Does hematology rotation impact the interest of internal medicine residents in considering hematology as a career?

BACKGROUND: The ongoing need for hematologists is not met in many parts of the world. The hematology rotation during internal medicine residency is an opportunity to attract more physicians to the hematology field. This study aimed to assess the impact of a hematology rotation on internal medicine residents' interest in considering a hematology career. METHODS: Internal medicine residents were invited to complete an anonymous questionnaire before and after a mandatory hematology rotation. Their interest in pursuing a hematology career was assessed by asking them to rate "Consider hematology as a career" on a 0 to 10 scale (0 = never, 10 = strongly agree). In addition, viewing the hematology workload as manageable, comfort in dealing with cancer and satisfaction with the hematologist lifestyle were assessed before and after the rotation. RESULTS: Sixty out of 62 IM residents completed the pre- and post-hematology rotation questionnaire (response rate 97%). 80% were in the age range of 25-29 years and 73% were males. Two-thirds were in the senior level (3rd and 4th year) of their residency program and 40% had a prior rotation in a hematology unit. Rating considering hematology as a career increased significantly from a median of 7 (IQR: 5-9) pre-rotation to 8.5 (IQR: 7-10) post-rotation (p = 0.0018). Subgroup analysis showed a significant increase in interest among subgroups except residents > 29 years of age, those with prior hematology rotation and junior residents (1st and 2nd year residency). The change in viewing hematology workload as manageable, comfort in dealing with cancer patients and perceiving the hematologist lifestyle as satisfactory were strongly positively correlated with the change in considering hematology as a career (p = 0.0014, < 0.0001 and < 0.0001; respectively). CONCLUSIONS: A hematology rotation is associated with an increase in the interest of internal medicine residents in considering hematology as a career. Further research is needed to Identify factors that may make hematology rotations an effective tool in attracting residents to the hematology field.

Combined Donepezil with Astaxanthin via Nanostructured Lipid Carriers Effective Delivery to Brain for Alzheimer's Disease in Rat Model.

Introduction: Donepezil (DPL), a specific acetylcholinesterase inhibitor, is used as a first-line treatment to improve cognitive deficits in Alzheimer's disease (AD) and it might have a disease modifying effect. Astaxanthin (AST) is a natural potent antioxidant with neuroprotective, anti-amyloidogenic, anti-apoptotic, and anti-inflammatory effects. This study aimed to prepare nanostructured lipid carriers (NLCs) co-loaded with donepezil and astaxanthin (DPL/AST-NLCs) and evaluate their in vivo efficacy in an AD-like rat model 30 days after daily intranasal administration. Methods: DPL/AST-NLCs were prepared using a hot high-shear homogenization technique, in vitro examined for their physicochemical parameters and in vivo evaluated. AD induction in rats was performed by aluminum chloride. The cortex and hippocampus were isolated from the brain of rats for biochemical testing and histopathological examination. Results: DPL/AST-NLCs showed z-average diameter 149.9 ± 3.21 nm, polydispersity index 0.224 ± 0.017, zeta potential -33.7 ± 4.71 mV, entrapment efficiency 81.25 ±1.98% (donepezil) and 93.85 ±1.75% (astaxanthin), in vitro sustained release of both donepezil and astaxanthin for 24 h, spherical morphology by transmission electron microscopy, and they were stable at 4-8 ± 2°C for six months. Differential scanning calorimetry revealed that donepezil and astaxanthin were molecularly dispersed in the NLC matrix in an amorphous state. The DPL/AST-NLC-treated rats showed significantly lower levels of nuclear factor-kappa B, malondialdehyde, ß-site amyloid precursor protein cleaving enzyme-1, caspase-3, amyloid beta (Aß1­42), and acetylcholinesterase, and significantly higher levels of glutathione and acetylcholine in the cortex and hippocampus than the AD-like untreated rats and that treated with donepezil-NLCs. DPL/AST-NLCs showed significantly higher anti-amyloidogenic, antioxidant, anti-acetylcholinesterase, anti-inflammatory, and anti-apoptotic effects, resulting in significant improvement in the cortical and hippocampal histopathology. Conclusion: Nose-to-brain delivery of DPL/AST-NLCs is a promising strategy for the management of AD.

