A Simple Tool for Recommending Postoperative Status After Lower Extremity Total Joint Replacement.

There is an increasing impetus to perform primary total hip arthroplasty and total knee arthroplasty on an outpatient basis and in the outpatient setting. However, with recent federal regulatory changes, orthopedic surgeons must now evaluate patients on a case-by-case basis to determine whether an inpatient admission will be medically necessary and appropriate. We thus created our prototype Lower Extremity Inpatient-Outpatient (LET-IN-OUT) total joint replacement tool as a simple, consistent way for other clinicians to identify specific major preoperative patient comorbidities and thus to recommend independently and objectively to the orthopedic surgeon postoperative inpatient or outpatient status for a given patient.

Case 263: Malaysian Charm Needles (Susuk).

History A 58-year-old woman was seen in the rheumatology clinic for bilateral wrist and knee pain that was unresponsive to physiotherapy and intra-articular steroid injections. Remote fracture of the left tibia from a motor vehicle collision was reported and was previously treated with conservative management. Serologic work-up for inflammatory disease was negative. The patient reported no prior surgical or medical history. Social history revealed remote immigration from Malaysia. Radiographs of the hands and knees were obtained.

Case 263.

History A 58-year-old woman was seen in the rheumatology clinic for bilateral wrist and knee pain that was unresponsive to physiotherapy and intra-articular steroid injections. Remote fracture of the left tibia from a motor vehicle collision was reported and was previously treated with conservative management. Serologic work-up for inflammatory disease was negative. The patient reported no prior surgical or medical history. Social history revealed remote immigration from Malaysia. Radiographs of the hands and knees were obtained ( Figs 1 - 4 ). [Figure: see text][Figure: see text][Figure: see text][Figure: see text].

Pacemaker-detected atrial fibrillation in patients with pacemakers: prevalence, predictors, and current use of oral anticoagulation.

BACKGROUND: Dual-chamber pacemakers frequently document atrial fibrillation (AF) in patients without symptoms. Pacemaker-detected AF is associated with a 2.5-fold increased risk of stroke, although it is not established whether oral anticoagulation reduces this risk. This study sought to determine the prevalence and predictors of pacemaker-detected AF and to document current oral anticoagulant use. METHODS: A retrospective analysis included all patients from a single academic hospital who had pacemakers capable of documenting AF. Blinded evaluation of all echocardiograms conducted within 6 months of implantation was performed. RESULTS: Of 445 patients, pacemaker-detected AF was present in 246 (55.3%), who were older (74.3 ± 13.7 years vs 71.7 ± 14.4, P = 0.046), more likely to have a history of clinical AF (29.7% vs 19.1%, P = 0.01), and had a larger left atrial volume index (34.4 ± 11.8 mL/m(2) vs 30.0 ± 9.9 mL/m(2), P = 0.019) than the patients without pacemaker-detected AF. Among patients without a clinical history of AF, left atrial volume index was higher among those with pacemaker-detected AF (33.7 ± 11.3 mL/m(2) vs 29.0 ± 10.1 mL/m(2), P = 0.034). Anticoagulants were used in 35.3% of patients with pacemaker-detected AF, compared with 21.6% of patients without (P < 0.05). In patients with pacemaker-detected AF, anticoagulants were used more frequently among patients who also had clinical AF (58.9%) compared with those without (23.7%, P < 0.001). CONCLUSIONS: Pacemaker-detected AF occurs in 50% of pacemaker patients and is treated with anticoagulants in less than 25% of patients who do not have a history of clinical AF. Clinical trials are needed to determine the role of anticoagulation in this population.

Ligand redox effects in the synthesis, electronic structure, and reactivity of an alkyl-alkyl cross-coupling catalyst.

The ability of the terpyridine ligand to stabilize alkyl complexes of nickel has been central in obtaining a fundamental understanding of the key processes involved in alkyl-alkyl cross-coupling reactions. Here, mechanistic studies using isotopically labeled (TMEDA)NiMe(2) (TMEDA = N,N,N',N'-tetramethylethylenediamine) have shown that an important catalyst in alkyl-alkyl cross-coupling reactions, (tpy')NiMe (2b, tpy' = 4,4',4' '-tri-tert-butylterpyridine), is not produced via a mechanism that involves the formation of methyl radicals. Instead, it is proposed that (terpyridine)NiMe complexes arise via a comproportionation reaction between a Ni(II)-dimethyl species and a Ni(0) fragment in solution upon addition of a terpyridine ligand to (TMEDA)NiMe(2). EPR and DFT studies on the paramagnetic (terpyridine)NiMe (2a) both suggest that the unpaired electron resides heavily on the terpyridine ligand and that the proper electronic description of this nickel complex is a Ni(II)-methyl cation bound to a reduced terpyridine ligand. Thus, an important consequence of these results is that alkyl halide reduction by (terpyridine)NiR(alkyl) complexes appears to be substantially ligand based. A comprehensive survey investigating the catalytic reactivity of related ligand derivatives suggests that electronic factors only moderately influence reactivity in the terpyridine-based catalysis and that the most dramatic effects arise from steric and solubility factors.