Comparison of 90-Day Perioperative Outcomes in Shoulder Arthroplasty Between the Elderly and Nonelderly Patients.

INTRODUCTION: As life expectancy increases, the incidence of shoulder arthroplasty continues to increase as well. There are few shoulder arthroplasty studies investigating perioperative complication, readmission, and mortality. Furthermore, with bundled payments on the horizon, the cost of shoulder arthroplasty has become a significant issue. Clarifying risk factors for the need for postdischarge acute care will be critical information due to the high cost of such care. The goal of this study was to compare discharge disposition, length of stay (LOS), perioperative complications, readmission, and mortality in elderly and nonelderly cohorts to determine whether age is a risk factor for shoulder arthroplasty. MATERIALS AND METHODS: We retrospectively compared 89 elderly patients (80 years or older) and 86 nonelderly patients (79 years or younger) who underwent hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, or revision shoulder arthroplasty from 2007 to 2015. Baseline characteristics were compared between the 2 cohorts. We then compared discharge disposition, LOS, 90-day complication rate, readmission, and mortality between the 2 cohorts. RESULTS: Average length of hospitalization and percentage of patients with greater than 2 days of hospitalization were significantly higher in the elderly cohorts. Forty-four percent of the elderly cohorts were discharged to a skilled nursing facility compared to 6% in the nonelderly cohorts (P < .0001). There were no significant differences found in 90-day major complication rate, readmission, or mortality. DISCUSSION: Shoulder arthroplasty is a valuable surgery for various indications in the elderly population. However, the likelihood of a patient to need a prolonged hospitalization or skilled nursing facility care after surgery are important questions that need to be answered. Our study shows that age over 80 years is a risk factor for prolonged hospitalization and need for skilled nursing facility care after shoulder arthroplasty. CONCLUSION: We conclude that elderly patients who undergo shoulder arthroplasty are significantly more likely to have extended hospitalizations and to be discharged to skilled nursing facilities compared to nonelderly patients.

Whole-genome sequencing revealed concurrent outbreaks of shigellosis in the English Orthodox Jewish Community caused by multiple importations of Shigella sonnei from Israel.

In December 2013, Public Health England (PHE) observed an increase in the number of cases of Shigella sonnei linked to the Orthodox Jewish Community (OJC). Ultimately, 52 cases of S. sonnei phage type (PT) P and PT7 were notified between November 2013 and July 2014. Whole-genome sequencing (WGS) was performed on a HiSeq 2500 platform (Illumina) on isolates of S. sonnei submitted to PHE during the investigation. Quality trimmed sequence reads were mapped to a reference genome using BWA-MEM, and single-nucleotide polymorphisms (SNPs) were identified using GATK2. Analysis of the core genome SNP positions (>90 % consensus, minimum depth 10×, MQ≥30) revealed that isolates linked to the outbreak could be categorized as members of distinct monophyletic clusters (MPCs) representing concurrent regional outbreaks occurring in the OJCs across the United Kingdom. A dated phylogeny predicted the date of the most recent common ancestor of the MPCs to be approximately 3.1 years previously [95 % highest posterior density (HPD), 2.4-3.4]. Isolates of S. sonnei from cases from the OJCs in Israel included in the phylogeny, branched from nodes basal to the UK OJC outbreak clusters, indicating they were ancestral to the UK OJC isolates, and that the UK isolates represented multiple importations of S. sonnei into the UK population from Israel. The level of discrimination exhibited by WGS facilitated the identification of clusters of isolates within the closely related bacterial populations circulating in the OJC that may be linked to a unique point sources or transmission routes, thus enabling a more appropriate public health response and targeted interventions.

Initial Stability of Cemented vs Cementless Tibial Components Under Cyclic Load.

BACKGROUND: Cement fixation of total knee components remains the gold standard despite resurgence in cementless fixation with the goal of long-term durable fixation. Initial stability is paramount to achieve bony ingrowth of cementless components. METHODS: Twelve cemented and cementless tibial baseplates were implanted into sawbones and tested using a physiological medial-lateral load distribution for 10,000 cycles to represent 8 weeks of in vivo function. Micromotion was measured at 5 locations around the baseplate during loading. RESULTS: Cycling had a significant effect on the change in micromotion between maximum and minimum loads at the anterior, medial, lateral, posteromedial, and posterolateral tray edge locations. A significant effect of fixation technique was detected for the anterior (P < .001), medial (P = .002), and lateral (P = .0056) locations but not for the posteromedial (P = .36) or posterolateral (P = .82) locations. Differences in micromotion between cemented and cementless components did not exceed 150 µm at any tested location. CONCLUSION: The micromotion experienced by cementless tibial components in the present study may indicate a lower initial mechanical stability than the cemented group. However, this difference in initial stability may be subclinical because the differences between average cemented and cementless micromotion were <150 µm at all measured locations under the loading regime implemented.

Intercontinental dissemination of azithromycin-resistant shigellosis through sexual transmission: a cross-sectional study.

