Outcomes following staged bilateral total hip replacement: does first-side surgery predict the second?

INTRODUCTION: Patient-reported outcome measures (PROMs) for bilateral staged total hip replacements (THRs) were reviewed to determine whether first-side surgery can predict second-side outcomes. METHODS: A retrospective review was undertaken of a consecutive cohort of staged bilateral THRs using the same approach, implant and technique, from August 2009 to February 2020. Minimal important change (MIC) in PROMs was set at ≥5. RESULTS: A total of 296 consecutive staged bilateral THRs were performed in 148 patients. Mean time interval between sides was 25 months (range 2-102). Mean age was 63.2 years for the first side and 65.3 years for the second; 62.8% of patients were female. Mean body mass index was 31.08 for the first side, increasing to 31.57 for the second side (p = 0.248). One-year follow-up PROMs were available for 96.6% and 92.5% of the first and second side, respectively. Mean PROMs improvement at 1 year was 26.4 for the first side and 25.1 for the second side (p = 0.207). Some 97.9% of patients achieved MIC for the first side and 96.3% for the second side (p = 0.092). Eight patients failed to reach an MIC on one side, all were female (p < 0.001); however, MIC was achieved for the contralateral side. Seven of eight patients (87.5%) achieved MIC by 2 years. CONCLUSIONS: This study identified no significant difference between first- and second-side PROMs improvements following staged bilateral THRs at 1-year follow-up. Failure to reach MIC on one side does not preclude success on the other. Female patients were more prone to not reach MIC at 1 year, but improvement was still subsequently achieved in the majority of cases. The informed consent process is able to reflect this expectation.

Stability analysis of COVID-19 model with fractional-order derivative and a delay in implementing the quarantine strategy.

This study presents methods of hygiene and the use of masks to control the disease. The zero basic reproduction number can be achieved by taking the necessary precautionary measures that prevent the transmission of infection, especially from uninfected virus carriers. The existence of time delay in implementing the quarantine strategy and the threshold values of the time delay that keeping the stability of the system are established. Also, it is found that keeping the infected people quarantined immediately is very important in combating and controlling the spread of the disease. Also, for special cases of the system parameters, the time delay can not affect the asymptotic behavior of the disease. Finally, numerical simulations have been illustrated to validate the theoretical analysis of the proposed model.

Factors associated with folic acid knowledge and intake among pregnant women in Sudan.

Preconceptual folic acid use is known to have a protective effect against neural tube defects (NTDs). This study assessed knowledge and determinants of awareness on folic acid use among pregnant women at Omdurman Maternity Hospital, Sudan during 2014. The standardized, anonymous questionnaire was used to collect data. Almost 80% of respondents had heard of folic acid. College-educated women (92.2%) knew more about folic acid and used it more often in the pre-conceptual period (8.3%). Doctors were the commonest source of information on folic acid (62%). Fewer subjects (8.9%) knew that it prevented birth defects, and 33.8% of subjects knew that green leafy vegetables are a source of folic acid. Of all subjects, only 3.2% use it preconceptually. Supplementation of folic acid preconceptually needs to be addressed in order to reduce the rate of NTDs found in Sudan.

Effect of intraoperative magnesium intravenous infusion on the hemodynamic changes associated with right lobe living donor hepatotomy under transesophageal Doppler monitoring-randomized controlled trial.

