Background and purpose - Gaining experience in the surgery room during residency is an important part of learning the skills needed to perform arthroplasties. However, in practice, patients are often ...not fully comfortable with trainee involvement in their own surgery. Therefore, we investigated complications, revision rates, mortality, and operative time of orthopedic surgeons and residents as primary surgeon performing total knee arthroplasties (TKAs) or total hip arthroplasties (THAs).
Patients and methods - In this multi-center retrospective cohort study, 3,098 TKAs and 4,027 THAs performed between 2007 and 2013 were analyzed. Complications, revisions, mortality, and operative time were compared for patients operated on by the orthopedic surgeon or a resident as primary surgeon. An additional analysis was performed to determine whether the complication risk was affected by the postgraduate year of the resident.
Results - Orthopedic complication rates were similar (TKA: orthopedic surgeon: 10%, resident: 11%; THA: 9% and 8%), revision rates (TKA: 3% and 2%, THA: 3% and 2%), or mortality rates (TKA: 0.1% and 0.3%, THA: 0.2% and 0.3%). For both procedures a higher non-orthopedic complication rate was found in the resident group (TKA: 8% and 10%; p = 0.03, THA: 8% and 10%; p = 0.01) and a slightly longer operative time (TKA: mean difference 9.0 minutes (8%); THA: 11.3 minutes (11%)).
Interpretation - Complications, revisions, and mortality were similar in TKAs or THAs performed by the resident as primary surgeon compared with surgeries performed by an orthopedic surgeon. This data can be used in teaching hospitals and may help to reassure patients.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
The glucocorticoid receptor (GR) is a member of the nuclear receptor superfamily, which controls programs regulating cell proliferation, differentiation, and apoptosis. We have identified an ...unexpected role for GR in mitosis. We discovered that specifically modified GR species accumulate at the mitotic spindle during mitosis in a distribution that overlaps with Aurora kinases. We found that Aurora A was required to mediate mitosis-driven GR phosphorylation, but not recruitment of GR to the spindle. GR was necessary for mitotic progression, with increased time to complete mitosis, frequency of mitotic aberrations, and death in mitosis observed following GR knockdown. Complementation studies revealed an essential role for the GR ligand-binding domain, but no clear requirement for ligand binding in regulating chromosome segregation. The GR N-terminal domain, and specifically phosphosites S203 and S211, were not required. Reduced GR expression results in a cell cycle phenotype, with isolated cells from mouse and human subjects showing changes in chromosome content over prolonged passage. Furthermore, GR haploinsufficient mice have an increased incidence of tumor formation, and, strikingly, these tumors are further depleted for GR, implying additional GR loss as a consequence of cell transformation. We identified reduced GR expression in a panel of human liver, lung, prostate, colon, and breast cancers. We therefore reveal an unexpected role for the GR in promoting accurate chromosome segregation during mitosis, which is causally linked to tumorigenesis, making GR an authentic tumor suppressor gene.
Significance We have discovered a role for the glucocorticoid receptor (GR) in coordinating cell division. We find enrichment of GR to mitotic spindles and demonstrate that GR knockdown causes accumulation of mitotic defects, including delayed anaphase, ternary chromosome segregation, and death in mitosis. Mitotic GR function requires the ligand-binding domain but not ligand binding, revealing a nontranscriptional and ligand-independent mechanism of action. Analysis of GR haploinsufficient cells and tissues reveals increased aneuploidy and DNA damage, and mice show an increased incidence of tumors in vivo, with further GR loss within those incident tumors. We also identify reduced GR expression in several common human cancers, thereby implicating GR as a novel tumor suppressor gene.
IntroductionCurrent literature is inconclusive about the optimal treatment of elderly patients with displaced intra-articular distal radius fractures. Cast treatment is less invasive and less ...expensive than surgical treatment. Nevertheless, surgery is often the preferred treatment for this common type of distal radius fracture. Patients with a non-acceptable position after closed reduction are more likely to benefit from surgery than patients with an acceptable position after closed reduction. Therefore, this study aims to assess non-inferiority of functional outcomes after casting versus surgery in elderly patients with a non-acceptable position following a distal radius fracture.Methods and analysisThis study is a multicentre randomised controlled trial (RCT) with a non-inferiority design and an economic evaluation alongside. The population consists of patients aged 65 years and older with a displaced intra-articular distal radius fracture with non-acceptable radiological characteristics following either inadequate reduction or redisplacement after adequate reduction. Patients will be randomised between surgical treatment (open reduction and internal fixation) and non-operative treatment (closed reduction followed by cast treatment). We will use two age strata (65–75 and >75 years of age) and a web-based mixed block randomisation. A total of 154 patients will be enrolled and evaluated with the patient-rated wrist evaluation as the primary outcome at 1-year follow-up. Secondary outcomes include the Disabilities of the Arm, Shoulder and Hand questionnaire, quality of life (measured by the EQ-5D), wrist range of motion, grip strength and adverse events. In addition, we will perform a cost-effectiveness and cost-utility analysis from a societal and healthcare perspective. Incremental cost-effectiveness ratios, cost-effectiveness planes and cost-effectiveness acceptability curves will be presented.Ethics and disseminationThe Research and Ethics Committee approved this RCT (NL56858.100.16). The results of this study will be reported in a peer-reviewed journal. We will present the results of this study at (inter)national conferences and disseminate the results through guideline committees.Trial registration numberClinicaltrials.gov (NCT03009890). Dutch Trial Registry (NTR6365).
