Outcome of kinematic alignment using patient-specific instrumentation versus mechanical alignment in TKA: a meta-analysis and subgroup analysis of randomised trials.

INTRODUCTION: Kinematic alignment (KA) in total knee arthroplasty (TKA) matches component position to the pre-arthritic anatomy of an individual patient, with the aim of improving functional outcomes. Recent randomised controlled trials (RCTs) comparing KA to traditional neutral mechanical alignment (MA) have been mixed. This collaborative study combined raw data from RCTs, aiming to compare functional outcomes between KA using patient-specific instrumentation (PSI) and MA, and whether any patient subgroups may benefit more from KA technique. MATERIALS AND METHODS: A literature search in PubMed, EMBASE and Cochrane databases identified four randomised controlled trials comparing patients undergoing TKA using PSI-KA and MA. Unpublished data including Western Ontario McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS) were obtained from study authors. Meta-analysis compared MA to KA change (post-op minus pre-op) scores. Subgroup-analysis on KA patients looked for subgroups more likely to benefit from KA and the impact of PSI accuracy. RESULTS: Meta-analyses of change scores in 229 KA patients versus 229 MA patients were no different from WOMAC (mean difference 3.4; 95% confidence interval - 0.5 to 7.3), KSS function (1.3, - 3.9 to 6.4) or KSS combined (7.2, - 0.8 to 15.2). A small advantage was seen for KSS pain in the KA group (3.6, 95% CI 0.2-7.1). Subgroup-analysis showed no difference between varus, valgus and neutral pre-operative alignment groups, and those who did and did not achieve KA plans. Pain-free patients at 1-year were more likely to achieve KA plans. CONCLUSION: Patient-reported outcome scores following TKA using PSI-KA are similar to MA. No identifiable subgroups benefited more from KA, and long-term results remain unknown. Inaccuracy of the PSI system used in KA patients could potentially affect outcome.

Enteric fever in the Pacific: a regional retrospective study from Auckland, New Zealand.

BACKGROUND: There are limited clinical data on enteric fever in the Pacific and New Zealand (NZ) compared with the Indian subcontinent (ISC) and South-East Asia (SEA). Our objective was to describe enteric fever in Auckland - a large Pacific city, focusing on disease acquired in these regions. METHODS: We reviewed enteric fever cases hospitalised in Auckland from January 2005 to December 2010. RESULTS: Microbiologically confirmed EF was identified in 162 patients. Travel regions: Pacific, 40 cases (25%) (Samoa, 38; Fiji, two), ISC, 72 (44%), SEA, seven (4%), other, three (2%), no travel, 40 (25%). Enteric fever rates for Auckland resident travellers were: India 50.3/100 000; Samoa 19.7/100 000.All Pacific cases were Salmonella Typhi. Of local isolates (without travel history), 38 were S. Typhi (36 fully susceptible, one multi-drug resistant (MDR) + nalidixic acid resistant (NAR), one unknown) and two S. Paratyphi (both NAR). Of non-Pacific travel, 56/82 (69%) isolates were S. Typhi, the remainder S. Paratyphi (15 isolates were fully susceptible, only 1% were MDR). Significant associations of serotype and antibiotic resistance with different travel regions and similarity of phage types (local and Pacific) were observed. Headache, vomiting and acute kidney injuries were more frequent with Pacific travel, while abdominal distension and cholecystitis with local disease. Shorter duration of treatment in the Pacific group was seen despite length of stay in hospital not being reduced. Local cases were associated with longer hospital admissions. CONCLUSIONS: One half of cases in Auckland are acquired either from Pacific or locally. Similarities mean that disease acquired locally is likely of Pacific origin.

Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery.

BACKGROUND: Several recent studies have investigated the role of C-reactive protein (CRP) as an early marker of anastomotic leakage following colorectal surgery. The aim of this systematic review and meta-analysis was to evaluate the predictive value of CRP in this setting. METHODS: A systematic literature search was performed using MEDLINE, Embase and PubMed to identify studies evaluating the diagnostic accuracy of postoperative CRP for anastomotic leakage following colorectal surgery. A meta-analysis was carried out using a random-effects model and pooled predictive parameters were determined along with a CRP cut-off value at each postoperative day (POD). RESULTS: Seven studies, with a total of 2483 patients, were included. The pooled prevalence of leakage was 9·6 per cent and the median day on which leakage was diagnosed ranged from POD 6 to 9. The serum CRP level on POD 3, 4 and 5 had comparable diagnostic accuracy for the development of an anastomotic leak with a pooled area under the curve of 0·81 (95 per cent confidence interval 0·75 to 0·86), 0·80 (0·74 to 0·86) and 0·80 (0·73 to 0·87) respectively. The derived CRP cut-off values were 172 mg/l on POD 3, 124 mg/l on POD 4 and 144 mg/l on POD 5; these corresponded to a negative predictive value of 97 per cent and a negative likelihood ratio of 0·26-0·33. All three time points had a low positive predictive value for leakage, ranging between 21 and 23 per cent. CONCLUSION: CRP is a useful negative predictive test for the development of anastomotic leakage following colorectal surgery.

