Management of peri-prosthetic joint infection and severe bone loss after total hip arthroplasty using a long-stemmed cemented custom-made articulating spacer (CUMARS).

BACKGROUND: There is little evidence on techniques for management of peri-prosthetic infection (PJI) in the context of severe proximal femoral bone loss. Custom-made articulating spacers (CUMARS) utilising cemented femoral stems as spacers was described providing better bone support and longer survival compared to conventional articulating spacers. We retrospectively report our experience managing PJI by adaptation of this technique using long cemented femoral stems where bone loss precludes use of standard stems. METHODS: Patients undergoing 1st stage revision for infected primary and revision THA using a cemented long stem (> 205 mm) and standard all-polyethylene acetabulum between 2011 and 2018 were identified. After excluding other causes of revision (fractures or aseptic loosening), Twenty-one patients remained out of total 721 revisions. Medical records were assessed for demographics, initial microbiological and operative treatment, complications, eradication of infection and subsequent operations. 2nd stage revision was undertaken in the presence of pain or subsidence. RESULTS: Twenty-one patients underwent 1st stage revision with a cemented long femoral stem. Mean follow up was 3.9 years (range 1.7-7.2). Infection was eradicated in 15 (71.4%) patients. Two patients (9.5%) required repeat 1st stage and subsequently cleared their infection. Three patients (14.3%) had chronic infection and are on long term suppressive antibiotics. One patient (4.8%) was lost to follow up before 2 years. Complications occurred in seven patients (33%) during or after 1st stage revision. Where infection was cleared, 2nd stage revision was undertaken in 12 patients (76.5%) at average of 9 months post 1st stage. Five (23.8%) CUMARS constructs remained in-situ at an average of 3.8 years post-op (range 2.6-5.1). CONCLUSIONS: Our technique can be used in the most taxing of reconstructive scenarios allowing mobility, local antibiotic delivery, maintenance of leg length and preserves bone and soft tissue, factors not afforded by alternative spacer options.

Does a dedicated hip fracture unit improve clinical outcomes? A five-year case series.

INTRODUCTION: The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures. MATERIALS AND METHODS: This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust's submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre. RESULTS: A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015). DISCUSSION: The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed. CONCLUSION: While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

Effect of feeding level on luteal function and progesterone concentration in the vena cava during early pregnancy in gilts.

This study assessed the effect of feeding level on progesterone concentration in the caudal vena cava during early pregnancy in gilts. Twenty-four Landrace gilts were allocated to either a high (2.8±0.02) or a low (1.5±0.01 kg day⁻¹) feeding level at Day 0 of pregnancy. Serial blood samples were collected every 15 min for 3 h before and 3 h after feeding on Days 6 and 9 of pregnancy. Embryo survival and development as well as in vitro luteal progesterone production were assessed at Day 10 of pregnancy. Progesterone concentration in the vena cava was pulsatile with gilts on the high feeding level having more pulses compared with Low gilts on Day 9 of pregnancy (P<0.05). On Day 6 the number of pulses did not differ significantly between treatments; however, the average progesterone concentration in the vena cava tended to be higher in the gilts on the high feeding level (P<0.10). Embryo survival at Day 10 was 92±3% for High gilts compared with 77±3% for Low gilts (P<0.05). No difference in embryo development between the treatments was seen. There was no difference between treatments in in vitro secretion of progesterone by luteal tissue. In conclusion, a high plane of nutrition positively affects progesterone secretion by the ovaries in early pregnancy.

Sernbo score predicts survival after intracapsular hip fracture in the elderly.

INTRODUCTION: The Sernbo score uses four factors (age, social situation, mobility and mental state) to divide patients into a high-risk and a low-risk group. This study sought to assess the use of the Sernbo score in predicting mortality after an intracapsular hip fracture. METHODS: A total of 259 patients with displaced intracapsular hip fractures were included in the study. Data from prospectively generated databases provided 22 descriptive variables for each patient. These included operative management, blood tests and co-mobidities. Multivariate analysis was used to identify significant predictors of mortality. RESULTS: The mean patient age was 85 years and the mean follow-up duration was 1.5 years. The one-year survival rate was 92% (± 0.03) in the low-risk group and 65% (± 0.046) in the high-risk group. Four variables predicted mortality: Sernbo score >15 (p=0.0023), blood creatinine (p=0.0026), ASA (American Society of Anaesthesiologists) grade >3 (p=0.0038) and non-operative treatment (p=0.0377). Receiver operating characteristic curve analysis showed the Sernbo score as the only predictor of 30-day mortality (area under curve 0.71 [0.65-0.76]). The score had a sensitivity of 92% and a specificity of 51% for prediction of death at 30 days. CONCLUSIONS: The Sernbo score identifies patients at high risk of death in the 30 days following injury. This very simple score could be used to direct extra early multidisciplinary input to high-risk patients on admission with an intracapsular hip fracture.

