Oxidized zirconium versus cobalt-chrome femoral heads in total hip arthroplasty: a multicentre prospective randomized controlled trial with ten years' follow-up.

AIMS: This study reports the ten-year wear rates, incidence of osteolysis, clinical outcomes, and complications of a multicentre randomized controlled trial comparing oxidized zirconium (OxZr) versus cobalt-chrome (CoCr) femoral heads with ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (XLPE) liners in total hip arthroplasty (THA). METHODS: Patients undergoing primary THA were recruited from four institutions and prospectively allocated to the following treatment groups: Group A, CoCr femoral head with XLPE liner; Group B, OxZr femoral head with XLPE liner; and Group C, OxZr femoral head with UHMWPE liner. All study patients and assessors recording outcomes were blinded to the treatment groups. The outcomes of 262 study patients were analyzed at ten years' follow-up. RESULTS: Patients in Group C were associated with increased mean liner wear rates compared to patients in Group A (0.133 mm/yr (SD 0.21) vs 0.031 mm/yr (SD 0.07), respectively; p < 0.001) and Group B (0.133 mm/yr (SD 0.21) vs 0.022 mm/yr (SD 0.05), respectively; p < 0.001) at ten years' follow-up. Patients in Group C were also associated with increased risk of osteolysis and aseptic loosening requiring revision surgery, compared with patients in Group A (7/133 vs 0/133, respectively; p = 0.007) and Group B (7/133 vs 0/135, respectively; p = 0.007). There was a non-statistically significant trend towards increased mean liner wear rates in Group A compared with Group B (0.031 mm/yr (SD 0.07) vs 0.022 mm/yr (SD 0.05), respectively; p = 0.128). All three groups were statistically comparable preoperatively and at ten years' follow-up when measuring normalized Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.410), 36-Item Short Form Health Survey (p = 0.465 mental, p = 0.713 physical), and pain scale scores (p = 0.451). CONCLUSION: The use of UHMWPE was associated with progressively increased annual liner wear rates after THA compared to XLPE. At ten years' follow-up, the group receiving UHMWPE demonstrated an increased incidence of osteolysis and aseptic loosening requiring revision surgery compared to XLPE. Femoral heads composed of OxZr were associated with trend towards reduced wear rates compared to CoCr, but this did not reach statistical significance and did not translate to any differences in osteolysis, functional outcomes, or revision surgery between the two femoral head components. Cite this article: Bone Joint J 2022;104-B(7):833-843.

Gender diversity in UK surgical specialties: a national observational study.

OBJECTIVES: To compare gender diversity between UK surgical specialties, assess trends over time, and estimate when gender parity might be achieved. DESIGN: Observational study. SETTING: National Health Service, UK. PARTICIPANTS: NHS Hospital & Community Health Service workforce statistics for 2011 to 2020 MAIN OUTCOME MEASURES: Logistic regression was used to compare female representation in 2020 between surgical specialties, and to examine for any significant trends between 2011 and 2020. The method of least squares was used to estimate when female representation of specialty registrars would reach 50% ('gender parity') for specialties with <40% female representation. RESULTS: In 2020, female consultant and specialty registrar representation was significantly different between surgical specialties (both p<0.001). Female representation for each specialty were as follows (from highest to lowest): Specialty Registrars-Ophthalmology 49.7%, Otolaryngology 48.2%, Paediatric Surgery 45.5%, Plastic Surgery 42.2%, General Surgery 39.8%, Urology 31.6%, Vascular Surgery 25.0%, Neurosurgery 24.7%, Cardiothoracic Surgery 21.3%, and Trauma and Orthopaedics 20.6%; Consultants-Ophthalmology 32.4%, Paediatric Surgery 31.7%, Plastic Surgery 20.9%, General Surgery 17.5%, Otolaryngology 17%, Vascular Surgery 13.7%, Urology 11.7%, Cardiothoracic Surgery 10.8%, Neurosurgery 8.2%, and Trauma and Orthopaedics 7.3%. There was a significant positive trend in female representation of specialty registrars between 2011 and 2020 for all specialties except for Paediatric Surgery (representation consistently >45%) and Vascular Surgery (representation consistently <30%). General Surgery was estimated to achieve gender parity of their specialty registrars by 2028, Urology by 2033, Neurosurgery by 2064, Trauma and Orthopaedics by 2070, and Cardiothoracic Surgery by 2082. CONCLUSIONS: Despite improvements over the last decade, gender disparity persists in the UK surgical workforce and there are significant differences between surgical specialties. Further work is necessary to establish the reasons for these observed differences with a specific focus on Vascular Surgery, Cardiothoracic Surgery, Neurosurgery, and Trauma and Orthopaedics.

