Abstract
Background
Total knee arthroplasty (TKA) periprosthetic joint infection (PJI) can be managed with debridement, antibiotic therapy, and implant retention (DAIR). Oral antibiotics can be used ...after DAIR for an extended time period to improve outcomes. The objective of this study was to compare DAIR failure rates and adverse events between an initial course of intravenous antibiotic therapy and the addition of extended treatment with oral antibiotics.
Methods
A multicenter observational study of patients diagnosed with a TKA PJI who underwent DAIR was performed. The primary outcome of interest was the failure rate derived from the survival time between the DAIR procedure and future treatment failure.
Results
One hundred eight patients met inclusion criteria; 47% (n = 51) received an extended course of oral antibiotics. These patients had a statistically significant lower failure rate compared to those who received only intravenous antibiotics (hazard ratio, 2.47; P = .009). Multivariable analysis demonstrated that extended antibiotics independently predicted treatment success, controlling for other variables. There was no significant difference in failure rates between an extended course of oral antibiotics less or more than 12 months (P = .23). No significant difference in the rates of adverse events was observed between patients who received an initial course of antibiotics alone and those who received a combination of initial and extended antibiotic therapy (P = .59).
Conclusions
Extending therapy with oral antibiotics had superior infection-free survival for TKA PJI managed with DAIR. There was no increase in adverse events, demonstrating safety. After 1 year, there appears to be no significant benefit associated with continued antibiotic therapy.
An extended course of oral antibiotics for 1 year following debridement and implant retention for patients with total knee arthroplasty periprosthetic joint infection appears to be efficacious and safe and to optimize antibiotic stewardship. Rate of adverse events were low.
Frailty is associated with morbidity and mortality in abdominal organ transplantation but has not been examined in lung transplantation.
To examine the construct and predictive validity of frailty ...phenotypes in lung transplant candidates.
In a multicenter prospective cohort, we measured frailty with the Fried Frailty Phenotype (FFP) and Short Physical Performance Battery (SPPB). We evaluated construct validity through comparisons with conceptually related factors. In a nested case-control study of frail and nonfrail subjects, we measured serum IL-6, tumor necrosis factor receptor 1, insulin-like growth factor I, and leptin. We estimated the association between frailty and disability using the Lung Transplant Valued Life Activities disability scale. We estimated the association between frailty and risk of delisting or death before transplant using multivariate logistic and Cox models, respectively.
Of 395 subjects, 354 completed FFP assessments and 262 completed SPPB assessments; 28% were frail by FFP (95% confidence interval CI, 24-33%) and 10% based on the SPPB (95% CI, 7-14%). By either measure, frailty correlated more strongly with exercise capacity and grip strength than with lung function. Frail subjects tended to have higher plasma IL-6 and tumor necrosis factor receptor 1 and lower insulin-like growth factor I and leptin. Frailty by either measure was associated with greater disability. After adjusting for age, sex, diagnosis, and transplant center, both FFP and SPPB were associated with increased risk of delisting or death before lung transplant. For every 1-point worsening in score, hazard ratios were 1.30 (95% CI, 1.01-1.67) for FFP and 1.53 (95% CI, 1.19-1.59) for SPPB.
Frailty is prevalent among lung transplant candidates and is independently associated with greater disability and an increased risk of delisting or death.
Periprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was ...associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself.
A multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints.
The septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119).
Compared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.
Diagnosis and treatment of culture negative total knee arthroplasty (TKA) periprosthetic joint infection (PJI) is challenging. There is debate over whether culture negative PJI confers increased risk ...of failure and which organisms are responsible. It is also unclear as to what factors predict conversion from culture negative to culture positivity. To address these issues, we performed an observational study to detect factors associated with transition from culture negative to culture positive TKA PJI in those patients that failed irrigation and debridement (I&D), determine the incidence of this transition, and identify those organisms that were associated with treatment failure.
A multicenter observational cohort study was performed on patients with TKA PJI as defined by Musculoskeletal Infection Society criteria without cultured organisms and treated with I&D. Primary outcome was failure defined as any subsequent surgical procedure. Secondary outcome included cultured organism within 2 years of initial I&D.
Two hundred sixteen TKA I&D procedures were performed for PJI, and 36 met inclusion criteria. The observed treatment failure rate for culture negative PJI treated with I&D was 41.67%. Of those culture negative I&Ds that failed, 53.33% became culture positive after failure. Of those that converted to culture positive, 62.5% were Staphylococcus species. The odds ratio associated with becoming culture positive following culture negative treatment failure in the setting of antibiotic administration prior to the initial I&D procedure was 0.69 (95% confidence interval 0.14-3.47, P = .65).
Many cases of culture negative TKA PJI treated with I&D eventually fail and become culture positive. Staphylococci are common organisms identified after culture negative PJI.
•Retrospective clinical review of 167 patients with breast cancer bone metastases.•Comprehensive study of clinical characteristics, prognostic factors, and survival.•First study to assess outcomes ...associated with operative vs. nonoperative treatment.•Utilizing surgical treatment involves a complex, personalized care decision.