BACKGROUND: Liver donors are subjected to specific postresection hemodynamic changes. The aim was to monitor these changes and to evaluate the effect of magnesium sulfate infusion (MgSO4) on these changes together with total anesthetic agents consumption. PATIENTS AND METHODS: A total of 50 donors scheduled for right hepatotomy were divided into two equal groups. Controls (C) received saline and magnesium group (Mg) received MgSO4 10% (30 mg/kg over 20 min) administered immediately after induction of anesthesia, followed by infusion (10 mg/kg/h) till the end of surgery. Hemodynamics, transesophageal Doppler (TED) data and anesthetic depth guided by Entropy were recorded. RESULTS: Postresection both groups demonstrated an increase in heart rate (HR) and cardiac output (COP) in association with lowering of systemic vascular resistance (SVR). The increase in HR with Mg was lower when compared with C, P = 0.00. Increase in COP was lower with Mg compared to (C) (6.1 ± 1.3 vs. 7.5 ± 1.6 L/min, P = 0.00) and with less reduction in SVR compared to C (1145 ± 251 vs. 849.2 ± 215 dynes.s/cm(5), P < 0.01), respectively. Sevoflurane consumption was lower with Mg compared to C (157.1 ± 35.1 vs. 187.6 ± 25.6 ml, respectively, P = 0.001). Reduced fentanyl and rocuronium consumption in Mg group are compared to C (P = 0.00). Extubation time, postoperative patient-controlled fentanyl were lower in Mg than C (P = 0.001). CONCLUSION: TED was able to detect significant hemodynamic changes associated with major hepatotomy. Prophylactic magnesium helped to reduce these changes with lower anesthetic and analgesics consumption and an improvement in postoperative pain relief.

Combination of vitamin E and clomiphene citrate in treating patients with idiopathic oligoasthenozoospermia: A prospective, randomized trial.

The most common cause of male infertility is idiopathic oligoasthenozoospermia. Empirical medical treatment for idiopathic male infertility is still a controversial issue. The aim of this study was to evaluate any possible effects of combining vitamin E as antioxidant and clomiphene citrate as antiestrogen on spermatozoa concentration and motility in comparison to give either of medications alone in patients with idiopathic oligoasthenozoospermia. This is a comparative prospective randomized study. Ninety patients with idiopathic oligoasthenozoospermia were randomized into equally three groups: Group A: received vitamin E (400 mg/day) for 6 months. Group B: received clomiphene citrate (25 mg daily) for 6 months. Group C: received combination of both drugs in the same doses for 6 months. All patients were subjected to the following: history taking, general and genital examination, semen analysis, serum FSH, total testosterone, and scrotal duplex. Semen examination was performed according to the guidelines of (WHO, 2010), at the start of treatment and was repeated after 3 months and after 6 months of treatment. Regarding vitamin E group, there was insignificant increase in mean sperm concentration after 6 months of treatment in comparison to baseline. On the other hand, there was a significant improvement of mean sperm concentration in the other two groups after 6 months of treatment, with more significance in combination therapy group (p = 0.001). The mean total sperm motility has improved in all patients groups, in comparison to baseline, with more significance in combination therapy group. In vitamin E group, it was 28.07 ± 9.65% (p = 0.000). For those in clomiphene citrate group, was 33.33 ± 14.10% (p = 0.003) and 40.50 ± 17.54% (p = 0.000) in combination therapy group. Combining antioxidant and anti-estrogen therapy is a valid option for the treatment of a selected group of men with unexplained isolated oligoasthenozoospermia.

Effect of primary neopharyngeal repair on acoustic characteristics of tracheoesophageal voice after total laryngectomy.

OBJECTIVES: The tracheoesophageal puncture technique of voice restoration enables successful voice rehabilitation after total laryngectomy. Because post-operative voice quality can vary significantly, depending on which type of hypopharyngeal repair is chosen, the aim of this study was to evaluate the effect of such repair on tracheoesophageal puncture voice after total laryngectomy. STUDY DESIGN: Prospective, clinical study. SETTING: Otolaryngology department, Tanta University, Egypt. METHODS: Tracheoesophageal puncture voice was quantitatively and qualitatively evaluated in 40 patients using a Provox 2TM prosthesis after standard total laryngectomy. The patients were divided, according to the type of hypopharyngeal repair, into four groups of 10 cases each, as follows: group one, pharyngoesophageal myotomy; group two, pharyngeal plexus neurectomy; group three, non-muscle vertical repair; and group four, transverse repair. These surgical groups were compared with each other with respect to different voice parameters. RESULTS: Patient profiles were almost equivalent in all surgical groups. The mean values of most of the parameters of quantitative tracheoesophageal puncture voice did not differ significantly, comparing the four surgical groups; however, a slightly significant difference was observed regarding loud intensity in the non-muscle repair group, and soft and loud jitter in the transverse repair group. Mean values for qualitative measures of intelligibility and communicative effectiveness did not show significant difference. However, a slightly significant difference was observed regarding fluency, word correctness, speaking rate and wetness, with higher values for all these parameters except wetness in the myotomy group, and higher values for wetness in the non-muscle repair group. CONCLUSION: The four hypopharyngeal repair types--primary pharyngoesophageal myotomy, pharyngeal plexus neurectomy, non-muscle vertical repair and transverse hypopharyngeal repair--were almost equivalent in prevention of pharyngoesophageal spasm in total laryngectomy patients who had undergone primary tracheoesophageal puncture for voice restoration.