Nose to Brain Delivery of Astaxanthin-Loaded Nanostructured Lipid Carriers in Rat Model of Alzheimer's Disease: Preparation, in vitro and in vivo Evaluation.

Background: Astaxanthin (AST) is a second-generation antioxidant with anti-inflammatory and neuroprotective properties and could be a promising candidate for Alzheimer's disease (AD) therapy, but is shows poor oral bioavailability due to its high lipophilicity. Purpose: This study aimed to prepare and evaluate AST-loaded nanostructured lipid carriers (NLCs), for enhanced nose-to-brain drug delivery to improve its therapeutic efficacy in rat model of AD. Methods: AST-NLCs were prepared using hot high-pressure homogenization technique, and processing parameters such as total lipid-to-drug ratio, solid lipid-to-liquid lipid ratio, and concentration of surfactant were optimized. Results: The optimized AST-NLCs had a mean particle size of 142.8 ± 5.02 nm, polydispersity index of 0.247 ± 0.016, zeta potential of -32.2 ± 7.88 mV, entrapment efficiency of 94.1 ± 2.46%, drug loading of 23.5 ± 1.48%, and spherical morphology as revealed by transmission electron microscopy. Differential scanning calorimetry showed that AST was molecularly dispersed in the NLC matrix in an amorphous state, whereas Fourier transform infrared spectroscopy indicated that there is no interaction between AST and lipids. AST displayed a biphasic release pattern from NLCs; an initial burst release followed by sustained release for 24 h. AST-NLCs were stable at 4-8 ±2°C for six months. Intranasal treatment of AD-like rats with the optimized AST-NLCs significantly decreased oxidative stress, amyloidogenic pathway, neuroinflammation and apoptosis, and significantly improved the cholinergic neurotransmission compared to AST-solution. This was observed by the significant decline in the levels of malondialdehyde, nuclear factor-kappa B, amyloid beta (Aß1­42), caspase-3, acetylcholinesterase, and ß-site amyloid precursor protein cleaving enzyme-1 expression, and significant increase in the contents of acetylcholine and glutathione after treatment with AST-NLCs. Conclusion: NLCs enhanced the intranasal delivery of AST and significantly improved its therapeutic properties.

Robotic Arm-Assisted versus Manual Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal-Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p < 0.001), and fewer PT visits (median [interquartile range] = 10.0 [8.0-13.0] vs. 11.5 [9.5-15.5] visits, p = 0.014). RA-TKA had shorter LOS (0.48 ± 0.59 vs.1.2 ± 0.59 days, p < 0.001) and higher proportion of home discharges (p < 0.001). RA-TKA and manual TKA had similar postoperative complications and 1-year PROMs. Although RA-TKA patients had longer operative times, they had shorter LOS and higher propensity for home discharge. In an era of value-based care models and the steady shift to outpatient TKA, these trends need to be explored further. Long-term and randomized controlled studies may help determine potential added value of RA-TKA versus manual TKA. This study reflects level of evidence III.

In-Hospital Mortality Is Associated With Low-Volume Hip Revision Centers After Septic Revision Total Hip Arthroplasty.

Revision total hip arthroplasty (rTHA) after septic failure is associated with higher morbidity and mortality compared with aseptic revisions. The goals of this study were to characterize (1) the in-hospital mortality rate for patients with septic rTHA, (2) the effect of hospital hip revision surgery volume (HRV) on mortality after septic rTHA, and (3) the independent risk factors associated with in-hospital mortality rates after rTHA with 2-year follow-up. The authors analyzed the Healthcare Cost and Utilization Project State Inpatient Databases of New York and Florida to identify cases of septic rTHA from 2007 to 2012 with International Classification of Diseases, Ninth Revision, codes. The authors included patients with (1) no history of THA for 2 years before the index admission and (2) 2 years of follow-up. Groups with primary THA and aseptic rTHA were identified as control groups. Logistic regression was used to evaluate independent associations. Of 3057 patients with septic rTHA, 5.2% (n=160) had in-hospital mortality vs 2.9% of those with primary THA (n=3525, P=.0001) and 2.1% of those with aseptic rTHA (n=252, P=.0001). Octogenarian status, medium-risk Elixhauser comorbidity score, and high-risk Elixhauser comorbidity score were independent risk factors for mortality (adjusted odds ratio [AOR]=1.587, 95% CI=1.103-2.282, P=.0128; AOR=2.439, 95% CI=1.680-3.541, P<.0001; and AOR=6.367, 95% CI=4.134-9.804, P<.0001, respectively). Undergoing rTHA in a high-HRV hospital was associated with lower odds of in-hospital mortality (AOR=0.539, 95% CI=0.332-0.877, P=.0127). Receiving care in a low-HRV hospital increased the risk of 2-year postoperative patient mortality. Similarly, older age and a higher comorbidity burden were independently associated with increased 2-year postoperative mortality. [Orthopedics. 2022;45(1):57-63.].