Aspirin monotherapy is a suitable standard thromboprophylactic agent following total hip arthroplasty.

INTRODUCTION: Aspirin is increasingly recognised as an efficacious thromboprophylactic agent with a superior safety profile compared to alternatives. Following our institution's previously published experience we implemented a risk-stratified protocol utilising aspirin as standard. We now present retrospective review of standard use of aspirin on fatal pulmonary embolism, all-cause mortality, and venous thromboembolism (VTE) following total hip arthroplasty (THA). METHODS: A consecutive series of elective THAs was identified. Prospectively maintained databases were analysed to yield demographic data and identify deaths or readmission data. Patients who died within 90 postoperative days underwent review of the complete medical record. RESULTS: 4204 THAs were included in the study cohort. VTE prophylaxis prescription was available in 3805. 2560 received aspirin (67.3%), 1049 enoxaparin (27.6%) and 193 warfarin (5.1%); there were no differences in 90-day all-cause mortality (p = 0.780) or VTE (p = 1) between groups. CONCLUSION: Our large series continues to demonstrate that aspirin for thromboprophylaxis following THA is effective in risk-stratified patients. Furthermore, we demonstrate that introduction of a departmental protocol establishing aspirin as standard practice was not associated with increased mortality or incidence of thromboembolism. Taken in conjunction with our previous cohort our series encompasses 11,420 consecutive THAs. There has been a single death following fatal PE in the aspirin group (0.02%) compared to 5 in the LMWH group (0.2%) and 1 in the warfarin group (0.06%). We join calls for large-scale randomised controlled trials to elucidate the place of aspirin in VTE prevention following hip arthroplasty.

Manganese hyperaccumulation capacity of Ilex paraguariensis A. St. Hil. and occurrence of interveinal chlorosis induced by transient toxicity.

Manganese (Mn) toxicity is common in plants grown on very acid soils. However, some plants species that grow in this condition can take up high amounts of Mn and are referred to as hyperaccumulating species. In this study, we evaluated the capacity of Ilex paraguariensis to accumulate Mn and the effect of excessive concentrations on plant growth and nutrition. For this, a container experiment was conducted using soils from different parent materials (basalt and sandstone), with and without liming, and at six doses of applied Mn (0, 30, 90, 270, 540 and 1,080 mg kg-1). Clonal plants grown for 203 days were harvested to evaluate yield, and leaf tissue samples were evaluated for Mn and other elements. Without liming and with high Mn doses, leaf Mn concentrations reached 13,452 and 12,127 mg kg-1 in sandstone and basalt soils, respectively; concentrations in excess of 10,000 mg kg-1 are characteristic of hyperaccumulating plants. Liming reduced these values to 7203 and 8030 mg kg-1. More plant growth accompanied increased Mn leaf concentrations, with a growth reduction noted at the highest dose in unlimed soils. Elemental distribution showed Mn presence in the mesophyll, primarily in vascular bundles, without high Mn precipitates. Interveinal chlorosis of young leaves associated with high Mn concentration and lower Fe concentrations was observed, especially in sandstone soil without liming. However, the occurrence of this symptom was not associated with decreased plant growth.