Managing problems with tracheoesophageal puncture for alaryngeal voice rehabilitation.

OBJECTIVES: The tracheoesophageal puncture (TEP) technique and the insertion of its associated voice prostheses may give rise to adverse events. We present our experience with this technique, paying special attention to the incidence and management of these adverse events. STUDY DESIGN: A retrospective clinical analysis was undertaken. METHODS: Seventy-five laryngectomized patients underwent TEP for voice restoration. They were divided into two groups: group one, 43 patients with secondary TEP; and group two, 32 patients with primary TEP. Patient medical records were reviewed for data on the incidence, management and outcome of adverse events encountered during patients' follow up. RESULTS: Problems that arose in the patients were itemized as either early or late. The same patient could develop one or more problems in either group. The management of these problems, concerning the creation and maintenance of the TEP and associated prostheses, was noted. In group one, results were initially favourable in 91 per cent of patients and still positive in 81.4 per cent after three years. In group two, early results were favourable in all patients, and only two patients asked for late elective closure of the TEP (with a success rate of 93.7 per cent). CONCLUSIONS: Via an intensive and multidisciplinary approach to problems, most of the inevitable adverse events could be solved adequately, minimizing the discomfort of patients who had undergone laryngectomy and indwelling voice prosthesis insertion.

Turner's syndrome in adulthood.

Turner's syndrome is the most common chromosomal abnormality in females, affecting 1:2,500 live female births. It is a result of absence of an X chromosome or the presence of a structurally abnormal X chromosome. Its most consistent clinical features are short stature and ovarian failure. However, it is becoming increasingly evident that adults with Turner's syndrome are also susceptible to a range of disorders, including osteoporosis, hypothyroidism, and renal and gastrointestinal disease. Women with Turner's syndrome have a reduced life expectancy, and recent evidence suggests that this is due to an increased risk of aortic dissection and ischemic heart disease. Up until recently, women with Turner's syndrome did not have access to focused health care, and thus quality of life was reduced in a significant number of women. All adults with Turner's syndrome should therefore be followed up by a multidisciplinary team to improve life expectancy and reduce morbidity.

Autoimmune thyroid syndrome in women with Turner's syndrome--the association with karyotype.

OBJECTIVE: Females with Turner's syndrome (TS) are at an increased risk of developing autoimmune thyroid disease. Studies assessing the influence of karyotype on thyroid autoimmunity in adults with TS have yielded conflicting results but have been limited by small numbers. The aim of this study was to determine the frequency of thyroid autoimmunity in a large cohort of women with TS and to assess the influence of karyotype on the development of thyroid disease. DESIGN, PATIENTS AND MEASUREMENTS: Data were available for 145 women with TS attending a dedicated adult Turner clinic. The mean age was 26 years (range 16-52 years). Information regarding the presence of thyroid disease, karyotype, thyroid autoantibodies and thyroid function was recorded in all. The chi-squared test with Yates' correction was used to assess the association between karyotype and thyroid autoimmunity. RESULTS: Forty-one per cent of women with TS had positive thyroid autoantibodies and 16% of women were hypothyroid on replacement therapy with thyroxine. However, 83% of women with an X-isochromosome had positive thyroid autoantibodies compared with 33% of women with other karyotypes (P < 0.0001). Women with an isochromosome-X karyotype were also significantly more likely to become frankly hypothyroid and require thyroxine compared with other karyotypes (37.5% isochromosome-X vs. 14% 45, X vs. 6% other karyotypes P = 0.0034). CONCLUSIONS: In this large cohort of women with TS we have shown that the risk of developing autoimmune thyroid disease is particularly high in women with an X-isochromosome, suggesting that a gene on the long arm of the X chromosome (Xq) may play an important pathogenetic role in the development of autoimmune thyroid disease.

