Background Kidney disease is associated with increased complications in total joint arthroplasty (TJA). The purpose of this study was to determine the association of kidney disease severity as ...measured by the chronic kidney disease (CKD) staging system with complications after TJA. Methods A retrospective review of 12,308 primary TJAs (6,361 hips, 5,947 knees) from 2008-2013 was performed. The following preoperative variables were obtained from medical records: chemistry 7 panel, Elixhauser comorbidities, and demographic factors. CKD stages were defined based on estimated glomerular filtration rate (eGFR) in ml/min/1.73m2 : (1) 90+, (2) 60-89, (3A) 45-59, (3B) 30-44, (4) 15-29, and (5) <15. Multivariate analysis was performed to assess the independent influence of CKD stage on the aforementioned endpoints. Results Patients with CKD stage greater than 2 demonstrated an increased odds of receiving transfusions (p=0.001), length of stay >3 days (p=0.010), acute kidney injury (p<0.001), septic revisions (p=0.002) and in-hospital complications (p<0.001) compared to all patients with eGFR > 60 when controlling for potential confounders. Only CKD stage 3A was significantly associated with septic revisions (90 days, p=0.004; 2 years p=0.002). Additionally, the relationship between eGFR and the above complications increased linearly rather than demonstrating a clear threshold at which the risk increased substantially. Discussion Severe CKD is associated with increased transfusion, length of stay, and in-hospital complications; and complications increased linearly with disease severity. Surgeons should be cognizant of this increase when evaluating TJA patients with renal disease.
Pheochromocytomas are rare catecholamine-producing neuroendocrine tumors that are usually benign, but which may also present as or develop into a malignancy. Predicting such behavior is notoriously ...difficult and there are currently no curative treatments for malignant tumors. This report follows from a workshop at the Banbury Conference Center, Cold Spring Harbor, New York, on the 16th-18th November 2003, held to review the state of science and to facilitate future progress in the diagnosis and treatment of malignant pheochromocytoma. The rarity of the tumor and the resulting fragmented nature of studies, typically involving small numbers of patients, represent limiting factors to the development of effective treatments and diagnostic or prognostic markers for malignant disease. Such development is being facilitated by the availability of new genomics-based tools, but for such approaches to succeed ultimately requires comprehensive clinical studies involving large numbers of patients, stringently collected clinical data and tumor samples, and interdisciplinary collaborations among multiple specialist centers. Nevertheless, the well-characterized hereditary basis and the unique functional nature of these neuroendocrine tumors provide a useful framework that offers advantages for establishing the pathways of tumorigenesis and malignancy. Such findings may have relevance for understanding the basis of other more common malignancies where similar frameworks are not available. As the relevant pathways leading to pheochromocytoma are established it should be possible to take advantage of the new generation of drugs being developed to target specific pathways in other malignancies. Again the success of this will require well-designed and coordinated multi-center studies.
The treatment effect of immunoselected allogeneic CD34+ blood cells was evaluated in two patients with poor graft function following BMT without evidence for immune-mediated rejection. Patient A had ...no signs of hematopoietic recovery up to day +34 post-BMT and patient B had normal leukocyte counts only with G-CSF support and remained platelet transfusion-dependent for > 200 days post-BMT. PBPC from the HLA-identical sibling BM donors were mobilized with G-CSF (2 x 5 micrograms/kg sc daily) for 5 days. Aphereses were performed on days 4 and 5 of G-CSF administration. CD34+ cells were separated from the pooled PBPC concentrates by immunoadsorption with the anti-CD34 moAb 12.8 in a biotin-avidin system. Patient A received 0.4 x 10(6) CD34+ and 4.3 x 10(5) CD3+ cells/kg body weight and patient B 3.4 x 10(6) CD34+ and 1.4 x 10(5) CD3+ cells/kg body weight. The trilineage repopulation of BM and the rapid improvement of peripheral blood parameters correlated with CD34+ cell infusion. Patients' blood and BM cell analyses proved the donor origin. Patient A died from CMV pneumonitis and multiorgan failure 27 days after CD34+ cell infusion (day +61 post-BMT). Patient B is still stable and in remission 260 days after CD34+ cell infusion (day +478 post-BMT). Neither patient suffered further exacerbation of GVHD). Thus, immunoselected allogeneic CD34+ blood cells might be appropriate for treatment of post-BMT graft failure.
