Total knee arthroplasty: Quality assurance and improved longevity costs less.

Background: There is an accepted variation in the financial cost of total knee arthroplasty (TKA) implants but it is not known whether this cost is reflected by the evidence in support of their use. A cost analysis study was carried out to determine the total cost of consumables of a TKA, and whether this was related to the supporting evidence and survivorship data. Methods: Intra-operative data for all unilateral, cemented, primary TKA over a 13 month period at a high-volume Orthopaedic Centre was collected. Level of evidence for each model was taken from the Orthopaedic Data Evaluation Panel (ODEP) website, and data from the UK National Joint Registry was used to assign survivorship (failure rates). Correlation was calculated using the Spearman rank correlation (r). Results: A total of 1301 TKA were performed at the study centre during the data collection period. The mean cost of consumables for a TKA with patella resurfacing (n = 816) was £1969.08 (range of £1061.46 and £5143.89), and without resurfacing (n = 485) was £1846.62 (range of £1118.98 and £4196.81). There was a negative correlation between price of implant and ODEP rating (r = -0.47), with increasing level of evidence being associated with a lower cost. There was a positive correlation between price of implant and rate of implant failure at the1-, 3- and 5-year time-points (r = 0.55, 0.44, 0.28 respectively), with increasing cost being associated with a higher failure rate. Conclusion: Higher financial cost of TKA prostheses was associated with a weaker level of supporting evidence and a higher failure rate. The increased financial cost of new implants may be justified as more data and evidence becomes available to support an advantage in its use over currently established implants.

Tracheal Invasion and Cardiopulmonary Compromise From Primary Thyroid Lymphoma.

Rapidly expanding thyroid lesions with tracheal invasion are typical characteristics of anaplastic and undifferentiated thyroid carcinomas, but primary thyroid lymphoma (PTL) must also be considered as a differential. Aggressive thyroid lesions can compromise the airway through compression and/or direct invasion of the tracheal wall. We present a rare case of PTL in a 57-year-old female patient who presented with worsening orthopnoea and hoarseness, followed by shortness of breath, secondary to direct invasion and compression of the trachea resulting in pulmonary edema and cardiomyopathy, requiring intensive care input. In view of the extent of the disease and associated repercussions, the patient underwent total thyroidectomy and chemotherapy, as part of her therapeutic regime, with metabolic and cardiovascular remission achieved. Histological diagnosis confirmed diffuse large B-cell lymphoma (DLBCL). PTL is a rare condition, with few cases reported in the literature. Fine needle aspiration cytology (FNAC) used traditionally in the diagnosis of thyroid lesions is less informative in PTL and core needle and incisional biopsy techniques, coupled with CT, can provide diagnostic clarity. Due to the unusual nature of PTL, it can pose diagnostic and management difficulties. Further studies are required and a multi-professional tailored approach should be adopted for each patient until a therapeutic consensus can be reached.

The Effect of Positive and Negative Poster Messages on Organ Donor Registration.

BACKGROUND: There is a mismatch between the number of people who require transplants and the number of organ donors. Promotional materials have been shown to increase rates of organ donor registration. This study assessed the impact on the intention to join the organ donor registry of a gain-framed message about lives saved through organ donation compared to a loss-framed message about lives lost waiting for a transplant. METHODS: Two posters were designed that were identical other than the slogan. One slogan was gain-framed: "One organ donor can save 9 lives!" and the other loss-framed: "3 people die every day in the UK waiting for an organ transplant." Twenty copies of each were distributed between hospitals in Cambridge and Newcastle, UK, for 20 weeks. After 10 weeks, the gain-framed and loss-framed posters swapped locations. Each poster had a QR code that linked to the online organ donor register sign-up form, and the click-through rate was used to determine registration. Analysis was performed using a 2-tailed sign binomial test. RESULTS: Sixty-eight registrations occurred over a 20-week period. Overall, there was no significant difference in registrations between gain- and loss-framed posters (37 vs 31, P = .54). However, poster location influenced registration, as prior to the location swap there was a significant difference in gain-framed vs loss-framed posters (28 vs 10, P = .005). Additionally, registration was significantly higher in Cambridge vs Newcastle (47 vs 21, P = .01). CONCLUSIONS: Posters can increase organ donor register (ODR) registration independent of gain- or loss-framing. However, poster location, both intra- and inter-hospital, significantly influences effectiveness.

Hawthorne effect on surgical studies.