Effects of pre-weaning dietary substitutions on plasma insulin and glucose profiles in primiparous sows.

The objective of this study was to investigate the effects of substituting 1 kg of a standard lactation diet with 1 kg of a sugar-rich (15.75 DE MJ/kg) or fat-rich (23.85 DE MJ/kg) diet during late lactation on blood glucose and insulin changes in primiparous sows. During a 4-week lactation period, 21 primiparous sows were fed to appetite with a standard lactation diet (14.10 DE MJ/kg). At 9 days before weaning, sows were assigned to a control (C, n = 7), fat (F, n = 6) or sugar (S, n = 8) treatment. During the treatment period (from 8 days before weaning until weaning), 1 kg of the lactation diet was substituted with 1 kg of a sugar-rich or fat-rich diet for S and F sows. At 3 days before weaning, serial blood samples were collected for a total of 228 min around feeding to establish pre- and postprandial plasma glucose and insulin concentrations. Preprandial plasma glucose and insulin concentrations did not differ between treatments (p > 0.05); however, mean plasma glucose and insulin concentrations were higher for S compared to F (p < 0.05) and intermediate for the C sows. Postprandial plasma concentrations of glucose and insulin were higher for the S sows than for C and F sows (p < 0.05). Sow body weight loss during late lactation did not differ between treatments (p > 0.05). The results from our study suggest that a sugar-enriched diet during the last week of lactation elevates circulating glucose and insulin concentrations and may potentially improve post-weaning fertility in primiparous sows.

Effects of pre-weaning energy substitutions on post-weaning follicle development, steroid hormones and subsequent litter size in primiparous sows.

The present study investigated the effects of pre-weaning energy substitutions on follicular development, endocrine characteristics and subsequent litter size in primiparous sows. Sows were fed a standard lactation diet (14.1 DE MJ/kg) and then allocated to a Control (C, n = 24), Fat (F, n = 23), Sugar (S, n = 23) or post-weaning Regumate (positive control; R, n = 22) treatment at 9 days before weaning of the C, F and S treatments. During the treatment period (8 days), 1 kg of the lactation diet was substituted with 1 kg of a fat-rich (F, 23.85 DE MJ/kg) or sugar-rich (S, 15.75 DE MJ/kg) substitution for F and S sows, respectively. For the R treatment, sows were weaned 8 days earlier than other treatments and fed a lactation diet at 3.5 kg with two doses of altrenogest as topdressing from 1 day before weaning until the day on which the other sows were weaned. The F treatment aimed to increase energy intake, and the S treatment aimed to elevate post-prandial glucose and insulin concentrations. Weaning-to-ovulation interval tended to be reduced in the S treatment compared with C (p = 0.06) and F (p = 0.08) treatments. Body weight (BW) loss during the treatment period, post-weaning follicle development, plasma oestradiol and pre-weaning leptin did not differ among C, F and S sows, although BW loss was lower and leptin was higher in the R treatment. Post-ovulatory progesterone concentration in the S treatment was higher (p < 0.05). Sows in the S and R treatments had a greater proportion of litters with larger litter sizes (p < 0.05). The outcome suggests that increasing circulating insulin and glucose concentrations during late lactation or a week of metabolic recovery positively improves subsequent litter size in primiparous sows.

Undernutrition during early follicle development has irreversible effects on ovulation rate and embryos.

This study assessed carry-over effects of energy level during the early antral phase and subsequent follicular phase on follicle recruitment and ovulation rate. Gilts (n=45) were fed a standard diet to a low (L, ~1.2kg day(-1)) or high (H, ~2.7kg day(-1)) level during the early antral (luteal) phase, and subsequently fed a H or L feed level during the follicular phase, resulting in four treatment groups (HH, HL, LH and LL). Follicle size at the end of the luteal phase was greater for gilts fed a high feed level previously (3.3vs3.0mm; P<0.05). During the follicular phase, high feeding increased follicle size at Day 5 (6.9vs6.2mm; P<0.005) and plasma oestradiol concentration (P<0.05). Nevertheless, a low feed level during the luteal phase reduced ovulation rate (14.4vs13.2; P<0.05) and embryo number (12.6vs10.5; P<0.05), and this was not counteracted by feed level during the follicular phase. Plasma progesterone concentration after ovulation was lower for LL gilts than for other treatments (P<0.05). These results indicate that undernutrition during early antral follicle development may have a residual effect on follicle recruitment and quality.