Elemental composition of yerba mate (Ilex paraguariensis A.St.-Hil.) under low input systems of southern Brazil.

Elemental composition of food can be used to determine nutritional potential as well as guiding legislation for establishing maximum acceptable limits (MAL) of metals in consumption products. This study aimed to determine the elemental background levels of yerba mate (Ilex paraguariensis A.St.-Hil.) under varied geologic formations in southern Brazil. Mature leaves were randomly collected from four wild-grown plants at thirty native sites in three states and analyzed for 32 elements. Since yerba mate is not washed to obtain the final product, leaves were analyzed with and without washing to assess foliar deposition. Concentration values of As, Ag, Be, Cs, Cr, Li, Se, Tl, U, and V were near detection limits, indicating low potential as a source and/or toxicity to the consumer. Washing decreased concentrations of Fe, Ti, As, Mo, Li, V, and Pb, suggesting atmospheric contributions/dust deposition. Concentrations of Mn (very high), Zn (high), and Ni (high) demonstrated that leaves could be an important source of these elements. Soil parent material affected elemental composition with basalt providing higher concentrations of Mn, P, and Co while Rhyodacite provided higher concentrations of K and Na. All samples exhibited Pb values below the MAL of 0.6 mg kg-1, but 23% of washed leaves and 20% of unwashed leaves had Cd concentrations close to or above the MAL value of 0.4 mg kg-1. Study results indicated that Cd MAL values for yerba mate in southern Brazil should be reassessed.

Percutaneous nephrostomy in obstructing pelvic malignancy does not facilitate further oncological treatment.

OBJECTIVE: The optimal management of patients with ureteric obstruction in advanced malignancy is unclear. How quality of life is affected by a nephrostomy and how many of these patients undergo further oncological treatment remains uncertain. The objective of this retrospective multicentre study was to look at the outcomes of patients who had percutaneous nephrostomy insertion for malignancy. METHODS: We identified patients who had a nephrostomy inserted for ureteric obstruction due to malignancy at our institution from January 2015 to December 2018. We obtained data retrospectively from our electronic patient record system. Patients who had nephrostomy insertion for other causes such as ureteric calculi or injury were excluded from the study. RESULTS: 105 patients underwent nephrostomy insertion during this time interval. 51.42% patients (n = 54) had urological malignancies (bladder and/or prostate cancer). The median LOS was 14 days (range 1-104 days) post-procedure and 39.04% (n = 41) had at least one 30-day readmission to hospital. The average starting creatinine level was 348 mmol/L (range 49-1133) and the average creatinine at discharge was 170 mmol/L (range 44-651). Although the average change in the creatinine (190 mmol/L) is statistically significant (p < 0.001), it did not seem to prolong life of the patients. Only 26 (24.76%) patients were alive (all-cause mortality) at the end of the 4-year period with an average life expectancy of 139 days following nephrostomy. Only 30.47% (n = 32) patients underwent further oncological treatment. CONCLUSION: In our series, most patients who had nephrostomy insertion for ureteric obstruction due to malignancy had no further oncological treatment following insertion. Percutaneous nephrostomy is a procedure not without associated morbidity and does not always prolong survival. Due to the poor prognosis in cases of advanced malignancy, we advocate multi-disciplinary decision-making prior to nephrostomy insertion.

Elemental composition and nutritional value of Araucaria angustifolia seeds from subtropical Brazil.

Consumed by populations in South America, Araucaria angustifolia seeds have received little study regarding elemental composition and nutritional value. Thirty-five seed sites from subtropical Brazil were sampled and seed concentrations of C, N, K, Ca, Mg, P, Fe, Zn, Mn, Cu, Mo, Ni, Co, Cr, Ba, and Cd were determined. The highest concentration of N was observed in samples from regions with Cfa climate (humid subtropical, oceanic climate, without dry season with hot summer) and igneous rock, which was superior to regions with Cfb climate (humid subtropical, oceanic climate, without dry season with temperate summer) and metamorphic rock. Seeds can be a source of nutrients: K (11.8 g kg-1), P (4.1 g kg-1), Mn (9.1 mg kg-1), Cu (7.2 mg kg-1), Mo (0.93 mg kg-1), and Cr (0.65 mg kg-1). Values for Ba (0.93 mg kg-1) and Cd (0.19 mg kg-1) indicated no risk to human health. This study expands knowledge regarding the elemental composition of A. angustifolia. Results indicate that these seeds have nutritional value, and their consumption can be a good strategy to improve overall human nutrition in this region of South America.

