Two-stage revision for the culture-negative infected total hip arthroplasty : A comparative study.

AIMS: Periprosthetic joint infection (PJI) remains a challenging complication following total hip arthroplasty (THA). It is associated with high levels of morbidity, mortality and expense. Guidelines and protocols exist for the management of culture-positive patients. Managing culture-negative patients with a PJI poses a greater challenge to surgeons and the wider multidisciplinary team as clear guidance is lacking. PATIENTS AND METHODS: We aimed to compare the outcomes of treatment for 50 consecutive culture-negative and 50 consecutive culture-positive patients who underwent two-stage revision THA for chronic infection with a minimum follow-up of five years. RESULTS: There was no significant difference in the outcomes between the two groups of patients, with a similar rate of re-infection of 6%, five years post-operatively. Culture-negative PJIs were associated with older age, smoking, referral from elsewhere and pre-operative antibiotic treatment. The samples in the culture-negative patients were negative before the first stage (aspiration), during the first-stage (implant removal) and second-stage procedures (re-implantation). CONCLUSION: Adherence to strict protocols for selecting and treating culture-negative patients with a PJI using the same two-stage revision approach that we employ for complex culture-positive PJIs is important in order to achieve control of the infection in this difficult group of patients. Cite this article: Bone Joint J 2018;(1 Supple A)100-B:3-8.

Peer review.

The maintenance of quality and integrity in clinical and basic science research depends upon peer review. This process has stood the test of time and has evolved to meet increasing work loads, and ways of detecting fraud in the scientific community. However, in the 21st century, the emphasis on evidence-based medicine and good science has placed pressure on the ways in which the peer review system is used by most journals. This paper reviews the peer review system and the problems it faces in the digital age, and proposes possible solutions.

Enhanced recovery in total hip replacement: a clinical review.

The outcome after total hip replacement has improved with the development of surgical techniques, better pain management and the introduction of enhanced recovery pathways. These pathways require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery and shorter admissions. In this review we present an evidence-based summary of some common interventions and methods, including pre-operative patient education, pre-emptive analgesia, local infiltration analgesia, pre-operative nutrition, the use of pulsed electromagnetic fields, peri-operative rehabilitation, wound dressings, different surgical techniques, minimally invasive surgery and fast-track joint replacement units.

Thoracic outlet syndromes in sport: a practical review in the face of limited evidence--unusual pain presentation in an athlete.

Despite thoracic outlet syndrome (TOS) being first described early in the 19th century, the subsequent literature seems limited, focusing on case reports and investigations providing little assistance in the management of equivocal presentations. Best practice clinical management, with little evidence base, poses great challenges for clinicians in deciding how to manage TOS, when to operate and which procedure should be undertaken. Furthermore, the implications of TOS and its surgical effects are poorly documented, with little evidence in the literature as to the impact of surgical intervention on athletes and their physiology or function. This paper describes a clinical example of TOS highlighting salient issues and examining the evidence to guide clinical management at each stage, in the case of a 26-year-old professional football player who suffered an acute onset of unilateral right shoulder to bicep pain associated with tingling in the hand. Clinicians managing similar cases in the future will have a reference point to assist their diagnosis, management and promote much needed research to further our understanding of this difficult syndrome.

Hypoglycaemic effect of Artemisia herba alba. II. Effect of a valuable extract on some blood parameters in diabetic animals.

Artemisia herba alba is widely used in Iraqi folk medicine for the treatment of diabetes mellitus. However, very few scientific and medical studies were carried out to assess the efficacy and toxicity of A. herba alba. In this study feeding diabetic rats and rabbits with 0.39 g/kg body weight of the aqueous extract of the aerial parts of the plant for 2-4 weeks shows a significant reduction in blood glucose level, prevents elevation of glycosylated haemoglobin level and possesses a hypoliposis effect, in addition to the protection against body weight loss of diabetic animals.

Hypoglycaemic effect of Artemisia herba alba. I. Effect of different parts and influence of the solvent on hypoglycaemic activity.

Artemisia herba alba is widely used in Iraqi folk medicine for the treatment of diabetes mellitus. Oral administration of 0.39 g/kg body weight of the aqueous extract of the leaves or barks produced a significant reduction in blood glucose level, while the aqueous extract of roots and the methanolic extract of the aerial parts of the plant produce almost no reduction in blood glucose level. The extract of the aerial parts of the plant seem to have minimal adverse effect and high LD50 value.

Hypoglycemic activity of Artemisia herba alba.

Artemisia herba alba has been widely used in Iraqi folk medicine for the treatment of diabetes mellitus. Oral administration of an aqueous extract (0.39 g/kg) of the aerial parts of this plant to normoglycemic and to alloxan-diabetic rabbits produced significant hypoglycemic activity, which was consistent and time-dependent.

