Very-short-term perioperative intravenous iron administration and postoperative outcome in major orthopedic surgery: a pooled analysis of observational data from 2547 patients.

BACKGROUND: Postoperative nosocomial infection (PNI) is a severe complication in surgical patients. Known risk factors of PNI such as allogeneic blood transfusions (ABTs), anemia, and iron deficiency are manageable with perioperative intravenous (IV) iron therapy. To address potential concerns about IV iron and the risk of PNI, we studied a large series of orthopedic surgical patients for possible relations between IV iron, ABT, and PNI. STUDY DESIGN AND METHODS: Pooled data on ABT, PNI, 30-day mortality, and length of hospital stay (LHS) from 2547 patients undergoing elective lower-limb arthroplasty (n = 1186) or hip fracture repair (n = 1361) were compared between patients who received either very-short-term perioperative IV iron (200-600 mg; n = 1538), with or without recombinant human erythropoietin (rHuEPO; 40,000 IU), or standard treatment (n = 1009). RESULTS: Compared to standard therapy, perioperative IV iron reduced rates of ABT (32.4% vs. 48.8%; p = 0.001), PNI (10.7% vs. 26.9%; p = 0.001), and 30-day mortality (4.8% vs. 9.4%; p = 0.003) and the LHS (11.9 days vs. 13.4 days; p = 0.001) in hip fracture patients. These benefits were observed in both transfused and nontransfused patients. Also in elective arthroplasty, IV iron reduced ABT rates (8.9% vs. 30.1%; p = 0.001) and LHS (8.4 days vs.10.7 days; p = 0.001), without differences in PNI rates (2.8% vs. 3.7%; p = 0.417), and there was no 30-day mortality. CONCLUSION: Despite known limitations of pooled observational analyses, these results suggest that very-short-term perioperative administration of IV iron, with or without rHuEPO, in major lower limb orthopedic procedures is associated with reduced ABT rates and LHS, without increasing postoperative morbidity or mortality.

Arthroscopic treatment for malunions of the proximal humeral greater tuberosity.

The purpose of this article was to report an arthroscopic treatment method for greater tuberosity malunion. Eight patients with malunion of the greater tuberosity were treated by arthroscopic acromioplasty, detachment of rotator cuff, tuberoplasty of the greater tuberosity and repair of the rotator cuff. On the basis of the UCLA rating scale, the overall score increased from 11.1 (range 9-14) to 30.2 (range 25-35) postoperatively, with one excellent result, six good results, and one poor result. All patients had less pain than preoperatively. Full activity level was achieved in two patients, five patients had only slight functional restriction, and one patient had mild limitation in activities of daily living. Seven patients returned to their previous occupations without restrictions. One patient did not return to work because of residual upper extremity weakness. We conclude that arthroscopic tuberoplasty is a good method for the treatment of greater tuberosity malunion.

Characterization of the molecular changes associated with the overexpression of a novel epithelial cadherin splice variant mRNA in a breast cancer model using proteomics and bioinformatics approaches: identification of changes in cell metabolism and an increased expression of lactate dehydrogenase B.

