Re-admissions treble the risk of late mortality after primary total hip arthroplasty.

BACKGROUND: Following a total hip arthroplasty (THA), early hospital re-admission rates of 3-11% are considered as 'acceptable' in terms of medical care cost policies. Surprisingly, the impact of re-admissions on mortality has not been priorly portrayed. Therefore, we sought to determine the mortality rate after 90-day re-admissions following a THA in a series of patients from a captive medical care program. PATIENTS AND METHODS: We prospectively analysed 90-day readmissions of 815 unilateral, elective THA patients operated upon between 2010 and 2014 whose medical care was the one offered by our institution. We stratified our sample into readmitted and non-readmitted cohorts. Through a Cox proportional hazards model, we compared demographic characteristics, clinical comorbidities, surgical outcomes and laboratory values between both groups in order to determine association with early and late mortality. RESULTS: We found 37 (4.53%) re-admissions at a median time of 40.44 days (IQR 17.46-60.69). Factors associated with re-admission were hospital stay (p = 0.00); surgical time (p = 0.01); chronic renal insufficiency (p = 0.03); ASA class 4 (p = 0.00); morbid obesity (p = 0.006); diabetes (p = 0.04) and a high Charlson index (p = 0.00). Overall mortality rate of the series was 3.31% (27/815). Median time to mortality was 455.5 days (IQR 297.58-1170.65). One-third (11/37) of the re-admitted patients died, being sepsis non-related to the THA the most common cause of death. After adjusting for confounders, 90-day re-admissions remained associated with mortality with an adjusted HR of 3.14 (CI95% 1.05-9.36, p = 0.04). CONCLUSIONS: Unplanned re-admissions were an independent risk factor for future mortality, increasing three times the risk of mortality.

Entropy generation across Earth's collisionless bow shock.

Earth's bow shock is a collisionless shock wave but entropy has never been directly measured across it. The plasma experiments on Cluster and Double Star measure 3D plasma distributions upstream and downstream of the bow shock allowing calculation of Boltzmann's entropy function H and his famous H theorem, dH/dt≤0. The collisionless Boltzmann (Vlasov) equation predicts that the total entropy does not change if the distribution function across the shock becomes nonthermal, but it allows changes in the entropy density. Here, we present the first direct measurements of entropy density changes across Earth's bow shock and show that the results generally support the model of the Vlasov analysis. These observations are a starting point for a more sophisticated analysis that includes 3D computer modeling of collisionless shocks with input from observed particles, waves, and turbulences.

Nonlinear development of shocklike structure in the solar wind.

We report first in situ multispacecraft observations of nonlinear steepening of compressional pulses in the solar wind upstream of Earth's bow shock. The magnetic field of a compressional pulse formed at the upstream edge of density holes is shown to suddenly break and steepen into a shocklike structure. During the early phase of development thermalization of ions is insignificant. Substantial thermalization of ions occurs as gyrating ions are observed at the steepened edge. These observations indicate that the mechanisms causing the dissipation of magnetic fields (currents) and ions are different in the early phase of shock development.

Kinetic Alfvén Wave Turbulence and Transport through a Reconnection Diffusion Region.

We demonstrate from observations that kinetic Alfvén waves may play an important role in facilitating magnetic reconnection. These waves radiate outwards from the diffusion region oblique to the magnetic field in a conelike pattern delimited by the X line separatrices with outward energy fluxes equivalent to that contained in the outstreaming ions. It is shown that the wave vectors reverse across the X and symmetry lines and have a large out of plane component. We estimate that these waves drive significant transport through the diffusion region.

Mode conversion and anomalous transport in Kelvin-Helmholtz vortices and kinetic Alfvén waves at the Earth's magnetopause.

Observations at the Earth's magnetopause identify mode conversion from surface to kinetic Alfvén waves at the Alfvén resonance. Kinetic Alfvén waves radiate into the magnetosphere from the resonance with parallel scales up to the order of the geomagnetic field-line length and spectral energy densities obeying a k(perpendicular)(-2.4) power law. Amplitudes at the Alfvén resonance are sufficient to both demagnetize ions across the magnetopause and provide field-aligned electron bursts. These waves provide diffusive transport across the magnetopause sufficient for boundary layer formation.

Solitary electromagnetic pulses detected with super-Alfvénic flows in Earth's geomagnetic tail.

Solitary nonlinear (deltaB/B>>1) electromagnetic pulses have been detected in Earth's geomagnetic tail accompanying plasmas flowing at super-Alfvénic speeds. The pulses in the current sheet had durations of approximately 5 s, were left-hand circularly polarized, and had phase speeds of approximately the Alfvén speed in the plasma frame. These pulses were associated with a field-aligned current J(parallel) and observed in low density (approximately 0.3 cm(-3)), high temperature (T(e) approximately T(i) approximately 3x10(7) K), and beta approximately 10 plasma that included electron and ion beams streaming along B. The wave activity was enhanced from below the ion cyclotron frequency to electron cyclotron and upper hybrid frequencies. The detailed properties suggest the pulses are nonlinearly steepened ion cyclotron or Alfvén waves.

Diagnóstico y tratamiento de un seudoquiste gigante del páncreas / Diagnosis and treatment of a giant seudocyst of pancreas

Se realizó un estudio de un paciente con un seudoquiste gigante del páncreas postpancreatitis aguda, el diagnóstico se realizó por ultrasonografía, estudio contrastado de estomago y duodeno y tomografía axial computarizada, el tratamiento consistió en una cistoyeyunostomía en asa con una yeyunoyeyunostomía al pie del asa, la evolución postoperatoria fue excelente (AU)

A study was perfomed about a patient with a gigantic pancreatic seudocyst, the diagnosis was done by ultrasonography, contrast study stomach and dudodenum and computed tomography, the treatment was perfomed by a cystojejunostomy in loop with jejunojejunostomy distal to the anastomosis side to side, the outcome was excellent(AU)

A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients.