In-hospital Mortality after Septic Revision TKA: Analysis of the New York and Florida State Inpatient Databases.

The aims of this study were to investigate (1) in-hospital mortality rates following septic revision total knee arthroplasty (rTKA); (2) compare septic rTKA mortality rates between differing knee revision volume (KRV) hospitals; and (3) identify independent risk factors associated with in-hospital mortality after septic rTKA (up to 2-year follow-up). The Healthcare Cost and Utilization Project State Inpatient Databases of New York and Florida were used to identify septic rTKA, and control groups of aseptic rTKA and primary TKA between 2007 and 2012 via International Classification of Diseases, Ninth Revision codes. Mortality was compared between septic rTKA and aseptic rTKA/primary TKA control groups. Hospital KRV was stratified, and independent risk factors of in-hospital mortality were identified and analyzed using unadjusted and adjusted logistic regression analyses. In this study, 3,531 septic rTKA patients were identified; 105 (3%) patients suffered in-hospital mortality, compared with the control aseptic rTKA (n = 178; 1.7%; p < 0.0001) and primary TKA groups (n = 930; 0.6%; p < 0.0001). Being an octogenarian (adjusted odds ratio [AOR]: 2.361; 95% confidence interval [CI]: 1.514-3.683; p < 0.0002) and having a medium- or high-Elixhauser comorbidity score was associated with in-hospital mortality (AOR: 2.073; 95% CI: 1.334-3.223; p = 0.0012, and AOR: 4.127; 95% CI: 2.268-7.512, p < 0.0001). There were no significant in-hospital mortality rate differences in high- versus medium- versus low-KRV hospitals (1.9 vs. 3.6 vs. 2.9%, respectively, p = 0.0558). Age >81 years and higher comorbidity burden were found to contribute to increased risk of 2-year postoperative mortality after septic rTKA. This association could not be established for hospital KRV.

Nonunion and Reoperation Following Proximal Interphalangeal Joint Arthrodesis and Associated Patient Factors.

BACKGROUND: Proximal interphalangeal joint (PIPJ) arthrodesis can provide reliable pain relief and restore hand function in patients with PIPJ arthritis. However, there is a paucity of literature on patient-specific preoperative risk factors that are associated with adverse outcomes after PIPJ arthrodeses. Therefore, the primary purpose of this study was to assess preoperative predictors of nonunion and reoperation after PIPJ arthrodesis. METHODS: This study identified all patients who underwent PIPJ arthrodesis at a single community practice between 1987 and 2013. The final analysis included 415 PIPJs treated with arthrodesis. The mean follow-up was 1.3 years. Data on preoperative diagnosis, demographics, comorbidities, and operative techniques were recorded, as well as the occurrence of nonunions and reoperations. Logistic regression models were used to identify independent risk factors of nonunion and reoperation. RESULTS: There were 40 nonunions (10%) and 62 reoperations (15%). Of the reoperations, there were 39 incidences of isolated hardware removal, 9 irrigation and debridement, 8 amputations, 5 revision arthrodeses, and 1 corrective osteotomy. The highest number of nonunions occurred in the traumatic diagnosis group (37%), followed by the rheumatoid group (23%) and the scleroderma group (15%). The highest number of reoperations occurred within the traumatic joint disorder group (40%), followed by the rheumatoid group (24%) and the scleroderma group (11%). Multivariate analysis revealed that male sex (P < .01) and hepatic disease (P = .03) were significant risk factors of nonunion. Male sex was also significantly associated with increased reoperation risk (P < .01). CONCLUSION: Risks of nonunions and reoperations after PIPJ arthrodeses are low; however, these findings may guide clinicians and patients in the preoperative decision-making process and help with targeted postoperative surveillance to mitigate these risks.