Bone is the most common distant site of breast cancer metastasis. Skeletal lesions can cause significant morbidity due to pain, pathologic fracture, and electrolyte abnormalities. Current treatment for patients with bone metastases (BoM) from breast cancer is highly personalized and often involves a multidisciplinary approach with chemotherapy, hormone therapy, bone-targeted antiresorptive agents, radiation therapy, and surgery. We have retrospectively collected clinical data from a series of patients with bone metastases to evaluate the clinical characteristics, prognostic factors, and survival patterns of patients with breast cancer BoM receiving standard multimodal therapy.
A consecutive series of 167 patients with breast cancer BoM treated at a single institution between August 2013 and March 2020 were identified. Clinical information was obtained from the medical record and survival analyses were performed to evaluate patient outcomes and identify prognostic factors.
Thirty-seven patients (22%) presented with de novo BoM – bone metastases at the time of breast cancer diagnosis – and were 2.6 times more likely to die within the study period than those with asynchronous BoM (HR = 2.62, p = <0.0001). Patients who received bone-targeted medical therapy were 61% less likely to die after BoM diagnosis than those who did not (HR = 0.39, p = 0.001). Operative stabilization of BoM was more frequently employed in patients with lytic (p = 0.02) or mixed (p = 0.02) tumors than it was for those with blastic lesions. Patients treated with surgery had a lower overall bone metastasis survival than those treated without (p < 0.03).
These findings reflect the current patterns in metastatic breast cancer treatment and associated outcomes. In a series of 167 consecutive patients, we demonstrate the natural history of breast cancer with BoM being treated with modern multimodal therapy. Understanding these treatment patterns and prognostic factors enhances the provider’s ability to counsel patients and direct appropriate treatments.
Background: Ultrasound (US) measurement of cross-sectional area (CSA) of the median nerve has emerged as a viable alternative to electromyography/nerve conduction studies (EMG/NCS) for diagnosis of ...carpal tunnel syndrome (CTS). The purpose of this study is to compare CSA of the median nerve between US and MRI using current MRI and US technology. The null hypothesis is there is no difference between US and MRI CSA measurements. Methods: The study design was an observational cohort, enrolling patients presenting to clinic with MRI of the wrist. Participants with clinical signs and symptoms of CTS were excluded. The CSA measurements of the median nerve on MRI T1-weighted axial images were performed by a hand fellow blinded to results of US measurements, and US measurement of median nerve CSA was performed by a hand fellowship trained surgeon blinded to results of the MRI measurements. Results were analyzed via percent error, Pearson correlation, and t tests. Results: Twenty participants were enrolled with mean age of 29.4 years. Four left wrists and 16 right wrists were measured. The US mean CSA of the median nerve was 6.8 mm2 (±2.330 mm2). The MRI mean CSA of the median nerve was 6.8 mm2 (±2.153 mm2), P = .442. Pearson correlation between modalities was 0.93, suggesting near-perfect correlation. Mean percent error was 8.8%. Conclusions: Results of this study suggest that US is an accurate method to measure CSA of the median nerve at the carpal tunnel inlet. The mean difference between US and MRI was unlikely to be clinically significant.
Researchers observed pre-kindergarten through second-grade public school classrooms, specifically noting child-centered and teacher-directed pedagogical approaches, by simultaneously examining: (a) ...student behavior and activities, (b) teacher instructional orientation and rationale, and (c) overall classroom environment. Dissimilar to previous studies, researchers noted the nature of activity structure and various student demographic variables. Additionally, unlike prior classroom observation studies that included an overwhelming percentage of white students, the current study was comprised of a large percentage of Hispanic and African American students. The findings revealed: little to no variation existed in the activities in which young children were engaged in their classrooms, nor in the instructional practices utilized by their early childhood teachers; however, three statistically significant findings showed: (a) students taught by teachers rated as having a higher developmentally appropriate instructional practices (DAIP) scores were more likely to be on-task and less likely to be off-task; (b) students taught by teachers with a higher DAIP score were more likely to be working kinesthetically, answering teacher-posed questions, and freely exploring; and (c) students taught by teachers with a lower DAIP score were more likely to be distracted and/or not engaging in activity. The findings are important, since young children continue to be taught in a direct instructional manner that focuses on students’ test performance—despite research showing the unfavorable effects that highly teacher-centered, scripted classrooms have on young students’ engagement and learning outcomes.
The International Baccalaureate (IB) programme utilizes an inquiry-based multi-disciplinary approach and focuses on the teaching of critical-thinking skills. The IB programme is growing at a rapid ...rate within the United States, with the overall number of IB schools having more than doubled in the last five years. The purpose of the present study was two-fold: (a) to specifically focus on classroom instruction and students' behavior within Texas IB schools, and (b) to highlight the importance of systematic classroom observation as an evaluative method; in particular, the simultaneous use of three observation instruments to illustrate the importance of examining instruction from multiple perspectives. Systematic observations of 85 classrooms from eight Texas IB schools revealed that instruction in most of the schools was active, with teachers often engaging students, exploring new skills and key concepts, explaining, elaborating, and evaluating. Overall, the general instructional practices and student behaviors/activities observed were favorable and were higher than those found in similar classrooms in Texas schools. The amount of time that students were observed as being on-task was dramatically higher than the amount of student on-task time measured in other observational studies.
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