Variability of memory B cell markers in a cohort of common variable immune deficiency patients over 6 months.

Common Variable Immunodeficiency Disorder (CVID) is a complex disorder that predisposes patients to recurrent and severe infections. Immunophenotypic classification schemes were developed to categorize patients with CVID into phenotypic and prognostic groups based on different memory B cell subsets. Whether the B cell subset analysis is stable over time has not been investigated. B cell phenotyping in patients with CVID (n = 15) and sex- and age-matched controls (n = 26) were carried out according to the three B cell classifications. Patients with CVID were evaluated monthly over 6 months. Controls were assessed once during the study. We scored how often each patient was assigned to the same group within each classification. The Freiburg classification assigned patients to the same group at a rate of 73% and the Paris classification at 88%. The EUROclass classification of smB- versus smB+ was at 90%. The two subclassifications [(smB-21low or smB-21norm) and transitional B] were at 87% and 97%, respectively. The level of naïve B cells measured in all patients with CVID during the 6-month evaluation was the most stable B cell subset. We conclude that all classifications systems show considerable variability, but the EUROclass classification was the most reliable scheme for our 15 CVID and 26 healthy cohorts. Our results indicate that phenotypic classifications within CVID will be difficult while there is variability of commonly used assays.

Can we predict sputum eosinophilia from clinical assessment in patients referred to an adult asthma clinic?

BACKGROUND: There is overwhelming evidence that asthma guidelines aimed at reducing airway inflammation are superior to those based on clinical symptoms alone. This involves targeting eosinophilic inflammation with inhaled corticosteroids. AIM: Because induced sputum is not readily available, our study set out to investigate whether the collective or singular use of routine asthma investigations can predict sputum eosinophilia. METHODS: Eighty patients underwent skin prick testing, blood tests (IgE, full blood count), spirometry, exhaled fraction nitric oxide (FeNO), PD15 to hypertonic saline, and induced sputum testing at first assessment. A predictive model for sputum eosinophilia (defined as ≥3% eosinophils) was sought using routinely available tests. RESULTS: Fifty-four subjects underwent both induced sputum and FeNO testing. Seventeen (30%) revealed eosinophilic inflammation, nine (16%) neutrophilic, four (7%) mixed granulocytic and 26 (46%) paucigranulocytic. Positive predictors for sputum eosinophilia included low forced expiratory volume in 1 s (FEV(1))% predicted, raised serum eosinophil, positive smoking history, Polynesian ethnicity and negative asthma family history. There was a non-statistically significant trend for FeNO predicting sputum eosinophilia. The best combination of predictors was low FEV(1)% predicted, raised serum eosinophil, positive smoking history and negative family history of asthma. CONCLUSION: This study demonstrates that the serum eosinophil count and FEV(1) combined with aspects of a clinical history may provide a simple and practical alternative to assessment of airway (sputum) eosinophilia in the clinical setting. A full blood count can be performed at a substantially lesser cost and with greater accessibility than induced sputum. We feel the time has come for the clinical utility of the serum eosinophil count to be revisited.

Does CT scanning predict the likelihood of a positive transbronchial biopsy in sarcoidosis?

BACKGROUND: Transbronchial lung biopsy (TBB) has a variable diagnostic yield in sarcoidosis. It was hypothesised that the extent and pattern of parenchymal disease on CT scanning would predict the likelihood of a positive TBB result. METHODS: Patients with sarcoidosis (n = 77) were included if they had undergone a CT scan within 6 weeks of TBB. Ethnicity, symptoms, pulmonary function and site and results of TBB and bronchoalveolar lavage (BAL) were recorded. CT scans were scored quantitatively for patterns of parenchymal disease (nodular, reticular, consolidation and ground glass) on a lobar basis. RESULTS: 39 patients (50.6%) had a positive TBB. Symptoms, ethnicity, treatment, lung volumes and chest radiographic stage were not predictors of a positive biopsy. Female gender, reduced percentage predicted carbon monoxide transfer factor and a higher percentage of lymphocytes in the BAL fluid were associated with a positive biopsy, as were higher total lung score, reticular pattern and ground-glass opacity. The associations were more significant for the total lobar score and the lobar ground-glass score of the lobe biopsied. On multivariate analysis gender, percentage of lymphocytes in the BAL fluid and total lung score were independent predictors of a positive TBB. CONCLUSION: The total extent of parenchymal disease on the CT scan in addition to the pattern and lobar distribution predicts the likelihood of a positive TBB at bronchoscopy.