Effect of rhamnolipids on the fungal elimination of toluene vapor in a biotrickling filter under stressed operational conditions.

The application of rhamnolipids in a fungal-cultured biotrickling filter (BTF) has a significant impact on toluene removal. Two BTFs were used; BTF-A, a control bed, and BTF-B fed with rhamnolipids. The effect of empty bed residence times (EBRTs) on toluene bioavailability was investigated. Removal of toluene was carried out at EBRTs of 30 and 60 s and inlet loading rates (LRs) of 23-184 g m-3 h-1. At 30 s EBRT, when inlet LR was increased from 23 to 184 g m-3 h-1, the removal efficiency (RE) decreased from 93% to 50% for the control bed, and from 94% to 87% for BTF-B. Increasing the EBRT simultaneously with inlet LRs, confirms that BTF-A was diffusion-limited by registering a RE of 62% for toluene inlet LR of 184 g m-3 h-1, whereas BTF-B, achieved RE > 96%, confirming a significant improvement in toluene biodegradability. Overall, the best performance was observed at 60 s EBRT and inlet LR of 184 g m-3 h-1, providing a maximum elimination capacity (EC) of 176.8 g m-3 h-1 under steady-state conditions. While a maximum EC of 114 g m-3 h-1 was observed under the same conditions in the absence of rhamnolipids (BTF-A). Measurements of critical micelle concentration showed that 150 mg L-1 of rhamnolipids demonstrated the lowest aqueous surface tension and maximum formation of micelles, while 175 mg L-1 was the optimum dose for fungal growth. Production rate of carbon dioxide, and dissolved oxygen contents highlighted the positive influence of rhamnolipids on adhesive forces, improved toluene mineralization, and promotion of microbial motility over mobility.

MAKO Robotic-Arm Assisted Total Knee Arthroplasty: Surgical Technique From the Office to the Operating Room.

Recently, robotic assistance has become more readily available to perform total knee arthroplasties. However, training can often be time consuming and there can be a learning curve. Therefore, the purpose of this article is to clearly and concisely describe the preoperative planning and surgical technique for using one version of robotic assistance, specifically the MAKO platform (MAKO Surgical Corp. [Stryker], Fort Lauderdale, Florida), for a standard osteoarthritic knee with a varus deformity that is commonly encountered by joint arthroplasty surgeons.

Resident Involvement in Posterior Lumbar Interbody Fusion is Associated With Increased Readmissions and Operative Time, But No Increased Short-term Risks.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim was to compare rates of adverse events and additional posterior lumbar interbody fusion (PLIF) cases assisted by residents versus cases performed solely by an orthopedic attending. SUMMARY OF BACKGROUND DATA: PLIF is a widely accepted surgical technique for the management of a variety of spinal conditions requiring spinal stabilization and fusion. However, no published studies have assessed the effects of resident involvement on intraoperative and postoperative outcomes in PLIF. METHODS: This retrospective study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry from 2007 to 2012 to identify patients who underwent PLIF procedures. A propensity score matching model was utilized to reduce patient cohort variances. The perioperative data and outcomes in the matched population were analyzed using paired t test and the McNemar test in order to assess, based on resident presence, the rates of postoperative adverse events, readmission, reoperation within 30 days, and operative time. RESULTS: In total, 1633 patients undergoing PLIF were included in the study, with 24.62% involving resident participation. The propensity score matching algorithm yielded 396 well-matched resident and nonresident pairs. Patients undergoing PLIF involving a resident were associated with a higher rate of readmission (1.77% vs. 0.00%; P=0.008), and longer operative time (245.7 vs. 197.7 min; P<0.001). However, these procedures were not associated with any significant difference in minor or severe adverse events. CONCLUSIONS: Resident involvement in PLIF was associated with an increased rate of readmissions, and operative time; however, was not associated with an increase in minor or severe adverse events. Further investigation is needed to characterize the role of resident involvement based on level of training experience, as well as methods to improve the learning curve to independence while reducing postoperative hospital length of stay. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

The use of neutrophil-to-lymphocyte ratio (NLR) as a marker for COVID-19 infection in Saudi Arabia: A case-control retrospective multicenter study.