Hormone replacement therapy may improve hepatic function in women with Turner's syndrome.

OBJECTIVE: Women with Turner's syndrome (TS) have recently been shown to be at an increased risk of developing chronic liver disease. There has been some concern that oestrogen replacement therapy may exacerbate hepatic dysfunction. The aim of this study was to assess hepatic function in women with TS and to determine the effect of oral oestradiol valerate on liver enzymes. DESIGN AND PATIENTS: A retrospective review of liver enzymes of 80 women with TS, followed by a prospective study looking at serum liver enzyme concentrations in 20 women with TS following 3 months on and off hormone replacement therapy (HRT) (oestradiol valerate, 2 mg/levonorgestril 75 microg). MEASUREMENTS: Liver enzymes (gamma glutamyl transferase, aspartate transaminase and alkaline phosphatase), albumin and bilirubin were measured on and off HRT. Viral hepatitis serology and liver autoantibodies were tested in patients with abnormal liver function. RESULTS: Thirty-five out of 80 women (44%) had elevated serum liver enzyme concentrations. Two women (2.5%) had a mildly raised serum bilirubin, but protein synthesis was normal in all subjects. HRT resulted in a significant fall in all liver enzymes (P < 0.05) but did not affect serum protein concentrations CONCLUSIONS: Women with Turner's syndrome often have elevated liver enzymes. Oestrogen/progestagen therapy using oestradiol valerate improves liver function in this group of patients. The mechanisms behind this are unclear.

Hypertension is a major risk factor for aortic root dilatation in women with Turner's syndrome.

Women with Turner's syndrome (TS) have a threefold increase in mortality, primarily as a result of their cardiovascular complications. Recently, the risk of fatal aortic dissection has come to light as a major cause of mortality in women with TS. The aim of this study was to assess the prevalence of aortic root dilatation in a group of women with TS and to investigate the factors contributing to its development. Thirty-eight women with TS attending a dedicated adult Turner clinic were examined clinically and by M-mode and two-dimensional echocardiography on at least one occasion. Aortic root dilatation was defined as an aortic root diameter greater than the 95th centile for body surface area. Fasting serum lipid concentrations were measured in all women. Additionally, 18 subjects underwent noninvasive assessment of central arterial stiffness using applanation tonometry. Fifty percent of subjects were hypertensive and a similar number had an abnormal echocardiogram. A bicuspid aortic valve was present in 33% of subjects, 16 women (42%) had ascending aortic root dilatation. This was associated with a bicuspid aortic valve in four women and hypertension in 11. Two women had isolated aortic root dilatation. Aortic root diameter was significantly associated with systolic blood pressure (r = 0.5, P = 0.003) and left ventricular thickness (r = 0.5, P = 0.02). There was no association with serum lipids or arterial compliance. Structural cardiac abnormalities are present in up to 50% of women with Turner's syndrome. Aortic root dilatation is a significant risk in women with Turner's syndrome and is closely dependent on blood pressure. Aortic root dilatation does not appear to be related to atherosclerosis and is more likely to be due to a mesenchymal defect. Regular surveillance of the aortic root diameter is essential in all women with Turner's syndrome and hypertension should be treated aggressively when present in order to minimize the risk of potentially fatal aortic dissection.

Autoclaved Leishmania major vaccine for prevention of visceral leishmaniasis: a randomised, double-blind, BCG-controlled trial in Sudan.