Isolated nocturnal desaturation in COPD: prevalence and impact on quality of life and sleep.

BACKGROUND AND AIMS: The clinical impact of nocturnal desaturation on health related quality of life (HRQL) and sleep in chronic obstructive pulmonary disease (COPD) has been little studied. The aim of this study was to evaluate the prevalence and clinical impact of nocturnal desaturation in a typical outpatient population with COPD. PATIENTS AND METHODS: Between 2002 and 2005, consecutive patients with COPD attending outpatient services at the study centre underwent resting oximetry if they were not on domiciliary oxygen therapy. If their resting saturations were less than 95%, overnight pulse oximetry was performed. Significant nocturnal desaturation was defined as spending more than 30% of at least one of two nights with a saturation of less than 90%. The Chronic Respiratory Questionnaire (CRQ) and Short Form 36 (SF36) were used to assess HRQL, and the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Score (ESS) and Functional Outcomes of Sleep (FOSQ) questionnaires were used to assess sleep quality and daytime function. RESULTS: Of 1104 patients, 803 underwent resting oximetry and 79 had resting oxygen saturations of less than 95%. Of these, 59 agreed to undergo overnight oximetry (mean age 70 years, forced expiratory volume in 1 s 37.2% predicted, resting Po(2) on air 8.9 kPa). Significant nocturnal desaturation was seen in 29 (49.2%) of the 59 subjects. Assuming the less hypoxic patients do not have nocturnal desaturation, the prevalence of nocturnal desaturation in the whole clinic population could be estimated at 4.8%. There were no significant differences in CRQ, SF36, PSQI, ESS or FOSQ scores for desaturators compared with non-desaturators. CONCLUSION: Significant nocturnal desaturation was common in patients with COPD with resting saturations of less than 95%, but was estimated to have a prevalence of less than 5% in the whole outpatient population. Nocturnal desaturation was not associated with impairment of HRQL, sleep quality or daytime function.

B-type natriuretic peptide and left ventricular dysfunction on exercise echocardiography in patients with chronic aortic regurgitation.

OBJECTIVE: To determine whether plasma levels of B-type natriuretic peptide (BNP) predict left ventricular (LV) dysfunction on exercise echocardiography in patients with moderate to severe aortic regurgitation (AR). DESIGN: Case-control study. SETTING: Outpatient cardiology departments. PATIENTS: 39 asymptomatic or mildly symptomatic patients with chronic moderate to severe AR and a normal LV ejection fraction (>50%), and 10 normal controls. MAIN OUTCOME MEASURES: Plasma level of BNP and echocardiographic measures of LV function at rest and immediately after treadmill exercise. RESULTS: LV end systolic volume index (LVESVI) was significantly increased in AR patients with normal BNP (0.05 for all). However, there were modest but statistically significant associations between the plasma level of BNP and severity of AR indicated by a greater AR:LV outflow tract width ratio (r = 0.37, p = 0.02) and lower diastolic blood pressure (r = -0.44, p = 0.004). Increased BNP was also associated with a greater LVESVI (r = 0.33, p = 0.04) and lower LV longitudinal strain rate (r = -0.037, 0.02) on echocardiography after exercise. CONCLUSIONS: In moderate to severe AR compensatory LV remodelling can occur with no increase in plasma BNP. Increased BNP is associated with more severe regurgitation and changes consistent with early LV dysfunction on exercise echocardiography.

A randomized evaluation of the acute efficacy, acceptability and tolerability of flutter and active cycle of breathing with and without postural drainage in non-cystic fibrosis bronchiectasis.

Airway clearance is integral to the management of bronchiectasis, yet there is no evidence as to the optimal modality. The aim of this randomized prospective study was to evaluate the acute efficacy, acceptability and tolerability of three airway clearance techniques in non-cystic fibrosis (non-CF) bronchiectasis. Flutter, active cycle of breathing technique (ACBT) and ACBT with postural drainage (ACBT-PD) were evaluated in random order over a week in 36 patients (mean age 62 years, range 33-83), with stable non-CF bronchiectasis. Total sputum wet weight for ACBT-PD was twice that of either ACBT alone or Flutter. No objective difference in treatment duration was noted. All three techniques were well accepted and tolerated. Patient preference was 16 (44%) for Flutter, eight (22%) ACBT and 12 (33%) for ACBT-PD. Patient demography, factors such as upper airways or reflux symptoms, previous use or acute efficacy did not predict preference. This is the first randomized systematic evaluation of acute efficacy, acceptability and tolerability of Flutter, ACBT and ACBT-PD in non-CF bronchiectasis. All three techniques were well tolerated but ACBT-PD proved superior in terms of acute efficacy. Patient preference for treatment modality could not be predicted.