BACKGROUND: Breast cancer (BC) is the most common female cancer and the leading cause of cancer death in women worldwide. Alterations in epithelial cadherin (E-cadherin) expression and functions are associated to BC, but the underlying molecular mechanisms have not been fully elucidated. We have previously reported a novel human E-cadherin splice variant (E-cadherin variant) mRNA. Stable transfectants in MCF-7 human BC cells (MCF7Ecadvar) depicted fibroblast-like cell morphology, E-cadherin wild-type downregulation, and other molecular changes characteristic of the epithelial-to-mesenchymal transition process, reduced cell-cell adhesion, and increased cell migration and invasion. In this study, a two-dimensional differential gel electrophoresis (2D-DIGE) combined with mass spectrometry (MS) protein identification and bioinformatics analyses were done to characterize biological processes and canonical pathways affected by E-cadherin variant expression. RESULTS: By 2D-DIGE and MS analysis, 50 proteins were found differentially expressed (≥ Δ1.5) in MCF7Ecadvar compared to control cells. Validation of transcript expression was done in the ten most overexpressed and underexpressed proteins. Bioinformatics analyses revealed that 39 of the 50 proteins identified had been previously associated to BC. Moreover, metabolic processes were the most affected, and glycolysis the canonical pathway most altered. The lactate dehydrogenase B (LDHB) was the highest overexpressed protein, and transcript levels were higher in MCF7Ecadvar than in control cells. In agreement with these findings, MCF7Ecadvar conditioned media had lower glucose and higher lactate levels than control cells. MCF7Ecadvar cell treatment with 5 mM of the glycolytic inhibitor 2-deoxy-glucose led to decreased cell viability, and modulation of LDHB expression in MCF7Ecadvar cells with a specific small interfering RNA resulted in decreased cell proliferation. Finally, a positive association between expression levels of the E-cadherin variant and LDHB transcripts was demonstrated in 21 human breast tumor tissues, and breast tumor samples with higher Ki67 expression showed higher LDHB mRNA levels. CONCLUSIONS: Results from this investigation contributed to further characterize molecular changes associated to the novel E-cadherin splice variant expression in BC cells. They also revealed an association between expression of the novel variant and changes related to BC progression and aggressiveness, in particular those associated to cell metabolism.

Integrating CAD modules in a PACS environment using a wide computing infrastructure.

PURPOSE: The aim of this paper is to describe a project designed to achieve a total integration of different CAD algorithms into the PACS environment by using a wide computing infrastructure. METHODS: The aim is to build a system for the entire region of Galicia, Spain, to make CAD accessible to multiple hospitals by employing different PACSs and clinical workstations. The new CAD model seeks to connect different devices (CAD systems, acquisition modalities, workstations and PACS) by means of networking based on a platform that will offer different CAD services. This paper describes some aspects related to the health services of the region where the project was developed, CAD algorithms that were either employed or selected for inclusion in the project, and several technical aspects and results. RESULTS: We have built a standard-based platform with which users can request a CAD service and receive the results in their local PACS. The process runs through a web interface that allows sending data to the different CAD services. A DICOM SR object is received with the results of the algorithms stored inside the original study in the proper folder with the original images. CONCLUSIONS: As a result, a homogeneous service to the different hospitals of the region will be offered. End users will benefit from a homogeneous workflow and a standardised integration model to request and obtain results from CAD systems in any modality, not dependant on commercial integration models. This new solution will foster the deployment of these technologies in the entire region of Galicia.

Automatic characterization of thoracic aortic aneurysms from CT images.

Accurate determination of the diameter is an important step for diagnosis and follow-up of aortic abnormalities such as aneurysms, caused by dilation of the vessel lumen. In this work we focus on the development of an automatic method for measuring the calibre of the thoracic aorta. The method is based on the application of principal component analysis on normal planes extracted from the aorta to establish the main axis of each section of the vessel. Two experiments were performed in order to test the accuracy and the rotational invariance of the developed method. Accuracy was determined by using a database of 15 clinical cases, where our method and a commercial software, which was considered as the gold standard, were compared. For the rotational invariance check, phantom images in different orientations were obtained and the diameter was measured with the proposed method. For clinical cases, a good agreement was observed between our method and the gold standard. The Bland Altman plots indicated that all of the values were within the acceptable limits of agreement with a bias of 0.2mm between both methods. For phantom cases, an ANOVA test revealed that the results achieved for the data sets acquired for the different orientations were not statistically different (F=1.88, p=0.153), which demonstrates the robustness of the method for rotations. The proposed method is applicable for measuring the diameter in all tested cases, and the results achieved underscored the capability of our approach for automatic characterization of thoracic aortic aneurysms.

