Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway. / Factores determinantes de la duración de la estancia hospitalaria en pacientes operados de artroplastia primaria total de rodilla usando un protocolo de recuperación mejorada (ERAS).

INTRODUCTION: There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure. OBJECTIVE: To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS). METHODS: A retrospective study is carried out on patients undergoing primary total knee arthroplasty at a University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed. RESULTS: Average age of 71.7 ± 8.2 years, 62.4% were women and the 77.3% were classified as ASA II. The significantly associated factors to an increased length of stay are: age (P = .001), ASA scale (P = .04), day of surgery (P < .001), blood transfusion (P < .001), postoperative haemoglobin level at 48-72 h (P < .001), the time of first postoperative mobilization to ambulate and climb stairs (P < .001), the need for analgesic rescues (P = .003), and the presence of postoperative nausea and vomiting (P = .008). CONCLUSIONS: There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimize the quality of care and available health resources.

Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway. / Factores determinantes de la duración de la estancia hospitalaria en pacientes operados de artroplastia primaria total de rodilla usando un protocolo de recuperación mejorada (ERAS).

INTRODUCTION: There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure. OBJECTIVE: To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS). METHODS: A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed. RESULTS: Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASAII. The significantly associated factors to an increased length of stay are: age (P=.001), ASA scale (P=.04), day of surgery (P<.001), blood transfusion (P<.001), postoperative hemoglobin level at 48-72h (P<.001), the time of first postoperative mobilization to ambulate and climb stairs (P<.001), the need for analgesic rescues (P=.003), and the presence of postoperative nausea and vomiting (P=.008). CONCLUSIONS: There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimize the quality of care and available health resources.

Targeted next-generation sequencing identifies clinically relevant mutations in patients with chronic neutrophilic leukemia at diagnosis and blast crisis

Purpose. Chronic neutrophilic leukemia is a rare form of myeloproliferative neoplasm characterized by mature neutrophil hyperleukocytosis. The majority of patients harbor somatic mutations of CSF3R gene and are potentially amenable to targeted therapy with JAK inhibitors. The incidence and clinical significance of additional mutations requires clarification. Materials and methods. A next-generation sequencing approach for myeloid malignancy-associated mutations was applied to diagnostic and matched blast crisis samples from four chronic neutrophilic leukemia patients. Results. Next-generation sequencing confirmed the CSF3R T618I in all patients with identification of concurrent SRSF2, SETBP1, NRAS and CBL mutations at diagnosis. At blast crisis, clonal evolution was evidenced by an increased CSF3R T618I allele frequency and by loss or acquisition of CBL and NRAS mutations. Conclusion. The diagnostic utility of a targeted next-generation sequencing approach was clearly demonstrated with the identification of additional mutations providing the potential for therapeutic stratification of chronic neutrophilic leukemia patients (AU)

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Targeted next-generation sequencing identifies clinically relevant mutations in patients with chronic neutrophilic leukemia at diagnosis and blast crisis.

PURPOSE: Chronic neutrophilic leukemia is a rare form of myeloproliferative neoplasm characterized by mature neutrophil hyperleukocytosis. The majority of patients harbor somatic mutations of CSF3R gene and are potentially amenable to targeted therapy with JAK inhibitors. The incidence and clinical significance of additional mutations requires clarification. MATERIALS AND METHODS: A next-generation sequencing approach for myeloid malignancy-associated mutations was applied to diagnostic and matched blast crisis samples from four chronic neutrophilic leukemia patients. RESULTS: Next-generation sequencing confirmed the CSF3R T618I in all patients with identification of concurrent SRSF2, SETBP1, NRAS and CBL mutations at diagnosis. At blast crisis, clonal evolution was evidenced by an increased CSF3R T618I allele frequency and by loss or acquisition of CBL and NRAS mutations. CONCLUSION: The diagnostic utility of a targeted next-generation sequencing approach was clearly demonstrated with the identification of additional mutations providing the potential for therapeutic stratification of chronic neutrophilic leukemia patients.

Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practices.