Einstein-Podolsky-Rosen steering is a quantum phenomenon wherein one party influences, or steers, the state of a distant party's particle beyond what could be achieved with a separable state, by ...making measurements on one-half of an entangled state. This type of quantum nonlocality stands out through its asymmetric setting and even allows for cases where one party can steer the other but where the reverse is not true. A series of experiments have demonstrated one-way steering in the past, but all were based on significant limiting assumptions. These consisted either of restrictions on the type of allowed measurements or of assumptions about the quantum state at hand, by mapping to a specific family of states and analyzing the ideal target state rather than the real experimental state. Here, we present the first experimental demonstration of one-way steering free of such assumptions. We achieve this using a new sufficient condition for nonsteerability and, although not required by our analysis, using a novel source of extremely high-quality photonic Werner states.
•Crohn’s Disease extraintestinal joint symptoms may lead to total knee arthroplasty.•Crohn’s is an independent risk for 90-day and overall readmissions.•Crohn’s predictor of acute renal failure, ...pulmonary embolism, and blood transfusion.
Joint involvement is a common extraintestinal manifestation of Crohn’s Disease (CD) that may require total knee arthroplasty (TKA). There is a paucity of evidence regarding the relationship between CD and postoperative outcomes after TKA surgery. This study seeks to evaluate the impact of CD on 90-day and ≥2-year follow-up postoperative outcomes of TKA patients.
We retrospectively analyzed the Statewide Planning and Research Cooperative System database (2009–2013) and isolated ICD-9 codes for TKA patients (8154), while excluding those with any revision of knee replacements (0080–0084) and split into 2 groups with or without CD (5550–5559). Patient demographics and postoperative outcomes were compared. Logistic regression analyses with covariates (sex, race, Deyo score, age, and insurance) were utilized to evaluate the association of CD with 90-day and overall postoperative outcomes.
A total of 89,134 TKA patients were identified, 244 of whom had CD. Significant differences in age, race distribution, insurance, and Deyo score (all, p < 0.05) were found. Multivariable analysis demonstrated CD was an independent risk factor for 90-day and overall medical complications, surgical complications, and readmission. Univariate and multivariable analyses report CD had significant increased rates and was a predictor, respectively, of overall blood transfusions (OR 1.5 95% CI 1.1–2.0 p < 0.01), acute renal failure (OR 1.7 95% CI 1.1–2.6 p = 0.03), and pulmonary embolism (OR 2.5 95% CI 1.3–4.6 p = 0.01).
Patients with CD undergoing TKA have increased risk both 90-day and overall surgical and medication complications, as well as readmissions compared to patients without CD.
To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours.
Retrospective cohort study.
Three ...academic Level 1 trauma centers.
Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC.
Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality.
Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons).
Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Paroxysmal nocturnal hemoglobinuria (PNH) is clinically characterized by intravascular hemolysis, hemoglobinuria, iron deficiency anemia, and venous thrombosis. Pathophysiologically the disease has ...now been generally accepted as an acquired defect of phosphatidylinositol glycan (PIG)-anchored molecules on the cell surface of bone marrow-derived cells. This defect is functionally characterized by an abnormal susceptibility to complement-mediated lysis and has been described on erythrocytes, granulocytes, monocytes, and platelets. In contrast, contradictory data exist so far on the involvement of lymphocytes and natural killer (NK) cells. Using monoclonal antibodies (MoAbs) against newly defined PIG-linked surface structures such as CD48, CD55, and CD59, which are homogeneously expressed on lymphocytes of normal donors, we analyzed lymphocytes and their subpopulations in nine PNH patients by two color immunofluorescence. Our results showed that CD3+ T cells as well as CD16+ NK cells are at least partially involved in the deficient PIG-molecule surface expression. To more clearly define the defect in PNH, we generated NK clones from a PNH patient. Phenotypic analysis of these NK clones showed that they either were positive (n = 3) for PIG-linked surface structures such as CD48, CD55, and CD59 (eg, NKP1) or were completely negative (n = 7) for all of them (eg, NKP1). In functional tests the PIG-molecule negative clone NKP2 showed increased susceptibility to human complement compared with the PIG molecule positive clone NKP1. When analyzing the mRNA levels of the PIG-linked molecules CD55 and CD59 there was no difference at all between the two clones. We conclude from our data that NK cells as well as other lymphocyte subpopulations are involved in the PIG-linkage defect of PNH. These NK clones with differential expression of PIG-linked surface structures present for the first time ex vivo mutant cell lymphocyte lines that carry the defect leading to PIG deficiency in PNH.