BACKGROUND: Visceral leishmaniasis is a major cause of morbidity and mortality in the Sudan. Drug treatment is expensive, and drug resistance is becoming increasingly common. Safe, effective, and cheap vaccines are needed. We report the results of a vaccine trial against human visceral leishmaniasis. METHODS: We undertook a double-blind randomised trial to test the safety and efficacy of an autoclaved Leishmania major (ALM) promastigote vaccine (1 mg per dose). Of 5093 volunteers screened, 2306 had negative leishmanin skin tests and reciprocal titres of less than 6400 in the direct agglutination test. They were randomly assigned two doses of ALM mixed with BCG or BCG alone. Volunteers were followed up for 2 years. The primary endpoint was clinical visceral leishmaniasis or post-kala-azar dermal leishmaniasis. Analyses were by intention to treat. FINDINGS: Side-effects were confined to the injection site. The cumulative frequency of visceral leishmaniasis at 2 years did not differ significantly between the group assigned ALM plus BCG and that assigned BCG alone (133/1155 [11.5%] vs 141/1151 [12.3%], p=0.6). The vaccine efficacy was 6% (95% CI -18 to 25). The proportion of individuals showing leishmanin skin conversion was significantly higher in the ALM plus BCG group than in the BCG alone group throughout follow-up (303 [30%] vs 72 [7%] at 42 days). Individuals whose leishmanin test converted after vaccination (induration > or =5 mm) had a significantly lower frequency of visceral leishmaniasis than non-responders (27/375 [7.2%] vs 210/1660 [12.7%], p=0.003). INTERPRETATION: We found no evidence that two doses of ALM plus BCG offered significant protective immunity against visceral leishmaniasis compared with BCG alone. Leishmanin skin conversion with an induration of 5 mm or more in either group was associated with protection from the disease.

The effect of hormone replacement therapy on cardiovascular hemodynamics in women with Turner's syndrome.

Women with Turner's syndrome, the majority of whom are estrogen deficient, have an increased incidence of coronary artery disease. The aim of this study was to assess the effects of hormone replacement therapy (HRT) on central arterial hemodynamics, insulin sensitivity, and lipids in adults with Turner's syndrome. Twenty-one women with Turner's syndrome were studied prospectively, on and off 3 months of estradiol valerate in combination with levonorgestrel. The following measurements were made: body mass index, waist/hip ratio, serum lipids, fasting insulin and glucose, and mean arterial blood pressure. Aortic root pressure and waveforms were estimated noninvasively and the augmentation index (AI), a measure of aortic stiffness, was calculated. The AI was significantly lower during estrogen therapy (22% vs. 15%; P = 0.008), suggesting a reduction in central arterial stiffness. Fasting insulin and glucose concentrations were also significantly lower during HRT (P = 0.01 and P = 0.0004, respectively). There was no difference in body mass index, serum lipids, or brachial and aortic blood pressures on and off treatment. Total cholesterol was correlated with the AI (r = 0.4; P = 0.03). These results suggest that HRT in women with Turner's syndrome has a favorable effect on central arterial hemodynamics and insulin sensitivity. The lack of effect on serum lipids suggests that the effects of HRT on aortic compliance may be mediated by an improvement in endothelial function.

Outcome of transphenoidal surgery for acromegaly and its relationship to surgical experience.

