impingement and perforation of the anterior femoral cortex in cephalomedullary nailing: Systematic review and surgical techniques.

BACKGROUND: Anterior femoral cortical impingement and perforation are known risks of cephalomedullary nailing. The incidence of and risk factors for these findings have not been fully established in the literature. The purpose of this review was to answer: (1) What is the incidence of anterior femoral cortical impingement and perforation associated with cephalomedullary nailing of proximal femur fractures? (2) How does incidence vary by nail radius of curvature (ROC)? (3) What populations are at increased risk of impingement and perforation? (4) What surgical techniques prevent their occurrence? HYPOTHESIS: Our hypothesis was that impingement would be a relatively common finding following cephalomedullary nailing, and perforation would be much less frequent but still an appreciable risk. Secondarily, nails with a larger ROC would have a higher rate of impingement. PATIENTS AND METHODS: In this systematic review, PubMed, MEDLINE, and Cochrane databases were searched for articles from 1990-2020 written in English using the terms "cephalomedullary nail" or "femoral nail" and "perforation" or "impingement", and similar words. Inclusion criteria were studies discussing the complication of anterior femoral cortical impingement or perforation associated with the use of a cephalomedullary nail. Fourteen studies met inclusion criteria. Rates of anterior femoral cortical impingement or perforation, patient demographics, nail type, and ROC were extracted. Surgical techniques to prevent perforation were qualitatively reviewed. RESULTS: The rate of anterior cortical impingement with long cephalomedullary nails was 17.2% (192/1117 patients) and with short nails was 29.2% (176/602). The rate of anterior cortical perforation with long nails was 1.0% (11/1116) and with short nails was 0% (0/234). Long nails with ROC>150cm showed an impingement rate of 10.9% (62/567) and perforation rate of 1.1% (7/617 patients). Nails with ROC 150cm or 100cm had an impingement rate of 1.1% (1/93) and perforation rate of 0% (0/93). DISCUSSION: Impingement and perforation of the anterior femoral cortex during cephalomedullary nailing are appreciable risks that surgeons should anticipate and avoid, especially in certain populations and with nails with larger ROC. Surgeons may consider use of long nails with ROC 150cm and below, given a nearly 10-fold lower incidence of impingement and no reported perforations. LEVEL OF EVIDENCE: Therapeutic, level IV.

Posterior Spinal Fusion for Scoliosis in the Oldest Reported Patient with Crane-Heise Syndrome: A Case Report.

CASE: A 14-year-old adolescent girl with Crane-Heise syndrome-the oldest such patient in the literature-presented to our clinic with progressive scoliosis, including a 90° T6-L3 apex right curve. She underwent a T3-pelvis posterior spinal fusion. Intraoperatively, she had small, poorly visualized upper thoracic pedicles, incomplete fusion of the posterior spinal elements, and limitations of intraoperative neuromonitoring. Adherence to dysplastic scoliosis principles allowed for an uncomplicated procedure with an excellent correction. CONCLUSION: We discuss the surgical management of scoliosis in an adolescent with Crane-Heise syndrome. This is a very rare skeletal dysplasia, with 9 reported cases in the literature.

The Effects of Bundled Payment Programs for Hip and Knee Arthroplasty on Patient-Reported Outcomes.

BACKGROUND: Patient-reported outcomes are essential to demonstrate the value of hip and knee arthroplasty, a common target for payment reforms. We compare patient-reported global and condition-specific outcomes after hip and knee arthroplasty based on hospital participation in Medicare's bundled payment programs. METHODS: We performed a prospective observational study using the Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement trial. Differences in patient-reported outcomes through 6 months were compared between bundle and nonbundle hospitals using mixed-effects regression, controlling for baseline patient characteristics. Outcomes were the brief Knee Injury and Osteoarthritis Outcomes Score or the brief Hip Disability and Osteoarthritis Outcomes Score, the Patient-Reported Outcomes Measurement Information System Physical Health Score, and the Numeric Pain Rating Scale, measures of joint function, overall health, and pain, respectively. RESULTS: Relative to nonbundled hospitals, arthroplasty patients at bundled hospitals had slightly lower improvement in Knee Injury and Osteoarthritis Outcomes Score (-1.8 point relative difference at 6 months; 95% confidence interval -3.2 to -0.4; P = .011) and Hip Disability and Osteoarthritis Outcomes Score (-2.3 point relative difference at 6 months; 95% confidence interval -4.0 to -0.5; P = .010). However, these effects were small, and the proportions of patients who achieved a minimum clinically important difference were similar. Preoperative to postoperative change in the Patient-Reported Outcomes Measurement Information System Physical Health Score and Numeric Pain Rating Scale demonstrated a similar pattern of slightly worse outcomes at bundled hospitals with similar rates of achieving a minimum clinically important difference. CONCLUSIONS: Patients receiving care at hospitals participating in Medicare's bundled payment programs do not have meaningfully worse improvements in patient-reported measures of function, health, or pain after hip or knee arthroplasty.