Intraoperative chlorhexidine irrigation could be a valuable additive to systemic antibiotics to prevent infections after total joint arthroplasties. However, it may cause cytotoxicity and impair ...wound healing. This study evaluates the incidence of infection and wound leakage before and after the introduction of intraoperative chlorhexidine lavage.
All 4453 patients receiving a primary hip or knee prosthesis between 2007 and 2013 in our hospital were retrospectively included. They all underwent intraoperative lavage before wound closure. Initially, wound irrigation with 0.9% NaCl was standard care (n = 2271). In 2008, additional irrigation with a chlorhexidine-cetrimide (CC) solution was gradually introduced (n = 2182). Data on the incidence of prosthetic joint infections and wound leakage, as well as relevant baseline and surgical characteristics, were derived from medical charts. Chi-square analysis was used to compare the incidence of infection and wound leakage between patients with and without CC irrigation. Multivariable logistic regression was used to assess robustness of these effects by adjusting for potential confounders.
The prosthetic infection rate was 2.2% in the group without CC irrigation vs 1.3% in the group with CC irrigation (P = .021). Wound leakage occurred in 15.6% of the group without CC irrigation and in 18.8% of the group with CC irrigation (P = .004). However, multivariable analyses showed that both findings were likely due to confounding variables, rather than by the change in intraoperative CC irrigation.
Intraoperative wound irrigation using a CC solution does not seem to affect the risk of prosthetic joint infection or wound leakage. Observational data easily yield misleading results, so prospective randomized studies are needed to verify causal inference.
Level III—uncontrolled before and after the study.
Introduction
The COVID‐19 pandemic severely impacted musculoskeletal care. To better triage the notable backlog of patients, we assessed whether a digital medical history (DMH), a summary of health ...information and concerns completed by the patient prior to a clinic visit, could be routinely collected and utilised.
Methods
We analysed 640 patients using a rapid cycle, semi‐randomised A/B testing approach. Four rapid cycles of different randomised interventions were conducted across five unique patient groups. Descriptive statistics were used to report DMH completion rates by cycle/patient group and intervention. Multivariable logistic regression was used to determine whether age or anatomic injury location was associated DMH completion.
Ethical Approval
N/A (Quality Improvement Project)
Results
Across all patients, the DMH completion rate was 48% (307/640). Phone calls were time consuming and resource intensive without an increased completion rate. The highest rate of DMH completion was among patients who were referred and called the clinic themselves (78% of patients 63 out of 81 patients). Across all patients, increasing age (odds ratio OR: 0.985 (95% CI: 0.976–0.995), p = 0.002), patients with back concerns (OR: 0.395 (95% CI: 0.234–0.666), p = 0.001), and patients with non‐specific/other musculoskeletal concerns (OR: 0.331 (95% CI: 0.176–0.623), p = 0.001) were associated with decreased odds of DMH completion.
Discussion and Conclusion
DMHs can be valuable in helping triage orthopaedic patients in resource‐strapped settings, times of crisis, or as we transition towards value‐based health care delivery. However, further work is needed to continue to increase the completion rate about 50%.
The purpose of this study was to determine the neurological outcome after transverse sacral fractures in patients with neurological impairment.
A systematic review of the English, French, German, and ...Dutch literature was conducted. All study designs, including retrospective cohort studies and case reports, describing transverse sacral fractures were included. Two authors independently extracted the predefined data and scored the neurological impairment according to the Gibbons classification after the trauma and at the time of follow-up. The neurological outcomes were pooled according to the Gibbons classification.