The 2019 11th International Conference on Hantaviruses (ICH 2019) was organized by the International Society for Hantaviruses (ISH), and held on September 1–4, 2019, at the Irish College, in Leuven, ...Belgium. These ICHs have been held every three years since 1989. ICH 2019 was attended by 158 participants from 33 countries. The current report summarizes research presented on all aspects of hantavirology: ecology; pathogenesis and immune responses; virus phylogeny, replication and morphogenesis; epidemiology; vaccines, therapeutics and prevention; and clinical aspects and diagnosis.
•The 11th International Congress on Hantaviruses (ICH) was held in Leuven, Belgium, September 1–4, 2019.•New data were presented on hantavirus structure, mechanisms of cell entry, and pathways of immunopathology.•Phylogenetic analysis of hantavirus sequences from patients' sera and rodent hosts showed geographic-specific clustering.•The number of novel hantaviruses in non-rodent reservoirs (shrews, moles, and bats) is growing steadily.•Passive immunotherapy with neutralizing antibodies from patients, or from transchromosomic bovines, seem promising.
Abstract Background Adverse local tissue reactions (ALTR) and periprosthetic joint infection (PJI) can occur after metal-on-metal (MOM) total hip arthroplasty (THA), both potentially generating ...purulent synovial fluid (SF) and elevated white cell count. This makes it difficult to distinguish between diagnoses; therefore, we evaluated leukocyte esterase (LE) strip test’s reliability in ruling out PJI in ALTR revision THA. Methods and Materials 61 patients with ALTRs and an LE strip test were evaluated, excluding 15 cases with SF metallic debris. LE strip tests were classified -/trace, +(mildly positive), and ++(strongly positive). Results LE strip tests were ++, +, -/trace in 8 patients (13.1%), 14 (23.0%), and 39 (63.9%), respectively. Means and ranges of SF white cell count and polymorphonuclear percentage were 1,291.4 (0-10886 cells/uL), and 46.1% (0%-94%), respectively. Conclusion ++ LE strip test,in conjunction with preoperative workups, reliably rules out infection in 92.9% of patients undergoing THA revision secondary to ALTR.
The depth-dependent, as-grown and deformation-induced strain and dislocations partitioned through the interfaces in a two-phase layered NiAl–Cr(Mo) structure are directly measured at the mesoscale ...using 3-D X-ray microdiffraction. It is demonstrated that in the as-grown, undeformed state, neighboring submicron Cr solid solution and NiAl eutectic lamellae (doped with ∼3% Mo) form a heterointerface with 180° rotation around a 〈112〉 pole. It is shown that the mechanical response to the indentation of a layered composite with alternating Cr(Mo)–NiAl lamellae is distinct from the response of single-phase materials. In the center of the indent, after the load is released, the NiAl lamellae are under compressive forward stresses (with the same sign as the indentation-induced compression) while Cr solid solution lamellae are under tensile back stresses (with opposite sign from the indentation load). The depth-dependent alternation of compressive/tensile residual strains in the neighboring Cr solid solution and NiAl lamellae is understood in the framework of the Mughrabi’s composite model considering two types of structure elements: harder and softer regions. Under indentation, both kinds of lamellae are assumed to deform compatibly. After the load is released, residual forward stresses are formed in the harder lamellae, and back stresses are formed in the mechanically softer lamellae. Line-broadening analysis of the intensity distribution along the diffraction vector reveals a 15-times increase in dislocation density in the near-surface zone in the center of the indent. Such a large increase is typical for severe deformation.
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