OBJECTIVES: To assess the neutrophil-to-lymphocyte ratio (NLR) diagnostic and prognostic value in the context of Coronavirus disease-2019 (COVID-19) infection in Saudi Arabia. METHODS: A case-control study in which 701 confirmed COVID-19 patients (of which 41 were intensive care unit [ICU]-admitted) and 250 control subjects were enrolled. The study was conducted retrospectively in October on patients admitted to 3 separate hospitals in Saudi Arabia namely: King Abdullah Bin Abdulaziz University Hospital (Riyadh), Ohud Hospital (Madinah), and Nojood Medical Center (Madinah) between May and September 2020. Neutrophil-to-lymphocyte ratio was calculated based on absolute neutrophil and lymphocyte count. Institutional ethical approval was obtained prior to the study. RESULTS: Patients (median age 35 years), of which 54.8% were females, were younger than the control cohort (median age 48 years). Patients had significantly higher NLR compared to the control group. Intensive care unit admitted patients had significantly higher platelet, WBC and neutrophil counts. The ICU patients' NLR was almost twice as of the non-intensive patients. The NLR value of 5.5 was found to be of high specificity (96.4%) and positive predictive value (91.4%) in diagnosing COVID-19. Furthermore, it had a very good sensitivity (86.4%) in predicting severe forms of disease, such as, ICU admission. CONCLUSION: Neutrophil-to-lymphocyte ratio is an important tool in determining the COVID-19 clinical status. This study further confirms the prognostic value of NLR in detecting severe infection, and those patients with high NLR should be closely monitored and managed.

Assessment of the perioperative effect of vasopressin in patients undergoing laparoscopic myomectomy: A double-blind randomised study.

BACKGROUND AND AIMS: Myomectomy is associated with perioperative bleeding. The aim of the study is to evaluate the effect of intramyometrial vasopressin on blood loss and the associated cardiovascular complications during myomectomy. METHODS: The study included 194 patients classified into two groups- 1) Vasopressin group: the vasopressin was diluted as 0.1 unit/ml and 15 ml was injected by the surgeon in the plane between the myometrium and the myoma. 2) Control group: The patients received an equal amount of normal saline. The monitored parameters included the amount of blood loss, required blood transfusion, heart rate, mean arterial blood pressure, the incidence of hypertension, hypotension, bradycardia, tachycardia, electrocardiogram (ECG) changes and the blood troponin I level. RESULTS: The heart rate decreased significantly in both groups, but the decrease was lower with vasopressin than the control group through the time points T3 to T5 (P < 0.05) The mean arterial blood pressure increased significantly in both groups, but the increase was higher with vasopressin than the control group through T3 to T5 (P < 0.05). The amount of blood loss decreased significantly with vasopressin than the control groups (P = 0.001). The number of transfused packed red blood cells was lower with vasopressin than the control group (P = 0.001). The incidence of hypertension, bradycardia and atrial extrasystole was higher with vasopressin than the control group (P = 0.005, P = 0.012, P = 0.033, respectively). CONCLUSION: Intramyometrial vasopressin decreases blood loss and blood transfusion, but it is associated with cardiovascular complications that may be serious as reported in other studies. Therefore, anaesthesiologists and gynaecologists must follow the precautions to avoid and minimise the incidence of complications with intramyometrial vasopressin.

The Olerud Extensile Anterior Approach for Complex Distal Femoral Fractures: A Systematic Review.