In South Africa, both HIV and gender-based violence are highly prevalent. Gender inequalities give men considerable relational power over young women, particularly in circumstances of poverty and where sex is materially rewarded. Young women are often described as victims of men, but this inadequately explains women's observed sexual agency. This paper takes a different approach. We use qualitative interviews and ethnographic observation among 16 young women from the rural Eastern Cape to explore ways young women construct their femininities and exercise agency. The data were collected as part of an evaluation of Stepping Stones, which is a participatory behavioural intervention for HIV prevention that seeks to be gender transformative. Agency was most notable in particular stages of the dating 'game', especially relationship initiation. Constructions of desirable men differed but generally reflected a wish to avoid violence, and a search for mutual respect, sexual pleasure, romance, modernity, status and money. Agency was constrained once relationships were consented to, as men expected to control their partners, using violent and non-violent methods. Women knew this and many accepted this treatment, although often expressing ambivalence. Many of the women expressed highly acquiescent femininities, with power surrendered to men, as a 'choice' that made their lives in cultural terms more meaningful. In marked contrast to this was a 'modern' femininity, centred around a desire to be 'free'. A visible third position, notably emerging after the Stepping Stones intervention, rested not on a feminist challenge to patriarchy, but on an accommodation with men's power whilst seeking to negotiate greater respect and non-violence within relations with men. These multiple and dynamic femininities open up possibilities for change. They demonstrate the need to engage with women, both as victims of patriarchy and active supporters of the gender order. The multiplicity of women's hopes and desires and circumstances of emotional and relational fulfillment provides potential for interventions with women that acknowledge existing gender inequalities, validate women's agency, reduce violence and prevent HIV.

A mathematical model for patient skin dose assessment in cardiac catheterization procedures.

A mathematical model has been developed for the assessment of patient skin doses from cardiac catheterization procedures. This uses exposure and projection data stored in the DICOM image files. Since these contain only information about the acquisition runs, a correction is needed to estimate and include the contribution from fluoroscopy. Maximum skin doses calculated by the model were found to correlate well with those measured on Kodak EDR2 film. Three methods for including the contribution from fluoroscopy were investigated, and all successfully identified patients receiving skin doses in excess of 1 Gy. It is hoped to automate this tool for routine assessment of skin doses in our cardiac catheterization laboratories.

Kodak EDR2 film for patient skin dose assessment in cardiac catheterization procedures.

Patient skin doses were measured using Kodak EDR2 film for 20 coronary angiography (CA) and 32 percutaneous transluminal coronary angioplasty (PTCA) procedures. For CA, all skin doses were well below 1 Gy. However, 23% of PTCA patients received skin doses of 1 Gy or more. Dose-area product (DAP) was also recorded and was found to be an inadequate indicator of maximum skin dose. Practical compliance with ICRP recommendations requires a robust method for skin dosimetry that is more accurate than DAP and is applicable over a wider dose range than EDR2 film.

Film dosimetry for fluoroscopic procedures: potential errors.

Kodak EDR 2 film was calibrated across the range of beam qualities and exposure rates typically used in our cardiac catheterisation laboratory. Its dose-response curve was successfully modelled up to its saturation point of 1 Gy. The consistency of the film's response with film batch, time between exposure and processing processor and day-to-day variations in performance, was investigated. The effects of field size, exposure rate, beam quality and use of the dynamic wedge filter were quantified. The overall uncertainty in dose was estimated to be between -20% and +40%, at 160 mGy. This uncertainty increases as the film approaches its saturation point. In addition, some unusual artefacts were observed.

Barium enema: use of increased copper filtration to optimize dose and image quality.