BACKGROUND: The Hawthorne effect or 'observer effect' describes a change in normal behaviour when individuals are aware they are being observed. This may have an impact on effect estimates in clinical trials. The purpose of this study was to determine if the Hawthorne effect had been recorded as a risk of bias in surgical studies. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant literature search was conducted till March 2019. Eligible studies included those reporting or not reporting the Hawthorne effect in surgical studies from the following databases: MEDLINE, Embase, CINAHL, AMED, BNI, HMIC, PsycINFO, Web of Science, Cochrane Library, Google Scholar and OpenGrey. Two reviewers independently reviewed the papers, extracted data and appraised study methods using the Newcastle Ottawa Scale or the Cochrane risk of bias tool. Data were analysed descriptively. RESULTS: A total of 842 papers were identified, of which 16 were eligible. Six (37%) observational studies were identified with the aim of measuring the Hawthorne effect on their outcome with five reporting that the Hawthorne effect was responsible for the improvements in outcomes and one reporting no change in outcome due to the Hawthorne effect. Ten (63%) studies were identified, of which eight used the Hawthorne effect as an explanation to improvements seen in the control group or their secondary outcomes and two to compare their results with other studies. CONCLUSION: There is considerable between-study heterogeneity on how the Hawthorne effect relates to surgical outcomes. Further consideration on reporting and considering the importance of the Hawthorne effect in the design of surgical trials is warranted.

Making the weekend work: a local quality improvement project to establish and improve the quality of weekend handover.

Handover is widely identified by the National Confidential Enquiry into Patient Outcome and Death, the Royal College of Physicians (RCP) and Health Foundation as an area that can lead to shortcomings in patient care. We recognised that the current weekend handover process in the Trauma and Orthopaedics department at Frimley Park Hospital was dated, time-consuming and did not promote handover of sufficient patient details. The Royal College of Surgeons, British Medical Association and RCP have guidelines on handover. Our aim was to use these to establish the quality of handovers and introduce methods to better the accuracy and effectiveness of weekend handover in the department, thus improving patient care and safety. Initially, we measured the quality of the existing handover documentation for how comprehensively it was completed. We then implemented a two-step change, reauditing each step, resulting in a handover tool on the trust intranet. Finally, we repeated our audit to monitor sustainability. The 10 categories measured were: 'Patient name', 'Date of birth', 'Hospital number', 'Date of admission', 'Location', 'Consultant', 'Admission reason', 'Date of operation', 'Frequency of review' and discharge paperwork ('TTO'). The original handover documentation had good compliance with 'Patient name' (99%), 'Hospital number' (94%) and 'Admission reason' (91%) but was poor in all other categories, ranging from 12% to 84%. The only category that met its standard was 'Admission reason'. Almost every category improved with the new intranet tool. Five areas met their standard ('Patient name', 'Location', 'Consultant', 'Admission reason' and 'Frequency of review'). Specific prompts resulted in 100% compliance for 'Frequency of review'. The poorest compliance was again seen for 'TTO' (18%). In a short four months, we created an intranet handover tool that resulted in significant and sustainable improvements in the quality, detail and accuracy of handovers, making identification of sick patients safer and more efficient.

Cytological study on the regulation of lymphocyte homing in the chicken spleen during LPS stimulation.

The immune function of the chicken spleen depends on its different compartments of red and white pulps, but little is known about the mechanism underlying lymphocyte homing towards the different compartments. In the present study, the role of lymphocyte homing in the chicken spleen was investigated during lipopolysaccharide (LPS) stimulation. Morphological analysis demonstrated the cuboidal endothelial cells of the splenic sheathed capillary facilitated the passage of lymphocyte homing to the chicken spleen. The tissue-specific adhesion molecules- vascular cell adhesion molecule-1 (VCAM-1) and mucosal addressin cell adhesion molecule-1 (MADCAM-1) expressed on the sheathed capillary, which suggested the high endothelial venule (HEV)-like vessels of the chicken spleen. Electron microscope analysis showed LPS activated the endothelium of the sheathed capillary and recruited lymphocytes to the chicken spleen. Transferring of 5, 6- carboxyfluorescein diacetate, succinimidyl ester (CFSE) labeled lymphocytes depicted the rout of lymphocyte homing to the compartments of the chicken spleen was from the white pulp to the red pulp. Furthermore, the mRNA and protein levels of adhesion molecular integrin ß1 and VCAM-1 increased after LPS stimulation. The mechanism underlying the integrin ß1 and VCAM-1 during LPS stimulation might be associated with the integrin linked kinase (ILK)- dependent regulation of protein kinase B (PKB/AKT). This study firstly shows lymphocyte homing in the chicken spleen after LPS-induced inflammation. These results contribute to our knowledge of comparative immunology and provide a better means for investigating the pharmacological strategies concerning the possible role of lymphocyte homing in inflammation and immunological reactions in infectious disease.