[Predictive factors for transfusion requirements in patients over 65 years old with subcapital hip fracture]. / Factores predictivos de la necesidad de transfusión en la fractura subcapital de cadera en pacientes mayores de 65 años.

BACKGROUND AND OBJECTIVE: Our goal was to know the patient's clinical and hematologic characteristics that could influence the use of blood in subcapital hip fracture (SCHF). PATIENTS AND METHOD: A prospective study of all patients affected by SCHF having surgery during 1998. Patients younger than 65 years, with primary blood diseases or under anticoagulation therapy were excluded. Age, gender, elapsed time, type of SCHF (international AO classification), surgical procedure (nail vs. hip arthroplasty), transfusional procedure and total used; hemoglobin (Hb) and hematocrit (Hct) levels at days 0 and + 2 (if surgical procedure was not performed) and after surgery were studied. Also we analyzed different hematimetric parameters: VCM, HCM, and RDW, transfusional act and blood consume. Statistical univariant analysis included T-Student test for numeric variables and Pearson X2 test for string variables. Statistical significance differences were considered when p < 0.05. A multivariate stepwise logistic regression model was carried out. RESULTS: 75 patients with SCHF were studied: 18 B1, 8 B2 and 49 B3 according to AO classification. Male/female: 12/63; age 81(SD: 8) years (range 65-99). At the admission day, the Hb level was 128 (SD: 23) g/L; Hct 0.39 L/L (SD: 0.06) (range 13-52), HCM 30.3 pg, VCM 91.4 fL and RDW 14.3%. The elapsed time was 5 (SD: 2.8) days. 22 patients (29.3%) had anemia on admission. Surgery consisted of: nails in 23 (31%) and hip arthroplasty in 52 (69%) patients. At day + 2 (n: 36) Hb was 119 g/L (SD: 12) and Hct 0.36 L/L (SD: 0.04). 34 (45%) patients were not transfused. On the statitiscal univariant study, Hb and Hct levels at admission and after surgery, RDW (anisocytosis), type of fracture and the surgical act were all associated with a transfusional procedure. In the transfused patients the Hb level (119.9 g/L) was lower than in non-transfused ones (138 g/L) (p < 0.01). 71% hip arthroplasty patients were transfused vs 17% nail patients (p < 0.01). On the logistic regression only the preoperative Hb level (p < 0.01) was identified as an independent predictor of transfusion. CONCLUSIONS: These results invite us to improve the hematological parameters in this elderly population and to promote earlier and less aggressive surgical procedures (nails) and to promote the use of alternatives methods to reduce the use of allogenic blood.

Minifragment plating for fractures of the distal radius.

Twelve patients with fracture of the distal radius were treated by open reduction and internal fixation with titanium minifragment plates. There were 8 women and 3 men, with a mean age of 42 years. The mean follow-up was 18 months. According to the score of Gartland and Werley, 11 patients had an excellent result and one patient had a good result. All patients reported no pain in their activities of daily living and were satisfied with the result. All workers returned to work. One patient developed reflex sympathetic dystrophy which resolved with treatment. No patients needed plate removal because of irritation of the tendons. The results obtained with this technique appear promising, although more cases are needed to achieve a definitive conclusion.

Quantification of Right and Left Ventricular Function in Cardiac MR Imaging: Comparison of Semiautomatic and Manual Segmentation Algorithms.

The purpose of this study was to evaluate the performance of a semiautomatic segmentation method for the anatomical and functional assessment of both ventricles from cardiac cine magnetic resonance (MR) examinations, reducing user interaction to a "mouse-click". Fifty-two patients with cardiovascular diseases were examined using a 1.5-T MR imaging unit. Several parameters of both ventricles, such as end-diastolic volume (EDV), end-systolic volume (ESV) and ejection fraction (EF), were quantified by an experienced operator using the conventional method based on manually-defined contours, as the standard of reference; and a novel semiautomatic segmentation method based on edge detection, iterative thresholding and region growing techniques, for evaluation purposes. No statistically significant differences were found between the two measurement values obtained for each parameter (p > 0.05). Correlation to estimate right ventricular function was good (r > 0.8) and turned out to be excellent (r > 0.9) for the left ventricle (LV). Bland-Altman plots revealed acceptable limits of agreement between the two methods (95%). Our study findings indicate that the proposed technique allows a fast and accurate assessment of both ventricles. However, further improvements are needed to equal results achieved for the right ventricle (RV) using the conventional methodology.