The management of AO/OTA (AO Foundation/Orthopaedic Trauma Association) 33-C3 complex distal femoral fractures presents challenges for orthopaedic surgeons. The extensile anterior approach may be an appropriate alternative treatment technique. The purpose of this systematic review is to (1) evaluate the Olerud approach (extensile anterior approach) for the treatment of 33-C3 complex distal femoral fractures and (2) evaluate postoperative patient outcomes. A systematic literature search was performed to retrieve studies that evaluated the treatment of 33-C3 complex distal femoral fractures. The PubMed database query resulted in 429 studies. Two reviewers independently reviewed the studies, of which six were identified. Patient demographics, AO/OTA fracture, surgical intervention, follow-up duration, clinical outcomes, and postoperative complications were collected and analyzed. The systematic review included six studies reporting on 85 patients (43 males and 42 females); the mean patient age was 45 years (range: 16-101 years). The most common cause of injury was road/traffic accident (51 patients). The mean follow-up time was 26 months (range: 3-72 months). In five studies, the mean time for union was 5.8 months (range: 2-9 months). The three most commonly reported complications were infection (seven [8.2%] patients), failure/malunion (three [3.5%] patients), and delayed tibial tuberosity osteotomy healing (three [3.5%] patients). Seventy (82.4%) patients did not suffer any postoperative complications. Out of 72 patients, 7 (9.7%) had resultant varus/valgus deformity. Overall, 57.1% had excellent/good functional outcomes. Based on the systematic literature review, the extensile anterior approach may be a viable alternative surgical option for 33-C3 complex distal femoral fractures. Given the current literature, more comprehensive and extensive studies need to be performed to ensure the best possible outcome.

Operative Times in Primary Total Knee Arthroplasty: Can We Predict the Future Based on Contemporary Nationwide Data.

Recently, the Centers for Medicare & Medicaid Services announced its decision to review "potentially misvalued" Current Procedural Terminology (CPT) codes, including those for primary total knee arthroplasty (TKA). CPT 27447 is being reevaluated to determine contemporary relative value units for work value, with operative time considered a primary factor in this revaluation. Despite broader indications for TKA, including extension of the procedure to more complex patient populations, it is unknown whether operative times may remain stable in the future. Therefore, the purpose of this study was to specifically evaluate future trends in TKA operative times across a large sample from a national database. The American College of Surgeons National Surgical Quality Improvement Project database was queried from January 1, 2008 to December 31, 2017 to identify 286,816 TKAs using the CPT code 27447. Our final analysis included 140,890 TKAs. Autoregressive integrated moving average forecasting models were built to predict 2- and 10-year operative times. While operative times were significantly different between American Society of Anesthesiologists (ASA) classes 1 and 2 (p = 0.035), there were not enough patients in ASA class 1 to perform rigorous inference. Additionally, operative times were not significantly different between ASA classes 3 and the combined ASA classes 4 and 5 cohort (p = 0.95). Therefore, we were only able to perform forecasts for ASA classes 2 and 3. Operative time was found to be nonstationary for both ASA class 2 (p = 0.08269) and class 3 (p = 0.2385). As a whole, the projection models indicated that operative time will remain within 2 minutes of the present operative time, up to the year 2027. Our projections indicate that operative times will remain stable over the next decade. This suggests that there is a lack of evidence for reducing the valuation of CPT code 27477 based on intraservice time for TKA. Further study should examine operative time trends in the setting of evolving alternative payment models, increasing patient complexity, and governmental restrictions.

Removal of Well-Fixed Tibial Cone in Revision Total Knee Arthroplasty-A Uniquely Challenging Yet Necessary Scenario.

The number of revision total knee arthroplasties (TKA) performed in the United States continues to increase. While advancements in implant design and surgical technique have led to improved outcomes compared with historical data, these cases remain technically demanding with high rates of aseptic failure and worse patient reported outcome scores compared with primary total knee arthroplasty. One particular problem commonly encountered in revision knee arthroplasty is bone loss, particularly in the epiphyseal region, which negatively impacts the structural integrity of the implants. Various modular metaphyseal sleeves and cones in conjunction with stemmed implants have been designed to enhance metaphyseal fixation, corroborated by multiple studies demonstrating excellent midterm results involving cones, and sleeves. Commercially available revision systems that incorporate metaphyseal cones are currently widely utilized in revision TKA. For tibial defects, both symmetric and asymmetric cone options are available. Excellent midterm results have been reported with use of this device in the setting of severe proximal tibial bone loss in revision TKA surgery. With the enhanced fixation provided by various sleeve and cone augments, implant removal in the setting of recurrent infection or implant failure can be extremely challenging. Consequently, in this work, we sought to describe an algorithmic approach for removing a tibial cone in conjunction with the overlying tibial baseplate. A review of the literature has also been conducted for complex surgical techniques regarding removal of well-fixed implants in revision total knee arthroplasty.

