Debridement, antibiotics, and implant retention in non-oncological femoral megaprosthesis infections: minimum 5 year follow-up.

PURPOSE: Megaprostheses are increasingly utilised outside of the oncological setting, and remain at significant risk of periprosthetic joint infection (PJI). Debridement, antibiotic, and implant retention (DAIR) is an established treatment for PJI, however its use in non-oncological patients with femoral megaprostheses has not been widely reported. There are significant differences in patient physiology, treatment goals, and associated risks between these patient cohorts. METHODS: We identified 14 patients who underwent DAIR for a PJI of their femoral megaprostheses, between 2000 and 2014, whom had their index procedure secondary to non-oncological indications. Patients were managed as part of a multidisciplinary team, with our standardised surgical technique including exchange of all mobile parts, and subsequent antibiotic therapy for a minimum of 3 months. Patients were followed up for a minimum of 5 years. RESULTS: Patients included six proximal femoral replacements, five distal femoral replacements, and three total femoral replacements. No patients were lost to follow-up. There were six males and eight females, with a mean age of 67.2 years, and mean ASA of 2.3. Nine patients (64.3%) successfully cleared their infection following DAIR at a minimum of 5 year follow-up. Five patients (35.7%) required further revision surgery, with four patients cleared of infection. No patients who underwent DAIR alone suffered complications as a result of the procedure. CONCLUSIONS: The use of DAIR in these complex patients can lead to successful outcomes, but the risk of further revision remains high. The success rate (64.3%) remains on par with other studies evaluating DAIR in megaprostheses and in primary arthroplasty. This study indicates judicious use of DAIR can be an appropriate part of the treatment algorithm. LEVEL OF EVIDENCE: II.

Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway.

INTRODUCTION: We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. METHODS: An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. FINDINGS: Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. CONCLUSION: We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.

Utility of Pre-Hematopoietic Cell Transplantation Sinus CT Screening in Children and Adolescents.

BACKGROUND AND PURPOSE: The clinical benefit of pre-hematopoietic cell transplantation sinus CT screening remains uncertain, while the risks of CT radiation and anesthesia are increasingly evident. We sought to re-assess the impact of screening sinus CT on pretransplantation patient management and prediction of posttransplantation invasive fungal rhinosinusitis. MATERIALS AND METHODS: Pretransplantation noncontrast screening sinus CTs for 100 consecutive patients (mean age, 11.9 ± 5.5 years) were graded for mucosal thickening (Lund-Mackay score) and for signs of noninvasive or invasive fungal rhinosinusitis (sinus calcification, hyperattenuation, bone destruction, extrasinus inflammation, and nasal mucosal ulceration). Posttransplantation sinus CTs performed for sinus-related symptoms were similarly graded. Associations of Lund-Mackay scores, clinical assessments, changes in pretransplantation clinical management (additional antibiotic or fungal therapy, sinonasal surgery, delayed transplantation), and subsequent development of sinus-related symptoms or invasive fungal rhinosinusitis were tested (exact Wilcoxon rank sums, Fisher exact test, significance P < .05). RESULTS: Mean pretransplantation screening Lund-Mackay scores (n = 100) were greater in patients with clinical symptoms (8.07 ± 6.00 versus 2.48 ± 3.51, P < .001) but were not associated with pretransplantation management changes and did not predict posttransplantation sinus symptoms (n = 21, P = .47) or invasive fungal rhinosinusitis symptoms (n = 2, P = .59). CONCLUSIONS: Pre-hematopoietic cell transplantation sinus CT does not meaningfully contribute to pretransplantation patient management or prediction of posttransplantation sinus disease, including invasive fungal rhinosinusitis, in children. The risks associated with CT radiation and possible anesthesia are not warranted in this setting.

Antidepressant prescribing practices of outpatient psychiatrists.