Research indicates that 8.5% of all patients undergoing surgical procedures for more than 3 hours develop pressure ulcers. In some types of surgery, incidence rates in excess of 25% have been reported. An 11-month study was conducted on the safety and efficacy of an experimental alternating air device in comparison with a tertiary care facility's conventional practice. A series of 217 patients undergoing surgical procedures scheduled for a minimum of 3 hours were enrolled. No ulcers developed in the experimental group and 11 ulcers developed in seven patients in the control group (8.75% incidence rate). Of the 11 ulcers, one was Stage I, four were Stage II, and six were unstageable secondary to eschar. The difference between the groups is significant at the P = 0.005 level. Individuals who developed ulcers had a length of stay approximately 7 days longer than the hospital average for comparable patients who did not develop ulcers.

The use of bone grafts in the management of nonunions.

Nonunions can be frustrating complication for the lower extremity surgeon. The cessation of bone healing requires an understanding of its etiology before it may be treated appropriately. This article will review nonunions and, in the context of this special issue, discuss the role of bone grafts in their treatment.

Predicting the severity of cocaine-associated rhabdomyolysis.

STUDY OBJECTIVES: The syndrome of rhabdomyolysis associated with cocaine use has been recently described, but the incidence, severity, risk factors, and complications are unknown. This study sought to describe the spectrum of the syndrome and identify clinical features of patients at risk. DESIGN: Retrospective case series with analysis of common clinical features. SETTING: Medical emergency department of an urban teaching hospital serving an indigent population. TYPES OF PARTICIPANTS: ED patients with acute cocaine intoxication and a serum creatine kinase (all MM) of more than 500 U/L (8.3 ukat/L) who were admitted for in-hospital management. MEASUREMENTS AND MAIN RESULTS: Twenty-nine patients, representing 5% of cocaine-related patient visits, were identified over 20 months. Patients were divided into three groups: mild, characterized by anxiety, tachycardia, diaphoresis, dyspnea, or chest pain; moderate, characterized by delirium, agitation, fever, leukocytosis, or an elevated serum creatinine; and severe, characterized by seizure, coma, hypotension, arrhythmia, or cardiac arrest. There was a significant association between the rating system for level of intoxication and the severity of rhabdomyolysis and its complications (P less than .01). Patients at highest risk for complications of rhabdomyolysis were those in the moderate or severe groups. CONCLUSION: This classification system may be useful for the management of patients with acute cocaine intoxication, predicting those patients in whom aggressive therapy should be initiated in the ED to minimize the complications of rhabdomyolysis.

Unsuspected "isolated" dislocation of the radial head in an adult.

We have described a patient who as a child sustained a Monteggia's fracture that was neither diagnosed nor treated. Neurologic deficit and limitation of motion were clinically apparent. A high index of suspicion, careful examination of the patient, and high-quality roentgenograms should enable accurate diagnosis of this and similar lesions in less obvious cases, thus avoiding the complications of missed diagnosis.

Fractures of the femoral shaft treated surgically. Comparative results of early and delayed operative stabilization.

In a study of the results of operative reduction and internal stabilization of eighty-nine femoral fractures, operative reduction was performed within six days in fifty-four of the fractures and between seven and thirty days in thirty-five. Dual Eggers plates were used in sixty-three fractures; intramedullary nails, in eighteen; a nail-plate, in six; and a single plate, in two fractures. The criteria for ultimate healing were roentgenographic demonstration of bridging callus and the ability of the patient to bear full, unsupported weight on the extremity. Healing that occurred later than nine months after fracture was considered to be delayed. In the group treated by early operative management, the incidence of delayed union was 18 per cent and of non-union, 18 per cent. In the group treated by delayed operative management, the incidence of delayed union was 3 per cent and there were no instances of non-union. All ten non-unions, ten of the eleven delayed unions, and five of the six infections occurred in the early operative group.

Surface direct current bioelectric potentials in the normal and injured human thigh.

Skin bioelectric potentials were obtained from both normal and injured human thighs using surface direct current silver/silver chloride monitoring electrodes. Electrical patterns in normal subjects fell into 4 distinct groups. In subjects with injured thigh significant electrical differences were associated with bone formation. The findings are discussed.

Fractures of the scapula. An analysis of forty cases and a review of the literature.

In forty patients treated at The University of Texas Medical Branch Hospitals for fifty-two fractures of forty-one scapulae from 1961 through 1973, most of the fractures were the result of vehicular accidents. The thirty-eight fractures involving only the body, neck, or spine of thirty scapulae (without involvement of the acromion, glenoid, or coracoid process) were successfully treated with a sling and early active motion. Three other fractures involving body were associated with three fractures involving the glenoid. The eleven fractures of the acromiom, glenoid, or coracoid process resulted in loss of motion in ten of the eleven shoulders. For fractures of this type we now recommend immobilization in 60 degrees of abduction, 25 degrees of flexion, and 25 degrees of external rotation, with early active abduction exercises. Open reduction is rarely indicated, only when there is disruption of the glenohumeral joint.

Sedation of active acupuncture loci in the management of low back pain.

From 1971 to 1973 twenty-three consecutive patients with low back pain of undetermined etiology and two patients with arachnoiditis were treated by the sedation of active acupuncture loci located in the low back area. Sedation was accomplished by means of one to six injections of one-half milliliter of a local anesthetic at weekly intervals. Nineteen patients obtained complete relief and four patients were improved. The two patients with arachnoiditis showed no improvement.