Pig-shed air polluted by α-haemolytic cocci and ammonia causes subclinical disease and production losses.

There is mounting evidence that bacteria originating from pigs degrade the environment of the pig shed and adversely affect the health of the animals and the pig-shed workers. α-haemolytic cocci (AHC) occur in pig-shed environments, but are regarded as commensals. Ammonia is also a component of the pig-shed environment, and is known to damage upper respiratory tract epithelia. The aim of this study was to determine whether polluted air in pig sheds adversely affected performance indicators in pigs. Modelling revealed a direct effect of AHC on voluntary feed intake and hence AHC are not commensal. No direct effect of ammonia on the pigs was detected, but the combination of AHC and ammonia stimulated the immune system in a progressive manner, and there were direct effects of immune stimulation on food intake and growth resulting in poorer feed-conversion efficiency, even though the effects remained subclinical. The authors conclude that exposure of the respiratory epithelia of pigs to viable AHC in the presence of ammonia redirects nutrients away from production and towards the immune system, explaining the impact of poor pig-shed hygiene on production parameters.

Direct ovarian-uterine transfer of progesterone increases embryo survival in gilts.

This study employed a unilateral ovariectomy model to investigate the relevance of the local supply of progesterone (ovary) compared with the systemic supply of progesterone, in terms of embryo survival in the ipsilateral uterine horn as opposed to the contralateral uterine horn. Thirty gilts were unilaterally ovariectomised (ULO) during the luteal stage of their first oestrous cycle. Half of the ULO gilts were fed at 1.2 maintenance requirement (M), while the other half were fed at 2.4M. Across ULO gilts 0.8 more embryos survived in the ipsilateral horn compared with the contralateral horn at Day 35 of gestation (P<0.05). In ULO gilts on the 2.4M feed level the difference (+1.3; P<0.05) between the ipsi- and contralateral horn was more pronounced than on the 1.2M feed level (+0.4; NS). The higher feed level reduced circulating levels of systemic progesterone on Day 5 of pregnancy but not embryo survival at Day 35. However, post-implantation embryo survival was lower on the low feed level. In conclusion, these data indicate that local progesterone supply from the ovaries to the uterus contributes to the probability of embryo survival.

Incorporating model quality information in climate change detection and attribution studies.

In a recent multimodel detection and attribution (D&A) study using the pooled results from 22 different climate models, the simulated "fingerprint" pattern of anthropogenically caused changes in water vapor was identifiable with high statistical confidence in satellite data. Each model received equal weight in the D&A analysis, despite large differences in the skill with which they simulate key aspects of observed climate. Here, we examine whether water vapor D&A results are sensitive to model quality. The "top 10" and "bottom 10" models are selected with three different sets of skill measures and two different ranking approaches. The entire D&A analysis is then repeated with each of these different sets of more or less skillful models. Our performance metrics include the ability to simulate the mean state, the annual cycle, and the variability associated with El Niño. We find that estimates of an anthropogenic water vapor fingerprint are insensitive to current model uncertainties, and are governed by basic physical processes that are well-represented in climate models. Because the fingerprint is both robust to current model uncertainties and dissimilar to the dominant noise patterns, our ability to identify an anthropogenic influence on observed multidecadal changes in water vapor is not affected by "screening" based on model quality.

The effects of PG600 and boar exposure on oestrus detection and potential litter size following mating at either the induced (pubertal) or second oestrus.