Subcellular Evidence for Biogenesis of Autophagosomal Membrane during Spermiogenesis In vivo.

Although autophagosome formation has attracted substantial attention, the origin and the source of the autophagosomal membrane remains unresolved. The present study was designed to investigate in vivo subcellular evidence for the biogenesis of autophagosomal membrane during spermiogenesis using transmission-electron microscopy (TEM), Western blots and immunohistochemistry in samples from the Chinese soft-shelled turtle. The testis expressed LC3-II protein, which was located within spermatids at different stages of differentiation and indicated active autophagy. TEM showed that numerous autophagosomes were developed inside spermatids. Many endoplasmic reticulum (ER) were transferred into a special "Chrysanthemum flower center" (CFC) in which several double-layer isolation membranes (IM) were formed and extended. The elongated IM always engulfed some cytoplasm and various structures. Narrow tubules connected the ends of multiple ER and the CFC. The CFC was more developed in spermatids with compact nuclei than in spermatids with granular nuclei. An IM could also be transformed from a single ER. Sometimes an IM extended from a trans-Golgi network and wrapped different structures. The plasma membrane of the spermatid invaginated to form vesicles that were distributed among various endosomes around the CFC during spermiogenesis. All this cellular evidence suggests that, in vivo, IM was developed mainly by CFC produced from ER within differentiating spermatids during spermiogenesis. Vesicles from Golgi complexes, plasma membranes and endosomes might also be the sources of the autophagosome membrane.

Expression of TLR2/4 on Epididymal Spermatozoa of the Chinese Soft-Shelled Turtle Pelodiscus sinensis During the Hibernation Season.

Spermatozoa are known to be stored in the epididymis of the Chinese soft-shelled turtle Pelodiscus sinensis for long periods during hibernation, but the mechanism that underlies the sperm storage is poorly understood. This study was carried out to confirm the presence of TLR2/4 (Toll-like receptor 2/4) in epididymal spermatozoa during the hibernation season and to analyze whether TLRs play a role in sperm storage. The structure and ultrastructure of a spermatozoon during the hibernation stage were investigated using light- and transmission electron-microscopy. RT-PCR was used to analyze mRNA expression, while protein expression was determined via Western blot. TLR2/4 mRNA and proteins were detected in spermatozoa. Immunofluorescence staining was used to confirm TLR2/4 localization in the spermatozoon, and TLR2/4 were localized in the midpiece and the posterior segment of the head of the spermatozoon, which corresponded to the cytoplasmic droplets (CDs) of the turtle spermatozoon. As TLRs play critical roles in detecting and responding to invading pathogens, this study provided molecular evidence that TLR2/4 might contribute to sperm storage in the epididymides. Anat Rec, 299:1578-1584, 2016. © 2016 Wiley Periodicals, Inc.

Cellular evidence for nano-scale exosome secretion and interactions with spermatozoa in the epididymis of the Chinese soft-shelled turtle, Pelodiscus sinensis.

The epididymis is the location of sperm maturation and sperm storage. Recent studies have shown that nano-scale exosomes play a vital role during these complicated processes. Our aim was to analyze the secretory properties of epididymal exosomes and their ultrastructural interaction with maturing spermatozoa in the Chinese soft-shelled turtle. The exosome marker CD63 was primarily localized to the apices of principal cells throughout the epididymal epithelium. Identification of nano-scale exosomes and their secretory processes were further investigated via transmission electron microscopy. The epithelium secreted epididymal exosomes (50~300 nm in diameter) through apocrine secretion and the multivesicular body (MVB) pathway. Spermatozoa absorbed epididymal exosomes through endocytosis or membrane fusion pathways. This study shows, for the first time, that nano-scale exosomes use two secretion and two absorption pathways in the reptile, which may be contribute to long-term sperm storage.

Androgen-related sperm storage in oviduct of Chinese Soft-Shelled Turtle in vivo during annual cycle.