The purpose of this study was to determine and validate the optimum copper filtration for adult double contrast barium enema examinations. Entrance surface dose rates to polymethyl methacrylate slabs and corresponding image intensifier input kermas, were measured for various added copper filters. Image contrast was assessed using a Leeds TO.10 test object. Copper filter thickness of 0.3 mm was chosen, as this reduced entrance surface dose rate by 56%, without substantially degrading image contrast due to kV and mA saturation. 20 sets of clinical films taken with each of 0.3 mm copper, 0.1 mm copper and no copper were reviewed following randomization, by a specialist gastrointestinal radiologist. Each set of digital spot and conventional films was allocated a score for each of three regions of the bowel, on a scale of 0-3 for perceived barium coating. The Kruskal-Wallis test showed no significant difference in perceived coating between the three groups (Digital spot: sigmoid colon p=0.207, splenic flexure p=0.103, hepatic flexure p=0.894. Screen-film: left colon p=0.803, right colon p=0.487, transverse colon p=0.905). All examinations but one were classified as diagnostic. The remaining one was classified indeterminate, due to poor distension of the colon. On adding 0.3 mm copper filtration, the mean dose-area product per examination was reduced by 57%, from 17.7 Gy cm(2) to 7.6 Gy cm(2). The estimated reduction in effective dose was 11%, from 3.0 mSv to 2.7 mSv. X-ray tube loading increased by 30%, but this caused no overheating with our local examination protocol and schedule. Additional filtration of 0.3 mm copper for adult double contrast barium enemas has now been implemented in routine clinical use at our hospital.

A survey of World Wide Web use in middle-aged and older adults.

We conducted a survey to document World Wide Web use patterns in middle-aged (ages 40-59), young-old (ages 60-74), and old-old adults (ages 75-92). We conducted this survey of 550 adults 40 years old and over in southeastern Michigan, and the overall response rate was approximately 71%. The results suggested that (a) there are distinct age and demographic differences in individuals who use the Web; (b) middle-aged and older Web users are similar in their use patterns; (c) the two primary predictors for not using the Web are lack of access to a computer and lack of knowledge about the Web; (d) old-old adults have the least interest in using the Web compared with middle-aged and young-old adults; and (e) the primary content areas in learning how to use the Web are learning how to use electronic mail and accessing health information and information about traveling for pleasure. This research may serve as a preliminary attempt to ascertain the issues that must be faced in order to increase use of the World Wide Web in middle-aged and older adults.

Coarctation of the abdominal aorta and renal artery stenosis related to an umbilical artery catheter placement in a neonate.

Umbilical artery catheters have been associated with thrombotic complications, such as partial or complete occlusion in the aorta, the renal arteries, and other blood vessels. There have been few reports of the long-term consequences of either symptomatic or asymptomatic thrombi. We report a patient, now 22 years of age, born with a normal aorta, who developed hypertension at the age of 2 months after use of an umbilical artery catheter. An intravenous pylegram and nuclear renal scan were compatible with occlusion of left renal artery and of the distal aorta. At 6 months of age, the patient presented with reduced femoral pulses. Angiography demonstrated an acquired coarctation of the abdominal aorta and renal artery stenosis. An abdominal ultrasound performed at 22 years of age revealed partial obstruction of the lower abdominal aorta and marked atrophy of the left kidney. This case underlines the importance of long-term follow-up studies of infants who have undergone umbilical artery catheterizations.

Medication adherence in rheumatoid arthritis patients: older is wiser.

OBJECTIVES: To create a profile of individuals nonadherent to their medications in an age-stratified sample (ages 34-84) of community-dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed. DESIGN: A direct observation approach was used in conjunction with structural equation modeling. All participants were administered a preliminary assessment battery. Medications were then transferred to vials with microelectronic caps that recorded medication events for all medications for the next 4 weeks. PARTICIPANTS AND SETTING: A volunteer sample of 121 community-dwelling rheumatoid arthritis (RA) patients were recruited from newspaper ads, posters, and via informal physician contact from private rheumatology practices in Atlanta and Athens, Georgia. Written verification of the RA diagnosis and a disease severity rating were obtained from personal physicians before patients were enrolled in the study. Patients were tested in a private physician's office, and their medication adherence was monitored electronically for a month in their every-day work and home settings. MEASUREMENTS AND RESULTS: Structural equation modeling techniques were used to develop a model of adherence behavior. Cognitive and psychosocial measures were used to construct latent variables to predict adherence errors. The model of medication adherence explained 39% of the variance in adherence errors. The model demonstrated that older adults made the fewest adherence errors, and middle-aged adults made the most. A busy lifestyle, age, and cognitive deficits predicted nonadherence, whereas coping with arthritis-related moods predicted adherence. Illness severity, medication load, and physical function did not predict adherence errors. Omission of medication accounted for nearly all errors. CONCLUSION: Despite strong evidence for normal, age-related cognitive decline in this sample, older adults had sufficient cognitive function to manage medications. A busy lifestyle and middle age were more determinant of who was at risk of nonadherence than beliefs about medication or illness. Thus, practicing physicians should not assume that older adults have insufficient cognitive resources to manage medications and that they will be the most likely to make adherence errors. Very busy middle-aged adults seem to be at the greatest risk of managing medications improperly.