Surgery for parasitic lung infestations: roles in diagnosis and treatment.

Pulmonary parasitic infestations are a worldwide problem associated with significant morbidity and socioeconomic impact. They are known to have varied clinical presentations and radiological appearances. Prevention of parasite transmission and medical treatment of cases form the two pillars of control of these diseases. The role of surgery is limited to the diagnosis and definitive treatment of the minority of pulmonary parasitic afflictions, most notably hydatidosis. Despite surgery being established as the treatment of choice in pulmonary hydatid cysts (PHCs) for over half a century, variations and unresolved controversies persist regarding the best surgical technique. Complications brought on by cyst rupture, multiplicity and multi-organ involvement add complexity to treatment decisions. The development of video-assisted thoracoscopic surgery (VATS) brings the promise of reduced peri-operative morbidity but is yet to be universally accepted as a safe technique. In this review, we endeavor to discuss the common pulmonary infestations focusing on the current trends and controversies surrounding surgery for PHC.

The Immune Microenvironment, Genome-wide Copy Number Aberrations, and Survival in Mesothelioma.

INTRODUCTION: Results of recent clinical studies of immune checkpoint inhibitors in malignant pleural mesothelioma (MPM) have dampened initial enthusiasm. However, the immune environment and targets of these treatments such as programmed cell death protein 1 and its ligand programmed death ligand 1 (PD-L1) have not been well characterized in MPM. Using a large cohort of patients, we investigated PD-L1 expression, immune infiltrates, and genome-wide copy number status and correlated them to clinicopathological features. METHODS: Tissue microarrays were constructed and stained with PD-L1(clone E1L3N [Cell Signaling Technology, Danvers, MA]), cluster of differentiation 4, cluster of differentiation 8, and forkhead box P3 antibodies. PD-L1 positivity was defined as at least 5% membranous staining regardless of intensity, and high PD-L1 positivity was defined as at least 50%. Genomic DNA from a representative subset of 113 patients was used for genome-wide copy number analysis. The percent genome alteration was computed as a proxy for genomic instability, and statistical analyses were used to relate copy number aberrations to other variables. RESULTS: Among 329 patients evaluated, PD-L1 positivity was detected in 130 of 311 (41.7%), but high PD-L1 positivity was seen in only 30 of 311 (9.6%). PD-L1 positivity correlated with nonepithelioid histological subtype and increased infiltration with cluster of differentiation 4-positive, cluster of differentiation 8-positive, and forkhead box P3-positive lymphocytes. High PD-L1-positive expression correlated with worse prognosis (hazard ratio = 2.37, 95% confidence interval: 1.57-3.56, p < 0.001) in univariate analysis but not in multivariate analysis. Higher percent genome alteration was associated with epithelioid histological subtype and poorer survival (hazard ratio = 1.59, 95% confidence interval: 1.01-2.5, p = 0.04) but not PD-L1 expression. CONCLUSIONS: PD-L1 expression was associated with nonepithelioid MPM, poor clinical outcome, and increased immunological infiltrates. Increased genomic instability did not correlate with PD-L1 expression but was associated with poorer survival.

Principles of managing Vancouver type B periprosthetic fractures around cemented polished tapered femoral stems.

The management of periprosthetic fractures around total hip replacements is a complex and challenging problem. Getting it right first time is an important factor in reducing the morbidity, mortality and financial burden associated with these injuries. Understanding and applying the basic principles of fracture management helps increase the chance of successful treatment. Based on these principles, we suggest a treatment algorithm for managing periprosthetic fractures around polished tapered femoral stems.