Within gilt pools, incidences of delayed puberty attainment, failure to exhibit regular oestrous cycles and low first litter size are often high. Boar exposure is an effective method of accelerating puberty; however, the timing of gilt response can vary greatly. Although, PG600 (400 IU of PMSG and 200 IU of hCG; Intervet) can induce a rapid and synchronous ovulatory response, thus providing an alternative to boar contact, the quality of the response is often variable. This study compared the effect of PG600, either alone (NBC) or in conjunction with boar exposure (BC), on puberty attainment and maintenance of oestrous cyclicity. The effects of first mating these gilts at the hormonally induced (pubertal) or second oestrus on ovulation rate and early embryo survival were also studied. Eighty Large White cross terminal (Duroc) line gilts were used in this study. The study was conducted in two blocks, with 10 gilts allocated to each of the four treatments in each block. Gilts were artificially inseminated at the allocated oestrus, with the reproductive tracts collected at 26.5+/-0.29 days after first mating (mean+/-S.E.M.), and the number of corpora lutea and viable embryos recorded. Mean days-to-puberty was significantly reduced (P<0.05) when gilts received both PG600 and boar exposure as opposed to PG600 alone (5.7+/-0.15 versus 6.9+/-0.37 days; P<0.01). The proportion of gilts exhibiting an ovulatory response to PG600 was similar for the BC and NBC treatment groups (0.88 and 0.84); however, the proportion of gilts exhibiting visible signs of oestrus in response to PG600 was significantly higher for the BC compared to the NBC treatment groups (0.81 versus 0.49; P<0.05). Boar contact resulted in a numerical, but not significant, increase in the proportion of gilts exhibited a second oestrus (1.00 versus 0.76). There was no significant effect of boar contact on ovulation rate, embryo number or survival. Although ovulation rate was unaffected by oestrus at mating, embryo number was significantly increased (P<0.05) following mating at the second compared to the first oestrus (11.2+/-0.96 versus 7.8+/-1.17). In conclusion, the current data indicate that the timing of puberty attainment and oestrus detection are significantly improved when PG600 treated gilts receive full boar contact. Further, it is evident that mating gilts at their second as opposed to the hormonally induced oestrus significantly increases embryo number at day 26 post-mating.

Mixing gilts in early pregnancy does not affect embryo survival.

There is general acceptance that mixing sows during the first 3 weeks of gestation is detrimental to embryo development and survival. However, there is a paucity of data describing the influence of group housing and remixing during the first 14 days of gestation on pregnancy outcomes. Using 96 purebred maternal (Large White)/terminal (Duroc) line gilts, the current study determined the effects of regrouping, and the timing of regrouping, during the pre-implantation period on embryo mortality. The study was conducted in 2 blocks, with 12 gilts allocated to each of 4 treatments in each block. At 175 days of age, the combination of PG600 and 20 min of daily physical boar contact was used to stimulate puberty, with boar contact resuming 12 days after first detection of oestrus and gilts receiving two artificial inseminations (AIs), 24 h apart, at their second oestrus. After their first AI gilts were allocated to one of four treatment groups (n=12 gilts/treatment). Gilts in one treatment group were housed individually in stalls (STALL). The remaining gilts continued to be housed in their pre-AI groups and were either not remixed (NOMIX), or remixed to form new groups on day 3/4 (RMIXD3/4) or day 8/9 (RMIXD8/9) of gestation (day 0=day of first detection of second oestrus and first insemination). Group-housed gilts were housed in groups of 6, with a space allowance of 2.4 m2/gilt. All gilts were fed once a day (2.2 kg/gilt). Reproductive tracts were collected on day 26.6+/-0.13 of gestation, and the number of corpora lutea (CL) and viable embryos counted. Pregnancy rate was similar across all treatments, averaging 94.5% across the four treatment groups. The number of embryos present on day 26 of gestation was unaffected by housing treatments (P>0.05); gilts in the STALL, NOMIX, RMIXD3/4 and RMIXD8/9 groups possessed 13.2+/-0.67, 12.9+/-0.66, 14.1+/-0.46 and 13.8+/-0.57 embryos, respectively. Similarly, embryo survival rates were 0.91+/-0.04, 0.85+/-0.04, 0.91+/-0.02 and 0.87+/-0.05 for the STALL, NOMIX, RMIXD3.4 and RMIXD8/9 groups, respectively (P>0.05). In conclusion, the current data indicate that individually housing gilts immediately after their first AI does not improve embryo survival. There also appear to be no adverse effects on embryo development or survival when group-housed, mated gilts are remixed during the first 10 days of gestation.

Identification of human-induced changes in atmospheric moisture content.

Data from the satellite-based Special Sensor Microwave Imager (SSM/I) show that the total atmospheric moisture content over oceans has increased by 0.41 kg/m(2) per decade since 1988. Results from current climate models indicate that water vapor increases of this magnitude cannot be explained by climate noise alone. In a formal detection and attribution analysis using the pooled results from 22 different climate models, the simulated "fingerprint" pattern of anthropogenically caused changes in water vapor is identifiable with high statistical confidence in the SSM/I data. Experiments in which forcing factors are varied individually suggest that this fingerprint "match" is primarily due to human-caused increases in greenhouse gases and not to solar forcing or recovery from the eruption of Mount Pinatubo. Our findings provide preliminary evidence of an emerging anthropogenic signal in the moisture content of earth's atmosphere.