Do cognitive processes predict mental health in individuals with rheumatoid arthritis?

The purpose of the present study was to assess the hypothesis that intellectual functioning affects the mental health of individuals with rheumatoid arthritis. Structural equation modeling techniques were used to assess the relative contributions of age, education, intellectual functioning, self-efficacy, and pain to mental health. It was hypothesized that individuals with rheumatoid arthritis who had higher intellectual functioning and higher self-efficacy would report better mental health than those with lower intellectual functioning and self-efficacy. One hundred twenty-one adults aged 34 to 84 with rheumatoid arthritis completed a battery of cognitive tasks, and multiple measures of self-efficacy, pain, and mental health, twice in 1 month. The data provided a good fit to the hypothesized model. Intellectual functioning was directly related to mental health and, also, indirectly related to mental health through self-efficacy and pain. Older individuals who performed poorly on cognitive tasks reported less self-efficacy, more pain, and poorer mental health than those individuals who performed well on cognitive tasks.

Clinical use of rifampicin during routine reporting of rifampicin susceptibilities: a lesson in selective reporting of antimicrobial susceptibility data.

Increased use of rifampicin for in-patients was noted after the laboratory began reporting rifampicin susceptibilities routinely for all Gram-positive bacterial isolates. The appropriateness of rifampicin use was evaluated by chart review for in-patients administered rifampicin during two time periods, before and during routine rifampicin susceptibility reporting, respectively. While rifampicin susceptibility was reported routinely, four patients were subjected to potentially harmful misuse of rifampicin. These findings reconfirm the necessity of interdepartmental consultation and extensive staff education whenever a modification of antimicrobial susceptibility profile reporting is contemplated. Furthermore, they underscore the role of the clinical microbiology laboratory in guiding antimicrobial therapy through limited reporting of susceptibility data.

Adherence to antihypertensive medications across the life span.

Although treatment for hypertension is readily available, poor control of hypertension is a major health problem frequently manifested in late life. Researchers believe that one of the major causes of uncontrolled hypertension is failure to take medication as directed. In this preliminary study, the medication-taking behaviors of 48 adults diagnosed with hypertension, ranging in age from 35 to 87, were recorded for 2 months with credit card-sized bar-code scanners. The social-cognitive model (Park, 1992) for understanding medication adherence, which proposes that medication adherence is governed by both beliefs and cognitive factors, was used as a basis for this research. Therefore, measures of health behaviors, attitudes about health and medication taking, and cognitive function were recorded, as well as blood pressure readings. The main findings were that (a) the oldest-old and groups of middle-aged adults were the most nonadherent, whereas the young-old were more likely to adhere than the other age groups; (b) high blood pressure readings predicted adherence to antihypertensive medications; and (c) medication beliefs influenced adherence in some situations.

Effect of age on event-based and time-based prospective memory.

The magnitude of age differences on event- and time-based prospective memory tasks was investigated in 2 experiments. Participants performed a working memory task and were also required to perform either an event- or time-based prospective action. Control participants performed either the working memory task only or the prospective memory task only. Results yielded age differences on both prospective tasks. The age effect was particularly marked on the time-based task. Performance of the event-based prospective task, however, had a higher cost to performance on the concurrent working memory task than the time-based task did, suggesting that event-based responding has a substantial attentional requirement. The older adults also made a significant number of time-monitoring errors when time monitoring was their sole task. This suggests that some time-based prospective memory deficits in older adults are due to a fundamental deficit in time monitoring rather than to prospective memory.