Prognostic significance of hemoglobin level and autoimmune hemolytic anemia in SARS-CoV-2 infection.

Higher levels of D-dimer, LDH, and ferritin, all have been associated with the poor prognosis of COVID-19. In a disease where there are acute inflammation and compromised oxygenation, we investigated the impact of initial hemoglobin (Hgb) levels at Emergency Department (ED) triage on the severity and the clinical course of COVID-19. We conducted a cross-sectional study on 601 COVID-19 patients in a COVID-19 national referral center between 13 and 27 June 2020. All adult patients presented at our hospital that required admission or hotel isolation were included in this study. Patients admitted to the intensive care unit (ICU) had a lower initial Hgb than those admitted outside the ICU (12.84 g/dL vs. 13.31 g/dL, p = 0.026) and over the course of admission; the prevalence of anemia (Hgb < 12.5 g/dL) was 65% in patients admitted to ICU, whereas it was only 43% in non-ICU patients (odds ratio of 2.464, 95% CI 1.71-3.52). Anemic ICU patients had a higher mortality compared with non-anemic ICU patients (hazard ratio = 1.88, log-rank p = 0.0104). A direct agglutination test (DAT) for all anemic patients showed that 14.7% of ICU patients and 9% of non-ICU patients had autoimmune hemolytic anemia (AIHA). AIHA patients had significantly longer length of hospital stay compared with anemic patients without AIHA (17.1 days vs. 14.08 days, p = 0.034). Lower Hgb level at hospital presentation could be a potential surrogate for COVID-19 severity.

Effect of surfactin on removal of semi-volatile organic compound: Emphasis on enhanced biofiltration performance.

The performance of a lab-scale biotrickling filter (BTF) inoculated with a mixed fungal consortium was investigated for the simultaneous abatement of 2-ethylhexanol; a hydrophobic semi-volatile organic compound (SVOC), and propylene glycol monomethyl ether (PGME). The BTF performance was investigated in the presence of lipopeptide-type biosurfactant, surfactin. The effect of surfactin on the removal efficiency and elimination capacity was examined at stretched inlet loading rates (LR): 1.04 to 15.7 and 3.2-48 g m-3 h-1 of PGME and 2-ethylhexanol, respectively. Seeding the BTF with 50 mg L-1 of surfactin maintained high and consistent removal efficiencies of PGME and 2-ethylhexanol up to LRs of 15.7 and 32 g m-3 h-1, with removal efficiencies of 98.5 and 99%, respectively. Once the LR of 2-ethylhexanol increased to 48 g m-3 h-1, a substrate inhibition was observed, accompanied by a sudden decrease in removal efficiency from 99.2 to 62.3%. At the same LR, the BTF performance was improved by reseeding 100 mg L-1 of surfactin, hence, reinstated the removal efficiency of 2-ethylhexanol to 92.7% and achieving a maximum elimination capacity of 44.5 g m-3 h-1. This enhanced SVOC uptake rate was further confirmed by a considerable increase in reaction rate constant from 0.005 to 0.017 s-1. A batch study was also conducted at the end of the experimental run to better understand the correlation between surfactin concentrations and the time-dependent partition coefficient of 2-ethylhexanol. Biofilm microbial community structure revealed relative abundancy of 72 and 28% of Trichoderma asperellum and Fusarium solani, respectively. The findings of this study show for the first time that the removal of a semi-VOC such as 2-ethylhexanol is feasible in the presence of surfactin and hence improving the bioavailability of hydrophobic semi-VOC.

Comparative nucleotide sequencing of the VP1 capsid gene of recent isolates of foot-and-mouth disease virus serotype O from Egypt.

