Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study.

BACKGROUND: Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice. METHODS: From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was 'days alive and at home up to 30 days after surgery' (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice. RESULTS: Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3-5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25-27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%). CONCLUSION: Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if 'buy-in' from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov ( NCT03540667 ).

Reliability of scapular kinematics estimated with three-dimensional motion analysis during shoulder elevation and flexion.

BACKGROUND: Knowing the reliability of three-dimensional motion analysis to evaluate scapular kinematics during upper limb movements is essential to plan further research dedicated to understanding scapulothoracic joint movements relative to the global shoulder motion. RESEARCH QUESTION: The aim of this study was to assess the intra-subject as well as intra- and interrater reliability of scapulothoracic joint angles during shoulder elevation in scapular plane and shoulder flexion. METHODS: Twenty healthy participants (26.6 ± 3.5 years) were asked to perform maximum shoulder elevation in scapular plane as well as shoulder flexion. Reliability was assessed using the intraclass correlation coefficient (ICC) and its 95% confidence interval of scapular kinematics (rotation, tilting, pro-retraction) at each degree of global motion (shoulder elevation or shoulder flexion) between 0° to 150°. RESULTS: ICCs above 0.60 were accepted as good indicators for reliability. Intra-subject reliability was found to be very high (>0.9 for most part) for all scapulothoracic joint angles during both movements. Intra- and interrater reliability also showed good reliability being above 0.60 for the most part (except scapula tilting during shoulder elevation). Scapular kinematics showed low reliability during the respective first 10° and 20° of shoulder elevation and shoulder flexion. Furthermore, decreasing reliability was found above 120° of shoulder elevation or flexion. SIGNIFICANCE: This study generally showed good to high levels of reliability in the range of interest (20-120°) in evaluating scapula kinematics in healthy adults during shoulder elevation and flexion; these results are important for future research providing a better understanding of scapular kinematics.

Retrospective Evaluation of Changes in Gait Patterns in Children and Adolescents With Cerebral Palsy After Multilevel Surgery.

The purpose of this study was to retrospectively investigate changes in gait patterns after single-event multilevel surgery in children and adolescents with bilateral cerebral palsy. Three-dimensional instrumented pre- and postoperative gait data of 12 patients were compared to data of 12 healthy control subjects using principal component analysis to reduce the dimensionality of kinematic and kinetic gait data and detect gait differences. The differences between pre- and postoperative data and between postoperative data and data of control subjects were calculated using a linear mixed model. The results revealed 14 significant effects for pre- and postoperative waveforms and 11 significant effects for postoperative and control waveforms. Patients after single-event multilevel surgery walked with smaller internal foot progression angle throughout the gait cycle, lower knee flexion at initial swing, and earlier knee extension during terminal swing. Retained gait deviations included excessive pelvic tilt and internally rotated and flexed hips over the entire gait cycle. Contrary to our hypothesis, postoperative waveforms in the sagittal plane differed more from control waveforms than from preoperative waveforms. These results emphasize the importance of carefully planning further conservative therapy 2 years after single-event multilevel surgery.

French Osteotomy for Cubitus Varus in Children: A Long-term Study Over 27 Years.

BACKGROUND: Cubitus varus is a cosmetically unacceptable complication of supracondylar fractures of the elbow in children. We have performed the lateral closing wedge (French) osteotomy to correct the varus for 27 years. More complex osteotomies have been described to correct the associated hyperextension and internal rotation deformities and to prevent a prominent lateral condyle. METHODS: We retrospectively reviewed 90 consecutive patients (1986 to 2012). The mean age of the patients at surgery was 8.2 years (3 to 14 y). The varus angle (mean, 21.4 degrees; range, 8 to 40 degrees) was assessed preoperatively with the humero-elbow-wrist angle. The postoperative carrying angle (mean, 10.4 degrees) and the preoperative and postoperative range of movement were assessed clinically. The lateral condylar prominence index (LCPI) was retrospectively measured at union. RESULTS: Eighty-four (93.3%) of the patients had a good or excellent result. Six (6.7%) had a poor result (residual varus, loss of >20 degrees of preoperative range of flexion or extension or a complication necessitating resurgery). There were no neurovascular complications. The mean LCPI was +0.14. CONCLUSIONS: The results of the French osteotomy are comparable with the more technically demanding dome, step-cut translation, and multiplanar osteotomies, with a lower complication rate. The literature reports adequate remodeling of the hyperextension deformity (≤10 y) and the LCPI (≤12 y), and that the internal rotation deformity is well tolerated by the patient. LEVEL OF EVIDENCE: Level IV-case series.