BACKGROUND: A number of surgical series have been reported on the treatment of acromegaly and their results vary widely. The acceptable definition of remission has changed in recent years and it is known, though in a small series, that growth hormone levels of > 5 mU/l are still associated with an increased mortality from the condition. We have analysed data at this centre and examined the outcome of transphenoidal surgery for acromegaly, compared our results with recently published series from other centres and also assessed factors which might effect outcome including whether there is any demonstrable effect of the experience of the surgeon on outcome. PATIENTS AND METHODS: We have analysed data from all of our 139 patients in whom follow up data are available who have undergone initial transphenoidal surgery for acromegaly by one surgeon at this centre, between 1974 and 1995. Follow up was for a median of 5 years (range 1 month to 17 years). RESULTS: 67% of patients achieved the criterion for remission (mean GH < 5 mU/l). Success was related to tumour size and preoperative growth hormone values. Thus 91% of patients with microadenomas were in remission postoperatively compared to 46% of patients with macroadenomas. Analysis of the results according to the year of operation showed an improvement in success rates with time. More than 15 years ago, the success rate according to the growth hormone criteria set was 48% and the failure rate 52%. In contrast in the last 5 years analysed, the overall success rate was 74% with a failure rate of 26% (P < 0.04). The success rate for microadenomas was 50% initially, then remained 100%. The case mix was analysed and no change was found. We have also demonstrated an improvement in pituitary function (including normalization of preoperative elevated prolactin) with time so that pre 1981 16% of patients' pituitary function improved perioperatively but 10 years later this figure had risen to 34% (P < 0.03). There was no change over time in the development of pituitary hypofunction, complication rate or recurrence rate. CONCLUSION: Surgical treatment is a safe and effective treatment for acromegaly and remains the first choice of treatment for most acromegalic patients. The results of this centre compare favourably with series from other centres. We have demonstrated improved results, both in terms of post operative growth hormone values and pituitary function tests with time and increasing neurosurgical experience. We conclude that outcome for the surgical treatment for acromegaly is best achieved with one surgeon specialising in pituitary surgery. Improved operative outcome thus achieved has major cost implications and avoids the necessity for consideration of postoperative radiotherapy and the use of expensive growth hormone suppressing drugs in the postoperative period.

Medical problems in adult women with Turner's syndrome.

Turner's syndrome, the most common chromosome abnormality in females, is the consequence of complete absence or partial deletion of one X chromosome. It is associated with a wide spectrum of clinical features of which short stature and gonadal dysgenesis are almost invariably present. Women with Turner's syndrome have a reduced life expectancy primarily as a result of cardiovascular disease. They are also susceptible to a number of other disorders including autoimmune thyroiditis, osteoporosis, renal and gastrointestinal disease. Thus, women with Turner's syndrome should be followed up by a multidisciplinary team of physicians with an interest in the disorder following discharge from paediatric care. This review aims to highlight the problems associated with Turner's syndrome in adulthood and to discuss important management strategies.

The use of steroid replacement therapy for the management of Addison's disease.

Addison's disease is an uncommon but potentially life-threatening condition characterized by adrenal failure. All patients require lifelong glucocorticoid replacement to maintain life and most also need aldosterone substitution. There has been some recent interest in the physiological role in humans of the adrenal androgen, dehydroepiandrosterone. This paper reviews optimal glucocorticoid and mineralo-corticoid replacement therapy and provides the available data on dehydroepiandrosterone replacement.

The impact of obesity on cardiovascular risk factors in Turner's syndrome.

OBJECTIVE: To evaluate risk factors for coronary artery disease in women with Turner's syndrome which may contribute to the increased incidence of premature cardiovascular death noted in this disorder. DESIGN: Comparison of clinical and biochemical parameters in women with Turner's syndrome with those in women with normal karyotype. PATIENTS: Ninety-one women with Turner's syndrome attending a dedicated adult Turner's syndrome clinic and 22 control subjects were studied. MEASUREMENTS: Recumbent blood pressure, body mass index (BMI), fasting total cholesterol, triglycerides and high density lipoproteins (HDL) were measured in both study groups. RESULTS: Women with Turner's syndrome were more obese compared with women with a normal karyotype. They were more likely to be hypertensive and the obese patients had higher serum triglyceride concentrations. Hypertension was independent of obesity and may be under-recognized because of failure to compare with age-matched normal ranges. Lipoprotein changes were accounted for by the obesity. CONCLUSIONS: Women with Turner's syndrome may be at increased risk of developing coronary artery disease as a result of the higher frequency of hypertension and obesity. Routine screening of this population for risk factors for ischaemic heart disease is recommended.