A hybrid method based on level set and 3D region growing for segmentation of the thoracic aorta.

This study sought to develop a completely automatic method for image segmentation of the thoracic aorta. We used a total of 4682 images from 10 consecutive patients. The proposed method is based on the use of level set and region growing, automatically initialized using the Hough transform. The results obtained were compared to those of manual segmentation as performed by an external expert radiologist. Concordance between the developed method and manual segmentation ranged from 92.79 to 95.77% in the descending regions of the aorta and from 90.68 to 96.54% in the ascending regions, with a mean value of 93.83% being obtained for total segmentation.

Internal fixation and strut allograft augmentation for periprosthetic humeral fractures.

PURPOSE: To report 6 patients with periprosthetic humeral fractures treated with open reduction and internal fixation with plate and strut allograft augmentation. METHODS: 6 women aged 69 to 79 (mean, 73) years underwent open reduction and internal fixation with plate and strut allograft augmentation for periprosthetic humeral fractures (type C) after a fall. They had undergone reverse shoulder arthroplasty for rotator cuff arthropathy. The mean interval between the initial arthroplasty and the fracture was 17 (range, 11-21) months. RESULTS: The mean follow-up period was 14 (range, 12-16) months. The mean time to union was 5.4 (range, 4-6) months. All fractures united without complications. The mean Constant score at the last follow-up was 64 (range, 56-80). The range of shoulder movement and patient satisfaction were restored to pre-fracture status in all patients, except for one who had more pain in the lateral area of the arm (probably because of soft-tissue irritation by the plate and wires). Three patients had evidence of graft-to-host union and 3 others had graft resorption. CONCLUSION: Internal fixation with plate, cable wires and strut allogaft augmentation achieves satisfactory results for periprosthetic humeral fractures.

Two-plate fixation for humeral shaft non-unions.

PURPOSE. To review 22 patients who underwent 2-plate fixation for non-union of the humeral shaft. METHODS. 13 women and 9 men aged 32 to 76 (mean, 48) years underwent fixation for non-union of the humeral shaft, using a 2-plate construct, together with decortication, debridement, and bone grafting. The two 3.5-mm reconstruction plates were parallel and lying at 90 degrees to each other and fixed with screws purchasing into at least 6 cortices of each fragment for both plates. Fractures were located in the upper third (n=8) or middle third (n=14) of the humerus. Initial treatments included casting (n=9), coaptation splinting (n=8), multiple retrograde pinning (n=4), and Marchetti-Vicenzi nailing (n=1). 18 non-unions were atrophic and 4 were hypertrophic. Shoulder and elbow range of motion as well as functional results were evaluated. RESULTS. The time for union was 4.6 (range, 4-6) months. No implants were loose or broken. No nonunion or infection was noted. Functional results were excellent in 17 and good in 5 patients. One patient had iatrogenic radial nerve palsy that recovered within 3 months. CONCLUSION. Two-plate fixation achieves good results for humeral shaft non-unions.

Application of the iris filter for automatic detection of pulmonary nodules on computed tomography images.

We have developed a computer-aided diagnosis (CAD) system to detect pulmonary nodules on thin-slice helical computed tomography (CT) images. We have also investigated the capability of an iris filter to discriminate between nodules and false-positive findings. Suspicious regions were characterized with features based on the iris filter output, gray level and morphological features, extracted from the CT images. Functions calculated by linear discriminant analysis (LDA) were used to reduce the number of false-positives. The system was evaluated on CT scans containing 77 pulmonary nodules. The system was trained and evaluated using two completely independent data sets. Results for a test set, evaluated with free-response receiver operating characteristic (FROC) analysis, yielded a sensitivity of 80% at 7.7 false-positives per scan.