Patient-Reported Outcomes Following Total Hip Arthroplasty: A Multicenter Comparison Based on Surgical Approaches.

BACKGROUND: Comparisons of patient-reported outcomes (PROs) based on surgical approach for total hip arthroplasty (THA) in the United States are limited to series from single surgeons or institutions. Using prospective data from a large, multicenter study, we compare preoperative to postoperative changes in PROs between posterior, transgluteal, and anterior surgical approaches to THA. METHODS: Patient-reported function, global health, and pain were systematically collected preoperatively and at 1, 3, and 6 months postoperatively from patients undergoing primary THA at 26 sites participating in the Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement (ClinicalTrials.gov: NCT02810704). Outcomes consisted of the brief Hip disability and Osteoarthritis Outcome Score, the Patient-Reported Outcomes Measurement Information System Physical Health score, and the Numeric Pain Rating Scale. Operative approaches were grouped by surgical plane relative to the abductor musculature as being either anterior, transgluteal, or posterior. RESULTS: Between 12/12/2016 and 08/31/2019, outcomes from 3018 eligible participants were examined. At 1 month, the transgluteal cohort had a 2.2-point lower improvement in Hip disability and Osteoarthritis Outcomes Score (95% confidence interval, 0.40-4.06; P = .017) and a 1.3-point lower improvement in Patient-Reported Outcomes Measurement Information System Physical Health score (95% confidence interval, 0.48-2.04; P = .002) compared to posterior approaches. There was no significant difference in improvement between anterior and posterior approaches. At 3 and 6 months, no clinically significant differences in PRO improvement were observed between groups. CONCLUSION: PROs 6 months following THA dramatically improved regardless of the plane of surgical approach, suggesting that choice of surgical approach can be left to the discretion of surgeons and patients without fear of differential early outcomes.

Limited-access consumption of ascending ethanol concentrations in alcohol-preferring, nonpreferring, and Sprague-Dawley rats.

BACKGROUND: Ethanol intake and preference differences between the selectively bred alcohol-preferring (P) and nonpreferring (NP) rats have generally been studied in a continuous-access paradigm using 10% ethanol. Little is known about the consumption of lower concentrations of ethanol in these lines or consumption of a wide range of ethanol concentrations in limited-access paradigms. Recently, limited-access paradigms have been used to study the biological and pharmacological mechanisms of ethanol consumption in animal models. Such research would be informed by studies investigating ethanol oral self-administration within a limited-access context. Therefore, the current study addressed P, NP, and Sprague-Dawley (SD) rats' consumption of a wide range of ethanol concentrations in a 2-bottle-choice, limited-access procedure. METHODS: Male P, NP, and SD rats were given concurrent access to water and ethanol solutions for 1 h/d, 7 d/wk. Ethanol solutions were presented in an ascending series ranging from 0.01 to 20% (v/v) over 55 days. Ethanol intakes (g/kg), volumes of solutions consumed (mL/kg), and preference ratios were assessed for each rat line at each concentration. RESULTS: Clear differences among the 3 types of rats emerged at an ethanol concentration of 4%, although differences between P and NP rats emerged at concentrations as low as 1.8%. Alcohol-preferring rats almost exclusively preferred ethanol solutions over water at ethanol concentrations of 4% and above, whereas SD and NP rats' preference ratios were more variable. CONCLUSIONS: The results suggest that differences between P and NP rats exist at ethanol concentrations lower than those previously studied in continuous-access paradigms. They also provide a current description of the ranges of ethanol concentrations preferred by P, NP, and SD rats.

Squid is required for efficient posterior localization of oskar mRNA during Drosophila oogenesis.

The nuclear-cytoplasmic shuttling heterogeneous nuclear RNA-binding protein (hnRNP) Squid (Sqd) is required during Drosophila melanogaster oogenesis, where it plays a critical role in the regulation of the TGFalpha-like molecule Gurken (Grk). Three Sqd isoforms have been described, SqdA, S and B, and two of these, SqdA and SqdS, differentially function in grk mRNA nuclear export, cytoplasmic transport and translational control during oogenesis. Here, we report that Sqd is also required for the regulation of oskar (osk) mRNA, functioning in the cytoplasmic localization of the osk transcript. In oocytes from sqd females, osk mRNA is not efficiently localized to the posterior pole, but rather accumulates at the anterior cortex. Furthermore, anterior patterning defects observed in embryos from sqd females expressing only the SqdS protein isoform suggest that Sqd may also play a role in the translational regulation of the mislocalized osk mRNA. These findings provide additional support for models of mRNA regulation in which cytoplasmic events, such as localization and translational regulation, are coupled. These results also place Sqd among an emerging class of proteins, including such other members as Bruno (Bru) and Hrb27C/Hrp48, which function in multiple aspects of both grk and osk mRNA regulation during Drosophila oogenesis.