2019 Chitranjan S. Ranawat Award: Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor.

AIMS: To date, no study has demonstrated an improvement in postoperative outcomes following elective joint arthroplasty with a focus on nutritional intervention for patients with preoperative hypoalbuminaemia. In this prospective study, we evaluated differences in the hospital length of stay (LOS), rate of re-admission, and total patient charges for a malnourished patient study population who received a specific nutrition protocol before surgery. PATIENTS AND METHODS: An analytical report was extracted from the electronic medical record (EMR; Epic, Verona, Wisconsin) of a five-hospital network joint arthroplasty patient data set between 2014 and 2017. A total of 4733 patients underwent joint arthroplasty and had preoperative measurement of albumin levels: 2220 at four hospitals and 2513 at the study hospital. Albumin ≤ 3.4 g/l, designated as malnutrition, was found in 543 patients (11.5%). A nutritional intervention programme focusing on a high-protein, anti-inflammatory diet was initiated in January 2017 at one study hospital. Hospital LOS, re-admission rate, and 90-day charges were compared for differential change between patients in study and control hospitals for all elective hip and knee arthroplasty patients, and for malnourished patients over time as the nutrition intervention was implemented. RESULTS: Malnourished patients with nutritional intervention at the study hospital had shorter hospital LOS beginning in 2017 than malnourished patients at control hospitals during the same period (p = 0.04). Similarly, this cohort had significantly lower primary hospitalization charges, charges associated with hospital re-admissions, and 90-day total charges (p < 0.001). Inclusion of covariant potential confounders (age, anaemia, diabetes, and obesity) did not alter the conclusions of the primary statistical analysis. CONCLUSION: Joint arthroplasty outcomes were positively affected in study patients with low albumin when a high-protein, anti-inflammatory diet was encouraged. Elective surgery was neither cancelled nor delayed with a malnutrition designation. While the entire network population experienced improved postoperative outcomes, malnourished control patients did not experience this improvement. This study demonstrated that education on malnutrition can benefit patients. Cite this article: Bone Joint J 2019;101-B(7 Supple C):17-21.

[Efficacy and cost effectiveness of case management in patients with dementia]. / Wirksamkeit und Kostenwirksamkeit eines Case-Management-Programms bei Patienten mit Demenz.

BACKGROUND: The aim of the project was to evaluate case management for patients suffering from dementia in order to improve the quality of care and offer patients a chance to stay at home for a longer time. METHODS: The evaluation was prospective with a follow-up of 12 months. Data regarding efficacy and costs were taken from one local and three supraregional health insurance funds. Primary outcome was time remaining at home. RESULTS: Time remaining at home was 16.1 months with a mean of 12.2 months (p=0.02) in the control group. Regarding cost effectiveness, an additional month remaining at home costs between 41 and 53 EUR. CONCLUSION: Regarding time remaining at home, institutionalization and all-cause death, data indicate that case management seems to be an effective intervention in patients with dementia; however, further evaluations with a major number of observed patients and longer follow-up are necessary.

Liquid-liquid phase separation in solutions of ionic liquids: phase diagrams, corresponding state analysis and comparison with simulations of the primitive model.

Phase diagrams of ionic solutions of the ionic liquid C(18)mim(+)NTF(2)(-) (1-n-octadecyl-3-methyl imidazolium bistrifluormethylsulfonylimide) in decalin, cyclohexane and methylcyclohexane are reported and compared with that of solutions of other imidazolium ionic liquids with the anions NTF(2)(-), Cl(-) and BF4(-) in arenes, CCl(4), alcohols and water. The phase diagrams are analysed presuming Ising criticality and taking into account the asymmetry of the phase diagrams. The resulting parameters are compared with simulation results for equal-sized charged hard spheres in a dielectric continuum, the restricted primitive model (RPM) and the primitive model (PM) that allows for ions of different size. In the RPM temperature scale the critical temperatures vary almost linearly with the dielectric permittivity of the solvent. The RPM critical temperatures of the solutions in non-polar solvents are very similar, somewhat below the RPM value. Correlations with the boiling temperatures of the solvents and a dependence on the length of the side chain of the imidazolium cations show that dispersion interactions modify the phase transition, which is mainly determined by Coulomb forces. Critical concentrations, widths of the phase diagrams and the slopes of the diameter are different for the solutions in protic and aprotic solvents. The phase diagrams of the solutions in alcohols and water get a lower critical solution point when represented in RPM variables.

ESPEN Guidelines on Enteral Nutrition: Geriatrics.

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Effective suppression of multiply scattered light in static and dynamic light scattering.

The evaluation of conventional light-scattering experiments in turbid media is often highly complicated because of the presence of multiple scattering contributions. The three-dimensional (3-D) cross-correlation method presented provides an effective and handy method to suppress the influence of multiply scattered light. As the time dependence of the 3-D cross-correlation function is determined solely by the singly scattered light, the evaluation of the decay constant yields reliable values for the effective diffusion coefficient and the hydrodynamic particle size of the suspended particles. Furthermore, analysis of the amplitude of the 3-D cross-correlation function permits the determination of the differential scattering cross section even for highly turbid suspensions.

Carpal instability in the weight-bearing upper extremity.

The prevalence of carpal instability in a paraplegic population was investigated to establish an association between chronic repetitive stress on the wrist and the development of such instability. Nine of 162 paraplegic patients had static carpal instability and no history of an acute injury of the wrist. The predominant pattern of instability, found in eleven wrists (six patients), was non-dissociative volar intercalated segmental instability. The prevalence of carpal instability increased with the duration of weight-bearing on the upper extremity. Eighteen per cent of the patients in whom the spinal cord injury had occurred more than twenty years before the study had carpal instability. Carpal instability in these weight-bearing upper extremities and the increase in its prevalence with the duration of the forces across the wrist demonstrate an association between chronic repetitive stress on the wrist and carpal instability.

Studies on the diffraction image of a thermal lens.

We calculated the intensity distribution behind a thermal lens by using a numerical quadrature of the Fresnel diffraction integral and compared it to several given approximate models for laser light detection in the center behind a thermal lens, which includes a new approximate solution of the diffraction integral with applicability to strong thermal lenses. Consideration of the aberrant nature of the thermal lens is crucial even if the thermal lens is weak. A simple approximate formula for the position of the most intense interference ring stating a linear dependence of the thermal lens strength is given. The transverse profile of a weak thermal lens is discussed. It is shown that spherical aberration modifies the central intensity even if a Gaussian profile is observed.

Current concepts on the pathogenesis of osteonecrosis of the femoral head.

Treatment of atraumatic osteonecrosis of the femoral head is presently based not on disease prevention, but instead on the end-stage changes of bone associated with the necrotic lesion. Current diagnostic modalities are limited, by both cost and efficacy, in their ability to diagnose early-stage osteonecrosis. While many studies have assumed the cause of osteonecrosis is vascular occlusion, recent work suggests that alternate processes are primarily involved in the pathogenesis. By examining these concepts, a better understanding of osteonecrosis of the femoral head may lead to earlier diagnostic modalities and treatment protocols to prevent this devastating process from developing.