Toxicologic and histopathologic studies of Pleurotus ostreatus mushroom in mice.

The edible mushroom Pleurotus ostreatus (with locally reported toxic properties) was identified and collected 1-4 days after raining in the city of Baghdad. It was freshly extracted with distilled water at room temperature. Both oral and intraperitoneal routes were used for acute and subacute toxicity studies on mice. In spite of important toxicologic signs and findings on treated animals, the estimated 24-h LD50 values exceeded 3 g/kg for both routes of administration. However, the 30-day LD50 values were 319 mg/kg for oral and 1143 mg/kg for i.p. administration. Gross examination of the dissected organs revealed marked haemorrhages in the intestine, liver, lung and the kidney. Histopathologic examination revealed significant changes mainly in the liver, which took the form of inflammation and microabscesses. The present results were consistent with clinical findings available after human and animal ingestion of this mushroom in Iraq.

Some pharmacological, toxicological and phytochemical investigations on Centaurea phyllocephala.

Centaurea phyllocephala Boiss. has been used in folkloric medicine as an antidiabetic agent. Present investigations on various extracts of C. phyllocephala revealed that basal plasma glucose concentration and plasma glucose response to glucose load were either elevated or unchanged by the i.v. administration of these extracts in anaesthetized rats or by i.p. or oral administration of the extracts in conscious rats. The predominant effect of C. phyllocephala is the toxicity in rats and mice and this indicates the presence of some toxic or active compounds which merit phytochemical isolation. Further, C. phyllocephala extracts also caused either an initial brief hypotension followed by a delayed hypertension or produced no changes when injected i.v. in the rats. The hypotensive effect was inhibited by atropine whereas the hypertensive effect was prevented by phentolamine or guanethidine but not by hexamethonium. The alcoholic extract also induced an initial brief negative inotropic effect, followed by delayed prolonged positive inotropic and negative chronotropic effects on the spontaneous inotropic and negative chronotropic effects on the spontaneous contractions of the guinea pig right atrium. The initial depressing effect and the delayed positive inotropic effect were inhibited by pretreatment with atropine. The extract of C. phyllocephala also produced a contractile activity on guinea pig ileum strips and this could be prevented by atropine. No significant diuretic effect was produced by the extract. Phytochemical screening revealed that C. phyllocephala contains tertiary and quaternary alkaloids, sesquiterpene lactones, methylated flavones and their glycosides, as well as leuco- and proanthocyanidines. Further studies on sesquiterpene lactones and methylated flavones resulted in the isolation of lactones with alpha-methylene gamma-lactone and methylene side chain on the cyclopentyl ring as well as of four methylated flavones (hispidulin, nepetin, cirsiliol, jaceosidin) structurally closely related to the cytotoxic flavonoids of other Compositae plants.

Evaluation of combined adrenal demedullation and chronic guanethidine treatment as a sympathectomy procedure for metabolic studies.

The usefulness of a combination of adrenal demedullation and treatment with guanethidine (25 mg kg-1 day-1, i.p. for 14 days) as a sympathectomy procedure for metabolic studies was investigated in the rat. The procedure reduced markedly or abolished pressor and positive chronotropic responses to tyramine, nicotine or electrical stimulation of the sympathetic spinal outflow. Hyperglycaemic responses to nicotine or spinal sympathetic stimulation were abolished. Nicotine infusion in intact animals reduced glucose-induced hyperinsulinaemia. On the other hand nicotine infusion in sympathectomized animals produced a marked elevation in glucose-induced hyperinsulinaemia relative to that seen in intact animals. The early hyperinsulinaemic response to glucose infusion during sympathetic stimulation was markedly greater in sympathectomized rats compared with that seen in intact rats. The sympathectomy procedure did not modify the glycaemic responses to adrenaline or insulin or glucose-induced hyperinsulinaemia.

Some factors modifying the insulinotropic and cardiovascular effects of isoprenaline in the rat.

The effects of L-isoprenaline on plasma immunoreactive insulin (IRI) and glucose concentrations were examined in pentobarbitone anaesthetized rats. When given by bolus injection hyperinsulinaemia was produced only by very large doses of isoprenaline (100-200 micrograms/kg). Infusion of isoprenaline allowed the demonstration of hyperinsulinaemia at low dose rates (0.07-0.7 microgram kg-1 min-1). Pretreatment with phentolamine or production of a functional sympathectomy by bilateral adrenal demedullation and chronic guanethidine treatment augmented the hyperinsulinaemic effect of isoprenaline. Isoprenaline-induced hyperglycaemia was attenuated by sympathectomy and by phentolamine pretreatment, this attenuation being attributed to the augmented hyperinsulinaemic effect of isoprenaline under these conditions. The increase in heart rate and reduction in blood pressure produced by isoprenaline were also augmented in sympathectomized rats.