Long-term sperm storage in the female genital tract is essential for the appropriate timing of reproductive events in animals with asynchronous copulation and ovulation. However, the mechanism underlying the prolonged storage of spermatozoa is largely unexplored in turtles. In the present study, the role of androgen in sperm storage was investigated in the oviduct of the Chinese soft-shelled turtle, Pelodiscus sinensis. Morphological analysis revealed that spermatozoa were observed in the vagina, uterus and isthmus of the oviduct throughout the hibernation season. The increase of circulating testosterone and dihydrotestosterone levels were consistent with the arrangement of spermatozoa that had their head embedded among the cilia of the oviduct mucosal epithelium. Immunohistochemical analysis revealed that androgen receptor was distributed throughout the cytoplasm of gland cells and among the cilia of ciliated cells. Furthermore, marked variations in protein and mRNA levels of androgen receptor were validated through Western blot and qPCR analyses. The localization and the variation of androgen receptor demonstrated the crucial roles of androgens in sperm storage in the oviduct of P. sinensis. These results provide fundamental insights into the interaction of androgen and sperm storage and facilitate the elucidation of the mechanism of sperm storage in turtles.

Lymphocyte migration in the micro-channel of splenic sheathed capillaries in Chinese soft-shelled turtles, Pelodiscus sinensis.

The structural characteristics of the splenic sheathed capillary were investigated using light microscopy and transmission electron microscopy (TEM). This study mainly focused on lymphocyte migration to the splenic white pulp via micro-channels in Chinese soft-shelled turtles, Pelodiscus sinensis. The results showed that the sheathed capillaries in the turtle spleen were high endothelial venule (HEV)-like vessels. These capillaries consist of micro-channels that facilitate lymphocyte migration to the splenic white pulp. The micro-channel is a dynamic structure comprising processes of endothelial cells, supporting cells, and ellipsoid-associated cells (EACs), which provides a microenvironment for lymphocyte migration. The pattern of lymphocyte migration in the micro-channel of the turtle spleen includes the following steps: (i) lymphocyte first adheres to the endothelium of the sheathed capillary, passes through the endothelial cells, and traverses through the basement membrane of the sheathed capillary; (ii) it then enters into the ellipsoid combined with supporting cells and EACs; and (iii) lymphocyte migrates from the ellipsoid to the periellipsoidal lymphatic sheath (PELS) via the micro-channel. This study provides morphological evidence for lymphocyte migration in the micro-channels of turtle spleens and also an insight into the mechanism of lymphocyte homing to the splenic white pulp of reptiles.

Morphological and ultrastructural study of the efferent ductules in the Chinese soft-shelled turtle Pelodiscus sinensis.

Comparative study of the turtle excurrent duct system increases our understanding the evolution of sperm motility and fertility maintenance in higher vertebrates. Therefore, in this study we observed the histology and ultrastructure organization of efferent ductules in the Pelodiscus sinensis using light and transmission electron microscopy. The efferent ductules are extra- testicular and 22-28 in number originate from rete testis. The epithelium is entirely composed of two types of cells, the predominant non-ciliated and ciliated cells. The ciliated cells have long cilia that protrude into the lumen to form a meshwork. These cells associated with clusters of mitochondria in the supranuclear cytoplasm and possess coated vesicles, vacuole, intracellular spaces, and junction complexes. Ciliated cells in the proximal portion of the ductules contain an endocytic apparatus with coated pits and tubules in the apical cytoplasm. Interdigitations and lipid droplets are predominantly present around the nuclei of these cells. The non-ciliated cells have clusters of mitochondria present in both the supranuclear and perinuclear cytoplasm whereas, the nuclei of these cells are lightly stained. Moreover, the contour of the epithelium towards lumen is irregular as it has a deep indentation. The apical cytoplasm goes deep into the lumen to form cytoplasmic processes. This is the first study to describe the detailed features of efferent ductules in Pelodiscus sinensis with, special focus on the morphology of ciliated cells, as these cells are involved in the mixing of luminal fluid and transport of spermatozoa towards the distal region.

Expression of TLR2/4 in the sperm-storing oviduct of the Chinese soft-shelled turtle Pelodiscus sinensis during hibernation season.

The initiation of innate immunology system could play an important role in the aspect of protection for sperms long-term storage when the sperms got into oviduct of turtles and come into contact with epithelium. The exploration of TLR2/4 distribution and expression in oviduct during hibernation could help make the storage mechanism understandable. The objective of this study was to examine the gene and protein expression profiles in Chinese soft-shelled turtle during hibernation from November to April in the next year. The protein distribution of TLR2/4 was investigated in the magnum, isthmus, uterus, and vagina of the turtle oviduct using immunohistochemistry, and the gene expression of TLR2/4 was analyzed using quantitative real-time PCR (qRT-PCR). The results showed positive TLR2 protein expression primarily in the epithelium of the oviduct. TLR4 immunoreactivity was widely observed in almost every part of the oviduct, particularly in the epithelium and secretory gland membrane. Analysis of protein, mRNA expression revealed the decreased expression of TLR2/4 in the magnum compared with the isthmus, uterus, and vagina during hibernation. The protein and mRNA expression of TLR2 in the magnum, isthmus, uterus, and vagina was decreased in April compared with that in November. TLR4 protein and mRNA expression in the magnum, isthmus, uterus and vagina was decreased in November compared with that in April. These results indicated that TLR2/4 expression might protect the sperm from microbial infections. In contrast to the function of TLR2, which protects sperm during the early stages of hibernation, TLR4 might play a role in later stages of storage. The present study is the first to report the functions of TLR2/4 in reptiles.