BACKGROUND: The authors examined recent changes in the number and proportion of patients prescribed antidepressants by psychiatrists in outpatient private practice and characterized antidepressant prescription patterns by patient age, sex, race, payment source, and clinical diagnosis. METHODS: The authors analyzed physician-reported data from the 1985 and 1993-1994 National Ambulatory Medical Care Survey, focusing on visits to physicians specializing in psychiatry. Logistic regressions were used to examine associations between survey year and antidepressant prescription, adjusting for the presence of other variables. RESULTS: The proportion of outpatient psychiatric visits in which an antidepressant was prescribed increased from 23.1% (95% confidence interval [CI], 19.7%-26.5%) in 1985 to 48.6% (95% CI, 47.5%-49.7%) in 1993-1994. After controlling for several patient variables, psychiatric patients were approximately 2.3 (95% CI, 1.8-2.9) times more likely to receive an antidepressant in 1993-1994 than in 1985. In 1993-1994, selective serotonin reuptake inhibitors accounted for approximately half of the psychiatric visits with an antidepressant prescription. Increases in the rate of antidepressant prescription were particularly evident for children and young adults; whites; new patients; and patients with adjustment disorders, personality disorders, depression not otherwise specified or dysthymia, and some anxiety disorders. CONCLUSIONS: During the late 1980s and early 1990s, there was a significant increase in the prescription of antidepressants by office-based psychiatrists. This increase was greatest for patients with less severe psychiatric disorders.

Fc-gamma receptor-ligand interactions enhance macrophage GSIB4-binding activity.

Activated macrophages have an increased ability to bind the lectin Griffonia simplicifolia-IB4 (GSIB4). Since macrophages readily use the Fc-receptor (FcR) during several immunologic and inflammatory processes, it is important to determine whether interactions with this moiety affect GSIB4-binding ability. Peritoneal macrophages cultured in vitro with Fc fragments of immunoglobulin G (IgG), whole IgG, or heat-aggregated IgG demonstrate an increase in this function. Conversely, treatment of macrophages with (Fab')2 fractions alone has no direct effect on this activity. Although the GSIB4-binding response is minimally expressed by normal macrophages, it is more markedly apparent on macrophages from LPS-treated animals. In both cases, however, pretrypsinization of the cells renders them refractory to IgG-mediated induction of the GSIB4-binding response. Moreover, macrophages cultured independently with IgG subclasses 1, 2a, or 3 demonstrate that the magnitude of their response to this signal is directly associated with the type of subclass used. Although each subclass enhanced the response, in this study interactions with IgG2a produced the best results. Overall, however, the greatest GSIB4-binding activity is generated when FcRs are crosslinked by aggregated IgG rather than simply bound by independent monomeric interactions at the FcRs. This suggests that the event of appropriately interacting with the FcRs amplifies the GSIB4-binding function. Such a mechanism could play a key role in coordinating the humoral, cell-mediated, and innate responses of the immune system.

"Burnout" in group home houseparents.

Forty-seven houseparents of group homes for emotionally disturbed adolescents completed questionnaires measuring "burnout." There were profound differences between male and female subjects; for men, higher burnout scores were significantly correlated with higher salaries, screening prospective residents, and having no decision-making power in accepting residents. Women burned out more if they screened prospective residents or ran group meetings with residents. Significant relationships were also found between burnout and where time off was spent and support of friends, staff, and the organization. The author suggests that group home programs should differentially allocate tasks to men and women and should work with men on overly high expectations.

Use of ECT in the United States in 1975 and 1980.

The authors examined data from the National Institute of Mental Health regarding the use of ECT in the United States in 1975 and 1980. A total of 33,384 hospitalized patients were treated with ECT in 1980, representing 2.4% of all patients hospitalized in psychiatric facilities. The use of ECT decreased by 46% between 1975 and 1980. Of the type of facilities surveyed, only public general hospitals did not decrease their use of ECT. Patients with affective disorders received 69.8% of the ECT given, and patients with schizophrenia received 16.6%. Although more women than men received ECT, diagnosis and age were more important factors than sex.

A crosswalk from DSM-III-R to ICD-9-CM.

The authors describe a crosswalk, or translation, from DSM-III-R to ICD-9-CM. They present differences in the purposes and formatting of these two documents and discuss different levels of compatibility between the two. They demonstrate several problems at the code, rubric, and case levels of compatibility. Ninety-seven percent of DSM-III-R codes are compatible with ICD-9-CM at the case level. The problems in most cases are minor, and in the authors' opinion are not problems in actual clinical or medical records use. The development of DSM-IV and ICD-10 should include attention to translation issues early in the process from the perspectives of clinical work, research, and medical records.

Preliminary report on a crosswalk from DSM-III to ICD-9-CM.