No randomized controlled trials or prospective case series were found. A total of 139 articles were included, consisting of 81 case reports and 58 retrospective case series involving 521 patients. Regardless of the type of management, neurological recovery of at least 1 Gibbons category was reported in 62% of these patients. A comparison of the neurological outcome of nonoperatively treated patients and surgically treated patients showed similar neurological recovery rates. For the surgically treated patients, fixation of the fracture resulted in a better neurological improvement compared with an isolated decompression.
This review could not provide evidence of improved neurological recovery after surgical treatment compared with nonoperative treatment. When surgical treatment was considered, there was a low level of evidence that fixation of the fracture results in better neurological improvement compared with isolated decompression.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Blue native electrophoresis is used widely for the analysis of non-dissociated protein complexes with respect to composition, oligomeric state and molecular mass. However, the effects of detergent or ...dye binding on the mass and stability of the integral membrane proteins have not been studied. By comparison with analytical ultracentrifugation, we have evaluated whether the oligomeric state of membrane transport proteins is reflected reliably with blue native electrophoresis. For the analysis we have used two well-characterized transporters, that is, the major facilitator superfamily protein LacS and the phosphotransferase system EII(Mtl). For another member of the major facilitator superfamily, the xyloside transporter XylP from Lactobacillus pentosus, the complete analysis of the quaternary structure determined by analytical ultracentrifugation and freeze-fracture electron microscopy is presented. Our experiments show that during blue native electrophoresis the detergent bound to the proteins is replaced by the amphipathic Coomassie brilliant blue (CBB) dye. The mass of the bound CBB dye was quantified. Provided this additional mass of bound CBB dye is accounted for and care is taken in the choice and concentration of the detergent used, the mass of LacS, XylP and EII(Mtl) and four other membrane (transport) proteins could be deduced within 10 % error. Our data underscore the fact that the oligomeric state of many membrane transport proteins is dimeric.
: Differentiation between uncomplicated and complicated postoperative wound drainage after arthroplasty is crucial to prevent unnecessary reoperation. Prospective data about the duration and amount ...of postoperative wound drainage in patients with and without prosthetic joint infection (PJI) are currently absent.
: A multicentre cohort study was conducted to assess the duration and amount of wound drainage in patients after arthroplasty. During 30 postoperative days after arthroplasty, patients recorded their wound status in a previously developed wound care app and graded the amount of wound drainage on a 5-point scale. Data about PJI in the follow-up period were extracted from the patient files.
: Of the 1019 included patients, 16 patients (1.6 %) developed a PJI. Minor wound drainage decreased from the first to the fourth postoperative week from 50 % to 3 %. Both moderate to severe wound drainage in the third week and newly developed wound drainage in the second week after a week without drainage were strongly associated with PJI (odds ratio (OR) 103.23, 95 % confidence interval (CI) 26.08 to 408.57, OR 80.71, 95 % CI 9.12 to 714.52, respectively). The positive predictive value (PPV) for PJI was 83 % for moderate to heavy wound drainage in the third week.
: Moderate to heavy wound drainage and persistent wound drainage were strongly associated with PJI. The PPV of wound drainage for PJI was high for moderate to heavy drainage in the third week but was low for drainage in the first week. Therefore, additional parameters are needed to guide the decision to reoperate on patients for suspected acute PJI.
Abstract
Background
Escherichia coli is the most common cause of bacteremia in high-income countries. To enable the development and implementation of effective prevention strategies, a better ...understanding of the current epidemiology of invasive E. coli infections is needed.
Methods
A systematic review of literature published between 1 January 2007 and 31 March 2018 on the burden and epidemiology of E. coli bacteremia in populations that include adults in high-income countries was conducted. Meta-analysis was performed for descriptive purposes.
Results
During the studied time interval, the estimated incidence rate of E. coli bacteremia was 48 per 100 000 person-years, but this increased considerably with age: rates per 100 000 person-years were >100 in 55-to-75-year-olds and >300 in 75-to-85-year-olds. Overall, E. coli accounted for 27% of documented bacteremia episodes: 18% if hospital acquired, 32% if community-onset healthcare associated, and 33% if community acquired. The estimated case fatality rate was 12%. Approximately 44% of episodes were community acquired, 27% community-onset healthcare associated, and 27% hospital acquired. Urinary tract infection (UTI) was the primary source for 53% of episodes.
Conclusions
This systematic review confirms the substantial burden of E. coli bacteremia in older adults and justifies the implementation of community-level programs to prevent E. coli bacteremia and ideally UTI in this age group.
This systematic review regarding the epidemiology of Escherichia coli bacteremia in high-income countries shows that the disease burden is greatest in the elderly, and that most episodes have a community onset and result from urinary tract infection.
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