Uptake of ¹³¹I in households of thyroid cancer patients.

Fifty persons and pets living with thyroid cancer patients who were treated with large administered activities of I have been surveyed to ascertain their uptake of radioiodine from the domestic environment. All patients had been hospitalized for one night after the therapeutic administration, and the thyroids of the cohabitants were assayed 3-10 d after the patients returned home. Seven of the assays were positive for I in the thyroid gland. The transmitted quantities absorbed by the cohabitants were all less than 10 of the patients' burdens at discharge.

Utilization of imaging in pregnant patients: 10-year review of 5270 examinations in 3285 patients--1997-2006.

PURPOSE: To document the utilization of radiologic imaging in pregnant patients at one academic institution during a 10-year period (1997-2006). MATERIALS AND METHODS: The study was approved by the hospital institutional review board and was compliant with HIPAA. Informed consent was waived. At the authors' institution, pregnant patients exposed to radiation during imaging are recorded in a database compiled by the medical physics department. The authors retrospectively reviewed this database to document the number of patients, number of each type of imaging examination, date of the examination, and the estimated radiation dose to the fetus from 1997 to 2006. The authors searched the institution's medical records to obtain the total number of deliveries by year as a control for the total pregnant patient population. RESULTS: During the 10-year period, 5270 examinations were performed in 3285 pregnant patients (mean age, 28 years). The number of patients and examinations increased from 237 patients undergoing 331 studies in 1997 to 449 patients undergoing 732 examinations in 2006, an increase of 89% in patients and 121% in examinations. The total number of pregnant patients measured by deliveries increased 7%--from 8661 in 1997 to 9264 in 2006. Utilization rates (examinations per 1000 deliveries) of all radiologic examinations increased 107% from 1997 to 2006. The number of conventional radiographic examinations increased by an average of 7% per year, nuclear medicine examinations by 12% per year, and computed tomographic (CT) examinations by 25% per year. The average estimated fetal radiation exposure per examination was 0.43 mGy (range, 0.01-22.5 mGy) for conventional radiography, 4.3 mGy (range, 0.01-43.9 mGy) for CT, and 0.40 mGy (range, 0.01-7.7 mGy) for nuclear medicine examinations. CONCLUSION: For the comparison of 1997 to 2006, the radiologic utilization rate in pregnant patients increased by 107% from 1997 to 2006. The greatest increase was in CT.

"Cytokine storm" in the phase I trial of monoclonal antibody TGN1412: better understanding the causes to improve preclinical testing of immunotherapeutics.

The CD28-specific mAb TGN1412 rapidly caused a life-threatening "cytokine storm" in all six healthy volunteers in the Phase I clinical trial of this superagonist, signaling a failure of preclinical safety testing. We report novel in vitro procedures in which TGN1412, immobilized in various ways, is presented to human white blood cells in a manner that stimulates the striking release of cytokines and profound lymphocyte proliferation that occurred in vivo in humans. The novel procedures would have predicted the toxicity of this superagonist and are now being applied to emerging immunotherapeutics and to other therapeutics that have the potential to act upon the immune system. Data from these novel procedures, along with data from in vitro and in vivo studies in nonhuman primates, suggest that the dose of TGN1412 given to human volunteers was close to the maximum immunostimulatory dose and that TGN1412 is not a superagonist in nonhuman primates.

Simultaneous determination of 17 sulfonamides and the potentiators ormetoprim and trimethoprim in salmon muscle by liquid chromatography with tandem mass spectrometry detection.