The wide use of DSM-III by clinicians and researchers in the United States has led to difficulties in reporting to federal agencies, which adhere to a policy supporting the use of ICD-9-CM. To rectify this situation, three federal agencies collaborated to design a translation, or "crosswalk," from DSM-III to ICD-9-CM. The authors discuss some of the differences between the two systems, describe the development of the crosswalk, and make suggestions concerning future nosological and statistical systems.

Types of patients served by various providers of outpatient care in CMHCs.

Representative community mental health center (CMHC) survey data showed that psychiatrists differed from other CMHC providers of mental health services by serving the more seriously impaired patients who are admitted and readmitted to outpatient services. Psychiatrists also shared more outpatients with providers from other disciplines than providers in other disciplines shared with one another. The results are consistent with previous research on differences between disciplines and with the flight of psychiatrists from CMHCs but cast doubt on the hypothesis that psychiatrists see sicker patients than psychologists see because of differences in reimbursement between the two disciplines.

Use of ECT in the United States in 1975, 1980, and 1986.

OBJECTIVE: The objective was to analyze nationally representative data from the National Institute of Mental Health (NIMH) to update trends in the use of ECT in the United States. METHOD: The data are estimates from the NIMH Sample Survey Program for 1975, 1980, and 1986, which include representative samples of inpatients in psychiatric facilities in the United States. The authors' analyses use trend data from public general hospitals, private general hospitals, private psychiatric hospitals, and state and county mental hospitals. They report on 126,739 patients who received ECT in 1975, 1980, and 1986, focusing on data from 1980 and 1986. RESULTS: In 1986, 36,558 patients received ECT. This represents a decrease from the 1975 figure (58,667 patients) but no change from 1980 (31,514 patients). ECT was used primarily in private general hospitals (64%) and private psychiatric hospitals and much less often in public general hospitals and state and county mental hospitals. In 1986 over 90% of ECT recipients were white, and 84% had an affective disorder diagnosis. Although 71% of the patients who received ECT were women, hospital type and age were more important than gender in predicting ECT use. Individuals 65 years of age and older received ECT out of proportion to their numbers in inpatient care. CONCLUSIONS: The declining use of ECT in the United States ended in the 1980s. Few African Americans receive ECT, and its use is becoming more targeted toward patients with affective disorders. The amount of services research done on this modality is very small. Basic questions have yet to be answered, including who refers patients for ECT and why, and how ECT fits into the overall course of treatment.

The decline of state mental hospitals as training sites for psychiatric residents.

There has been national concern regarding the decreasing number of U.S. medical students entering psychiatric residency training programs in the 1970s at the same time that the Graduate Medical Education National Advisory Committee (GMENAC) report designated psychiatry as one of only three medical specialties with a manpower shortage. The authors document the decline in psychiatric residents in state mental hospitals from 1975 to 1980 and analyze five possible explanations for this absolute and relative decrease. They discuss approaches to altering the situation as well as the emerging role of the state mental hospital in the future training of psychiatric residents.

An in-depth study of long-term users of transcutaneous electrical nerve stimulation (TENS). Implications for clinical use of TENS.

This in-depth study examines the relationships between patient, stimulator and outcome variables in a large number of chronic pain patients utilising TENS on a long-term basis. 179 patients completed a TENS questionnaire designed to record age, sex, cause and site of pain and TENS treatment regime. Of these 179 patients, 107 attended our research unit for assessment of the electrical characteristics of TENS during self-administered treatment. Although a remarkable lack of correlation between patient, stimulator and outcome variables was found to exist, the analysis revealed much information of importance: 47% of patients found TENS reduced their pain by more than half; TENS analgesia was rapid both in onset (less than 0.5 h in 75% patients) and in offset (less than 0.5 h in 51% patients); one-third of patients utilised TENS for over 61 h/week; pulse frequencies between 1 and 70 Hz were utilised by 75% of patients; 44% of patients benefitted from burst mode stimulation. The clinical implications of these findings are discussed.

The consistency of pulse frequencies and pulse patterns of transcutaneous electrical nerve stimulation (TENS) used by chronic pain patients.