BACKGROUND: Shigellosis is an acute, severe bacterial colitis that, in high-income countries, is typically associated with travel to high-risk regions (Africa, Asia, and Latin America). Since the 1970s, shigellosis has also been reported as a sexually transmitted infection in men who have sex with men (MSM), in whom transmission is an important component of shigellosis epidemiology in high-income nations. We aimed to use sophisticated subtyping and international sampling to determine factors driving shigellosis emergence in MSM linked to an outbreak in the UK. METHODS: We did a large-scale, cross-sectional genomic epidemiological study of shigellosis cases collected from 29 countries between December, 1995, and June 8, 2014. Focusing on an ongoing epidemic in the UK, we collected and whole-genome sequenced clinical isolates of Shigella flexneri serotype 3a from high-risk and low-risk regions, including cases associated with travel and sex between men. We examined relationships between geographical, demographic, and clinical patient data with the isolate antimicrobial susceptibility, genetic data, and inferred evolutionary relationships. FINDINGS: We obtained 331 clinical isolates of S flexneri serotype 3a, including 275 from low-risk regions (44 from individuals who travelled to high-risk regions), 52 from high-risk regions, and four outgroup samples (ie, closely related, but genetically distinct isolates used to determine the root of the phylogenetic tree). We identified a recently emerged lineage of S flexneri 3a that has spread intercontinentally in less than 20 years throughout regions traditionally at low risk for shigellosis via sexual transmission in MSM. The lineage had acquired multiple antimicrobial resistance determinants, and prevailing sublineages were strongly associated with resistance to the macrolide azithromycin. Eight (4%) of 206 isolates from the MSM-associated lineage were obtained from patients who had previously provided an isolate; these serial isolations indicated atypical infection patterns (eg, reinfection). INTERPRETATION: We identified transmission-facilitating behaviours and atypical course(s) of infection as precipitating factors in shigellosis-affected MSM. The intercontinental spread of antimicrobial-resistant shigella through established transmission routes emphasises the need for new approaches to tackle the public health challenge of sexually transmitted infections in MSM. FUNDING: Wellcome Trust (grant number 098051).

Factors associated with travel to non-local genitourinary medicine clinics for gonorrhoea: an analysis of patients diagnosed in London, 2009-10.

We analysed factors associated with travelling to non-local genitourinary medicine clinics for gonorrhoea care in London. We used surveillance data on London residents attending genitourinary medicine clinics in 2009-10 and calculated distances between patients' areas of residence and both the nearest genitourinary medicine clinic and the clinic attended. Non-local clinics were attended by 5408 (46.7%) patients. Men having sex with men attended non-local services more than heterosexuals (OR 3.83, p < 0.001). Among heterosexual men, black Africans and black Caribbeans were more likely, and South Asians less likely, to attend non-local services compared to whites (OR [95%CI] 1.33 [1.04-1.72], 1.36 [1.11-1.67] and 0.46 [0.31-0.70] respectively). Similar associations, although not statistically significant, were found in women. People were more likely to attend local services if their local clinic provided walk-in and young people's services, weekend consultations and long opening hours. These findings could help design services meeting local population needs and facilitate prompt and equitable access to care.

Mortality of hepatitis B surface antigen-positive blood donors in England and Wales.

BACKGROUND: Large population-based cohort studies in areas of high hepatitis B virus (HBV) prevalence have provided the evidence establishing hepatitis B surface antigen (HBsAg) carriage as a risk factor for hepatocellular carcinoma (HCC) and liver disease. Fewer studies have examined this in Western countries, where both HBV infection and carriage are less common and transmission patterns differ. This is the only prospective population-based study to examine this relationship in Europe. METHODS: In all, 2681 male and 977 female blood donors in England and Wales, found to be HBsAg positive during routine blood-donation screening, were followed up from recruitment in 1970-1982 to December 1999 and their cause-specific mortality was analysed. This was compared with that of the general population of England and Wales. RESULTS: During a mean of 22 years of follow-up, 17.4% of the 420 deaths were due to HCC or liver disease. There were 20 deaths from HCC in male HBsAg carriers, representing a significantly high standardized mortality ratio (SMR) compared to the male population of England and Wales of 26 (SMR = 26.26; 95% CI: 16.04- 40.54). The HCC incidence rate in males was 33.5 per 100 000 person years and 4.4 per 100 000 person years in females. Men had 8.5 (SMR = 8.50; 95% CI: 6.25- 11.31) and women had 3.9 times the risk of death from liver disease (SMR = 3.89; 95% CI: 1.26-9.09). The risk of circulatory disease deaths was reduced in both males and females. There was a significant increased risk of non-Hodgkins lymphoma that was not apparent in the first decade of follow-up. The increased risk of HCC and liver disease in men fell with follow-up. CONCLUSION: Hepatitis B surface antigen carriage is a significant risk factor in England and Wales for both liver disease and HCC mortality. However, this risk has declined with duration of follow-up. This could be due to natural reversion to HBsAg negativity or as a result of treatment and avoidance of other risk factors. The increased risk of non-Hodgkins lymphoma seen in longer follow-up is likely to be related to HIV infection acquired subsequent to recruitment.

Role of electronic data exchange in an international outbreak caused by Salmonella enterica serotype Typhimurium DT204b.

From July through September 2000, patients in five European countries were infected with a multidrug-resistant strain of Salmonella Typhimurium DT204b. Epidemiologic investigations were facilitated by the transmission of electronic images (Tagged Image Files) of pulsed-field gel electrophoresis profiles. This investigation highlights the importance of standardized protocols for molecular typing in international outbreaks of foodborne disease.