Video-assisted thoracic surgery for left upper lobectomy for complex lesions: how to extend the indication with optimal safety?

The feasibility of extending the VATS approach to locally advanced NSCLC has been described with good clinical outcome. These complex resections are still technically challenging and patient safety must remain the highest priority. In this article, we describe our routine VATS approach for left upper lobectomy in proximal, locally advanced lesions. Both surgical and anaesthesiology teams are trained during simulation sessions to respond rapidly in case of urgent thoracotomy. Encircling arterial and venous vessels allow control of inadvertent bleeding during difficult dissection. Also, whenever needed the double vessel control technique is a time saver waiting for conversion to thoracotomy.

Isolation and genetic characterization of Toxoplasma gondii from alpaca (Vicugna pacos) and sheep (Ovis aries).

Alpacas are important to the economy of several countries. Little is known of Toxoplasma gondii infection in alpacas worldwide. In the present study, T. gondii was isolated and genetically characterized from alpacas for the first time. Alpacas (n = 16) and rams (n = 12) pastured on a farm in Virginia, USA, were examined at necropsy. Antibodies to T. gondii were determined by the modified agglutination test (MAT, 1:25) and found in 6 of 16 alpacas with titers of 1:100 (2 alpaca), 1:400 (2 alpacas), 1:800 (1 alpaca), and 1:1,600 (1 alpaca), and 5 of 12 rams in titers of 1:50 in one, 1:400 in one, 1:800 in one, 1:1,600 in one, and 1:3,200 in one. Tissues of all 16 alpacas were bioassayed in mice or in cats. Muscles (heart, skeletal muscle) of nine alpacas with MAT titers of 1:25 were fed to T. gondii-free cats; the cats did not shed oocysts. Viable T. gondii was isolated from tissues of two of six seropositive alpacas by bioassay in mice. Viable T. gondii was isolated from three of three seropositive sheep by bioassay in mice. Genotyping using cell-cultured tachyzoites revealed four genotypes, including one for ToxoDB PCR-RFLP genotype #2 (type III), one for genotype #3 (type II variant), one for genotype #170, and two for a new genotype designated as ToxoDB PCR-RFLP genotype #230. Thus, four of the five T. gondii isolates in the present study belonged to different genotypes. These results indicate a higher genetic diversity among T. gondii isolates circulating in the USA than previously realized.

The Changing Roles Of Pharmacists In Society

A clinical role for pharmacists has developed in response to the societal need to improve the use of medicines. Clinical role development has been led by initiatives in the hospital sector which have enabled Schools of Pharmacy to make shifts in the pre-graduate education of pharmacists. The increasing complexity in the management of drug therapy has given pharmacists clear roles that integrate within the healthcare team. The history is one in which the development of changing roles of pharmacists is an example of progress in healthcare delivery creating the need for revision of the curriculum for a whole profession. Milestones in the changing roles and in the preparation of pharmacists for those roles have been; Establishment of clinical pharmacy in the US hospitals and the doctorate (PharmD) as the professional entry qualification; postgraduate clinical pharmacy education in UK and elsewhere, notably Asia and Australasia; hospital pharmacist specialisation across the wide range of medical specialties; the clinical teaching of pharmacists; the concept of ‘pharmaceutical care’ as a factor in public health; changes in Schools of Pharmacy – with professors of pharmacy practice and a shift to patient-centred teaching. Future evolution of pharmacist roles will follow the wider use of quality systems to address errors in prescribing and drug administration; the automation of systems of drug prescribing and administration and improved documentation of care; widening of prescribing roles; increased patient education and higher patient expectations; patient-centred research in Schools of pharmacy; development of primary care and improved accessibility to pharmaceutical advice; integration of pharmacists’ public health roles in strategies to address prevention and management of disease.