This study records the consistency of transcutaneous electrical nerve stimulation (TENS) pulse frequency and pulse pattern used by 13 chronic patients over a 1 year period. The results show that patients prefer specific pulse frequencies and pulse patterns unique to the individual and that they turn to such frequencies and patterns on subsequent treatment sessions. Pulse frequencies and pulse patterns were not related to the cause and site of pain, a finding consistent with previous study in this laboratory. This observation, coupled with the large variability in pulse frequencies and pulse patterns used between individuals, implies that patients prefer such frequencies and patterns for reasons of comfort which may not be related to mechanisms specific to the pain system.

Effects of transcutaneous electrical nerve stimulation and aspirin on late somatosensory evoked potentials in normal subjects.

The effects on late somatosensory evoked potentials (SEPs) of transcutaneous nerve stimulation (TENS) and aspirin (600 mg), compared with placebo, were studied in 32 young, healthy male and female volunteers. SEPs were produced by electrical stimulation of the median nerve at moderate, non-painful, intensities. There was a reduction in the peak-to-peak amplitude of the late components N1P2 (N1 latency: 100-160 msec; P2 latency: 160-260 msec) of the SEP in all groups over time. TENS but not aspirin produced further significant changes compared with placebo, including a fall in N1P2 amplitude, an increase in N1 latency, and a decrease in the total excursion of the SEP between 25 and 450 msec after stimulus onset.

The effects of auricular transcutaneous electrical nerve stimulation (TENS) on experimental pain threshold and autonomic function in healthy subjects.

The present study examines the effects of auricular transcutaneous electrical nerve stimulation (TENS) on electrical pain threshold measured at the ipsilateral wrist and autonomic functions including skin temperature, blood pressure and pulse rate in 24 healthy subjects. TENS was administered as low frequency trains of pulses delivered at a 'strong but comfortable' intensity to 1 of 3 auricular points to be examined: (i) autonomic effects (autonomic point), (ii) pain threshold effects (wrist point), and (iii) placebo effects at an unrelated point (face point). A fourth untreated group was designated as a situation control. The main finding of the study was that auricular TENS produced no significant overall effects on experimental pain threshold or autonomic functions recorded under the present conditions. However, pain threshold was found to increase by over 50% of its pretreatment baseline in 4 subjects and by 30% in 6 subjects. This rise was not dependent upon the site of auricular TENS. The possible mechanisms of such changes are discussed.

Analgesic effects of different frequencies of transcutaneous electrical nerve stimulation on cold-induced pain in normal subjects.

The efficacy of transcutaneous electrical nerve stimulation (TENS) in producing analgesia in cold-induced pain was assessed using a range of 5 stimulating frequencies (10 Hz, 20 Hz, 40 Hz, 80 Hz and 160 Hz) in 83 normal healthy subjects. TENS significantly elevated ice pain threshold when compared with sham and control groups. TENS frequencies between 20 and 80 Hz produced greatest analgesia, while frequencies below and above this level (10 Hz and 160 Hz), although significantly elevating ice pain threshold, produced effects of a lesser magnitude. The frequency of pulse delivery was the governing factor as no significant differences in stimulus intensity were observed across the treatment groups. Measurement of ice pain tolerance was found to be unreliable under the present conditions. No significant relationships were observed between personality variables as measured by Eysenck Personality Questionnaires and the degree of TENS response.

The effect of various amine-depleting drugs on the fever response exhibited by rabbits to bacterial or leucocyte pyrogen.

1 The concentration of noradrenaline, dopamine and 5-hydroxytryptamine (5-HT) in the rabbit brainstem was measured during fevers produced by either an injection of bacterial pyrogen (BP) or continuous infusion of leucocyte pyrogen (LP). 2 Both procedures had little effect on the concentration of noradrenaline in the preoptic/hypothalamic area but significantly (P smaller than 0.001) lowered the concentration of noradrenaline in the midbrain and pons/medulla. 3 BP significantly (P smaller than 0.01) lowered the concentration of 5-HT in the preoptic/hypothalamic area but had no effect in the midbrain or pons/medulla, whereas LP significantly (P smaller than 0.01) lowered the concentration of 5-HT in the midbrain and pons/medulla but had little effect in the hypothalamus. 4 The concentration of dopamine throughout the brainstem was little affected by either BP or LP fevers. However the concentration in the midbrain was significantly reduced by LP (P smaller than 0.001). 5 Alpha-Methyltyrosine (200 mg/kg) pretreatment diminished the pyrogenic response to both BP and LP whilst p-chlorophenylalanine (300 mg/kg) slightly enhanced the response to both forms of challenge. 6 Reserpine (1 mg/kg) diminished both types of fever whilst a combination of alpha-methyltyrosine and p-chlorophenylalanine slightly enhanced the fevers produced by either BP or LP. 7 The results obtained are discussed in relation to the mechanisms involved in the production of fever and to the possible function of noradrenaline and 5-HT as thermoregulatory transmitters.