Since 2006, Egypt has been affected by eleven various foot-and-mouth disease virus (FMDV) lineages. Accordingly, the nucleotide sequences of the 1D gene and the genes encoding the external capsid protein of some isolates of serotype O (the most predominant epidemic serotype in the country) collected from 2004 to 2017 were determined. All of these viruses (including the vaccine strain) belonged to serotype O, topotype ME-SA, and lineage Sharquia-72, and their sequences were of 98.6-98.9% identical to that of strain O1/Sharquia/EGY/72 (DQ164871), and differed from cultured and clinical (D197E) virus strains. The characteristic sites on the surface of the structural proteins of the Egyptian serotype O, topotype ME-SA viruses were located at residues 138 and 198 of VP1, residue 132 of VP2, and residues 56 and 104 of VP3. Furthermore, a phylogenetic tree revealed that Sharquia-72 was the only lineage present in Egypt for many decades prior to 2007. Unfortunately, however, during the last decade, five lineages of two separate topotypes of FMDV serotype O were detected in Egypt. Lineages Sharquia-72 and PanAsia-2 belong to topotype ME-SA and show ~ 14.5 to 17.5% intra-lineage divergence. In addition, lineages Qal-13, Ism-16, and Alx-17 cluster within topotype EA-3 and show ~ 4.5 to 15% intra-lineage diversity. The predecessors of the Egyptian EA-3 viruses are likely to have been from Sudan. Finally, at least a penta- or hexavalent vaccine comprising strains representing the endemic FMDV topotypes should be implemented on a wide scale in Egypt, which could combat the incursion of new lineages.

Subchondral insufficiency fractures of the femoral head: systematic review of diagnosis, treatment and outcomes.

Subchondral insufficiency fractures of the femoral head (SIFFH) are a cause of femoral head collapse leading to degenerative hip disease. SIFFH is often mistaken for osteonecrosis given similar clinical and radiographic features. These similarities often lead to missed or delayed diagnosis which can often delay or change management. The purpose of this article is to systematically review the spectrum of demographics, diagnostic and treatment options, including hip preservation in young patient populations. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. All related peer-reviewed publications from January 1999 to January 2019 were reviewed using the following databases: Medline, EMBASE, Scopus and Web of Science. The systematic review identified 54 articles, encompassing 482 patients (504 hips) diagnosed with SIFFH. One hundred and seventy-six (35%) males and 306 (63%) females were included, with a mean age of 53.6 ± 17.5 years and mean body mass index of 23.4 ± 4.0 kg/m2. Mean follow-up was 23.4 ± 15.9 months. Treatment decisions were 256 (55%) non-operative, 157 (34%) total hip arthroplasty (THA), 24 (5%) transtrochanteric anterior rotational osteotomy, 9 (2%) hip arthroscopy, 7 (2%) hip resurfacing, 3 (1%) bone grafting, 3 (1%) hemiarthroplasty and 1 (1%) tantalum rod insertion. Overall, 35% of SIFFH hips were converted to THA at latest follow-up. A majority of SIFFH patients had symptom resolution with non-operative management. Failure most often resulted in THA. In younger patients, hip preservation techniques have shown promising early results and should be considered as an alternative.

Liposomal Bupivacaine Is Both Safe and Effective in Controlling Postoperative Pain After Spinal Surgery in Children: A Controlled Cohort Study.

STUDY DESIGN: Retrospective comparative cohort study. OBJECTIVE: To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. SUMMARY OF BACKGROUND DATA: LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. MATERIALS AND METHODS: A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)-median=2, interquartile range (IQR)=(0-5) vs. 5 (2.5-7); POD 2-3 (0-5) vs. 4 (3-6); P<0.001], lower overall opioid consumption (78.2 vs. 129 morphine milligram equivalents; P=0.0001) and consistently from POD 0 to 3 (mean differences; 7.47, 9.04, 17.2, and 17.3 morphine milligram equivalents, respectively; P<0.01), shorter LOS (median=3 d, IQR=3-4 vs. 4 d, IQR=4-6; P<0.001), and similar to-home DD (98% vs. 97%). Complications were similar among the cohorts in superiority and 10% noninferiority analyses. Patients in the LB cohort had lower odds for complications (odds ratio=0.77; 95% CI, 0.64-0.93; P=0.009 and 0.67; 95% CI, 0.50-0.90; P=0.008). CONCLUSIONS: This study demonstrated the safety and efficacy of LB when added to the current multimodal postoperative pain management regimens after pediatric spinal surgery. LEVEL OF EVIDENCE: Level III.