A simple, robust method using liquid chromatography/tandem mass spectrometry (LC/MS/MS) for the simultaneous determination of 17 sulfonamides [sulfanilamide (SNL), sulfacetamide (SAA), sulfaguanidine (SGD), sulfapyridine (SPY), sulfadiazine (SDZ), sulfathiazole (STZ), sulfamerazine (SMR), sulfamethoxazole (SOZ), sulfamoxole (SXL), sulfisoxazole (SXZ), sulfamethizole (SML), sulfamethazine (SMZ), sulfamethoxypyridazine (SMP), sulfamonomethoxine (SMM), sulfachloropyridazine (SCP), sulfaquinoxaline (SQX), and sulfadimethoxine (SDM)] and 2 potentiators [ormetoprim (OMP) and trimethoprim (TMP)] in fish tissue has been developed. The analytes were extracted from homogenized fish tissue with water-acetonitrile (50 + 50). The extract was clarified by centrifugation and a portion defatted with hexane. The analytes were partitioned into chloroform and evaporated to dryness. The redissolved residue was applied to a C18 reversed-phase column with a water-acetonitrile (0.1% acetic acid) gradient. All of the compounds were completely separated and detected in <10 min at 30 degrees C using LC/MS/MS. Standard curves were linear over the range of 0.02 to 5 ng injected. The limit of detection varied from 0.1 ng/g for SMZ and OMP to 0.9 ng/g for SXL and SOZ. Recoveries varied from 100% for SDM, SOZ, and SQX and 85% for SMR, OMP, and TMP to approximately 30% for SAA. Relative standard deviations for repeat analysis varied from 4% for SMZ and SCP to 23% for SAA.

CD8+ lymphocytes do not mediate protection against acute superinfection 20 days after vaccination with a live attenuated simian immunodeficiency virus.

In order to test the hypothesis that CD8+ cytotoxic T lymphocytes mediate protection against acute superinfection, we depleted >99% of CD8+ lymphocytes in live attenuated simian immunodeficiency virus macC8 (SIVmacC8) vaccinees from the onset of vaccination, maintained that depletion for 20 days, and then challenged with pathogenic, wild-type SIVmacJ5. Vaccinees received 5 mg per kg of humanized anti-CD8 monoclonal antibody (MAb) 1 h before inoculation, followed by the same dose again on days 3, 7, 10, 13, and 17. On day 13, peripheral CD8+ T lymphocytes were >99% depleted in three out of four anti-CD8 MAb-treated vaccinees. At this time attenuated SIVmacC8 viral RNA loads in anti-CD8 MAb-treated vaccinees were significantly higher than control vaccinees treated contemporaneously with nonspecific human immunoglobulin. Lymphoid tissue CD8+ T lymphocyte depletion was >99% in three out of four anti-CD8 MAb-treated vaccinees on the day of wild-type SIVmacJ5 challenge. All four control vaccinees and three out of four anti-CD8 MAb-treated vaccinees were protected against detectable superinfection with wild-type SIVmacJ5. Although superinfection with wild-type SIVmacJ5 was detected at postmortem in a single anti-CD8 MAb-treated vaccinee, this did not correlate with the degree of preceding CD8+ T lymphocyte depletion. Clearance of attenuated SIVmacC8 viremia coincided with recovery of normal CD8+ T lymphocyte counts between days 48 and 76. These results support the view that cytotoxic T lymphocytes are important for host-mediated control of SIV primary viremia but do not indicate a central role in protection against acute superinfection conferred by inoculation with live attenuated SIV.

Persistence and dissemination of simian retrovirus type 2 DNA in relation to viremia, seroresponse, and experimental transmissibility in Macaca fascicularis.

Endemic simian retrovirus (SRV) infection can cause fatal simian AIDS in Macaca fascicularis, but many individuals survive with few clinical signs. To further clarify the parameters of SRV pathogenesis, we investigated the persistence of viral DNA forms in relation to active viremia, antibody response, and transmissibility of infection. In M. fascicularis from endemically SRV-2-infected colonies, viral DNA was present in both linear and unintegrated long terminal repeat circular forms in peripheral blood mononuclear cells of all viremic and many nonviremic animals. Long-term followup of three individuals with distinct infection patterns demonstrated persistence of linear and circular forms of viral DNA in peripheral blood mononuclear cells and tissues, irrespective of viremia or antibody status, but reactivation of latent infections was not observed. The role of viral DNA in transmission and early pathogenesis of SRV-2 was investigated by inoculation of SRV-2 DNA-positive blood into groups of naïve M. fascicularis from either a viremic or nonviremic donor and subsequent analysis of the virological and serological status of the recipients. Transmission of SRV and development of anti-SRV antibodies were only observed in recipients of blood from the viremic donor; transfer of SRV provirus and unintegrated circular DNA in blood from the nonviremic donor did not lead to infection of the recipients. These results indicate that a proportion of M. fascicularis are able to effectively control the replication and infectivity of SRV despite long-term persistence of viral DNA forms in infected lymphocytes.