Analysis of the inhibition of pethidine N-demethylation by monoamine oxidase inhibitors and some other drugs with special reference to drug interactions in man.

1. N-Demethylation of pethidine was studied in microsomal suspensions from unstarved male rat liver and the N-demethylase identified as belonging to the class of hepatic microsomal mixed function oxidases.2. A study of the structure/action relationships of compounds inhibiting pethidine N-demethylase revealed that hydrazine derivatives including phenylhydrazine, methylphenylhydrazine and mebanazine were all potent competitive inhibitors.3. Pethidine N-demethylase was only slightly inhibited by histamine and amphetamine but not by adrenaline and ephedrine nor by several miscellaneous compounds including piperidine, N-ethylpiperidine, N-methylpiperidine, N-methylammonium, hydrallazine or pethidinic acid.4. Several psychotropic drugs were all found to be potent competitive inhibitors of pethidine N-demethylase. These included monoaminoxidase inhibitors (the most active being nialamide and phenoxypropazine [K(i)=0.01 mM]; the least active iproniazid [K(i)=1.05 mM]); the tranquillizers promazine, propiomazine and chlorpromazine and tricyclic antidepressants (opipramol [K(i)=0.01 mM], imipramine [K(i)=0.03 mM], desipramine [K(i)=0.03 mM] and amitryptyline [K(i)=0.03 mM]). Hydrocortisone [K(i)=0.3 mM], prednisolone [2.8 mM] and nalorphine [0.07 mM] were also inhibitors, whilst SKF 525A was the most active of all [K(i)=0.002 mM].5. These results are discussed in relation to the clinically observed drug interactions which may occur between monoamineoxidase inhibitors and pethidine. It is concluded that since many different groups of drugs, including monoamineoxidase inhibitors, tranquillizers, tricyclic antidepressants, steroids, nalorphine, SKF 525A and barbiturates compete for cytochrome P(450) reductase, it is possible that this mechanism may account, at least in part, for the observed interactions of these various drugs in man.

A method for measuring human behavioural and physiological responses at different stress levels in a driving simulator.

1. A method is described by which a car simulator can be used to measure, simultaneously, motor-perceptual performance and physiological responses of human subjects under different levels of task difficulty or stress.2. Motor-perceptual performance was measured in terms of reaction times taken by subjects to carry out steering, braking and operation of traffic indicators in the simulator. Subjects were instructed to carry out the different driving manoeuvres by means of a command panel containing five coloured lights. Three levels of task difficulty or stress were devised. In level 1 only the light signals were used. In level 2 the driving simulator film was shown and all of the light signals reinforced the movements of the car in the film. Level 3 was similar to level 2, with the exception that whilst some of the light signals reinforced the movements of the car, others deliberately conflicted with it.3. Physiological responses measured were heart rate, blood pressure, respiration and calf blood flow. Personality was also measured by means of the Cattell 16 personality factor questionnaire.4. Analysis of variance of the performance of 15 subjects showed significant variation between the three task levels (P=<0.001 for steering reaction times; P=<0.01 for brake and indicator reaction times). In all cases the reaction times were longest for level 3, indicating that this was the most difficult task. The number of anticipated responses to steering, braking and traffic indicator signals was highest in level 2, while the number of corrections to steering and braking responses was lowest in level 2. None of these differences was statistically significant.5. Of the physiological variables, the heart rate showed a progressive increase from task levels 1 to 3 but only those between levels 1 and 3 were statistically significant (P<0.05).6. The results are discussed in relation to the validity of the method. It is concluded that by means of this method it is possible to produce controlled and reproducible degrees of stress and under conditions which are also suitable for the investigation of pharmacological agents upon it.