Sperm storage and spermatozoa interaction with epithelial cells in oviduct of Chinese soft-shelled turtle, Pelodiscus sinensis.

Spermatozoa are known to be stored within the female genital tract after mating in various species to optimize timing of reproductive events such as copulation, fertilization, and ovulation. The mechanism supporting long-term sperm storage is still unclear in turtles. The aim of this study was to investigate the interaction between the spermatozoa and oviduct in Chinese soft-shelled turtle by light and electron microscopy to reveal the potential cytological mechanism of long-term sperm storage. Spermatozoa were stored in isthmus, uterine, and vagina of the oviduct throughout the year, indicating long-term sperm storage in vivo. Sperm heads were always embedded among the cilia and even intercalated into the apical hollowness of the ciliated cells in the oviduct mucosal epithelium. The stored spermatozoa could also gather in the gland conduit. There was no lysosome distribution around the hollowness of the ciliated cell, suggesting that the ciliated cells of the oviduct can support the spermatozoa instead of phagocytosing them in the oviduct. Immune cells were sparse in the epithelium and lamina propria of oviduct, although few were found inside the blood vessel of mucosa, which may be an indication of immune tolerance during sperm storage in the oviduct of the soft-shelled turtle. These characteristics developed in the turtle benefited spermatozoa survival for a long time as extraneous cells in the oviduct of this species. These findings would help to improve the understanding of reproductive regularity and develop strategies of species conservation in the turtle. The Chinese soft-shelled turtle may be a potential model for uncovering the mechanism behind the sperm storage phenomenon.

B-cell lymphoma-2 localization in the female reproductive tract of the Chinese soft-shelled turtle, Pelodiscus sinensis and its relationship with sperm storage.

The aim of the present study was to investigate the expression and localization of B-cell lymphoma-2 (Bcl-2) in the oviduct of the Chinese soft-shelled turtle, Pelodiscus sinensis, during the reproductive cycle to analyze the relationship between Bcl-2 and sperm storage. Bcl-2 expression was confirmed in the P. sinensis oviduct by western blot analysis. Hematoxylin-eosin staining showed that female P. sinensis stored sperm from November to April of the following year. The oviduct showed positive immunostaining for Bcl-2 of epithelial ciliated cells, gland ducts, and gland cells. Bcl-2 expression in the oviduct was associated with sperm storage occurrence. This indicates that the survival factor Bcl-2 may play a role in P. sinensis sperm storage.

Telocytes: novel interstitial cells present in the testis parenchyma of the Chinese soft-shelled turtle Pelodiscus sinensis.

Telocytes (TCs) are novel interstitial cells that have been found in various organs, but the existence of TCs in the testes has not yet been reported. The present ultrastructural and immunohistochemical study revealed the existence of TCs and differentiate these cells from the peritubular cells (Pc) in contact with the surrounding structures in the testes. Firstly, our results confirmed the existence of two cell types surrounding seminiferous tubules; these were Pc (smooth muscle like characteristics) and TCs (as an outer layer around Pc). Telocytes and their long thin prolongations called telopodes (Tps) were detected as alternations of thin segments (podomers) and thick bead-like portions (podoms), the latter of which accommodate the mitochondria and vesicles. The spindle and irregularly shaped cell bodies were observed with small amounts of cytoplasm around them. In contrast, the processes of Pc contained abundant actin filaments with focal densities, irregular spine-like outgrowths and nuclei that exhibited irregularities similar to those of smooth muscle cells. The TCs connected with each other via homocellular and heterocellular junctions with Pc, Leydig cells and blood vessels. The Tps of the vascular TCs had bands and shed more vesicles than the other TCs. Immunohistochemistry (CD34) revealed strong positive expression within the TC cell bodies and Tps. Our data confirmed the existence and the contact of TCs with their surroundings in the testes of the Chinese soft-shelled turtle Pelodiscus sinensis, which may offer new insights for understanding the function of the testes and preventing and treating testicular disorders.