Allograft reconstruction of segmental defects of the humeral head associated with posterior dislocations of the shoulder.

Six men underwent operative management of defects of the humeral head involving at least 40% of the articular surface, following posterior dislocation of the humeral head. The cause of dislocation was a grand mal seizure in three and a fall in three cases. In five cases the dislocation was reduced under general anaesthesia, and in all the posterior dislocation recurred early. Time between dislocation and surgery ranged from 7 to 8 weeks. The defect in the head, revealed by CT, was filled with an allogeneic segment of humeral head contoured to restore the spherical shape. All the patients returned to their occupation 4 months later. The mean duration of follow-up was 62.6 (60-68) months. At discharge, four of the men had no complaints of pain, instability, clicking or catching; two had pain, clicking, catching and stiffness. Radiographs and CT revealed no failures of fixation or of incorporation of the allograft. In four cases the contour and volume of the graft were maintained, but in the two with a bad clinical result, flattening and collapse of the graft and osteoarthrosis were observed. If the procedure fails, prosthetic reconstruction should be simple because the skeletal anatomy has not been distorted.

Preoperative haematinics and transfusion protocol reduce the need for transfusion after total knee replacement.

BACKGROUND: Unilateral total knee replacement (TKR) can result in a substantial blood loss and 30-50% of these patients receive allogeneic blood transfusion (ABT), this transfusion rate may be even higher among anaemic patients. PATIENTS AND METHODS: We assessed the requirements for ABT in 156 consecutive patients undergoing surgery for primary TKR, who received iron ferrous sulphate (256 mg/day; 80 mg of Fe(2+)), vitamin C (1000 mg/day) and folic acid (5mg/day) during the 30-45 days preceding surgery, and who were transfused if Hb <80 g/L and/or clinical signs/symptoms of acute anaemia/hypoxemia (Group 2). A previous series of 156 TKR patients serves as a control group (Group 1). RESULTS: Compared to those in Group 1, patients in Group 2 presented a lower transfusion rate (5.8% vs. 32%, for Group 2 and Group 1, respectively; p<0.01), and a lower transfusion index (1.78+/-0.44 vs. 2.22+/-0.65 units per transfused patient, respectively; p<0.05). After patient's stratification according to a preoperative Hb above or below 130 g/L, the differences in transfusion rate remained significant, although 19% of patients from Group 2 still needed ABT if their preoperative Hb <130 g/L. CONCLUSION: This protocol seems to be effective for avoiding ABT in non-anaemic TKR patients, whereas for anaemic patients another blood saving strategy, such us preoperative erythropoietin administration or postoperative blood salvage, should be added to further increase its effectiveness.

Management of types III and IV acetabular deficiencies with the longitudinal oblong revision cup.

Thirty-five longitudinal oblong revision (LOR) cups were used to reconstruct 29 type III and 6 type IV acetabular defects. Intraoperatively, we considered that cup contact was complete when we achieved a continuous contact between the cup periphery and the acetabular rim. When there were areas with a lack of contact, we considered that the contact was partial or incomplete. All patients were followed up for 4 to 8 years (mean = 6.3 years). At the latest follow-up, 30 cups were stable (85.8%) and 5 had migrated (14.2%). We found a significant relation between incomplete cup contact with the acetabular rim and subsequent failure (P = .042). The abduction angle was significantly increased in the group of unstable cups (P = .032) because of the migration of the acetabular component that became more vertical. Pain, limp, use of walking aids, functional level, and limb-length discrepancy significantly improved postoperatively (P < .0001). The Harris hip score improved from a mean preoperative score of 37 points to that of 79 points (P < .01). This implant showed satisfactory stability at early to midterm follow-up.

Perioperative intravenous iron, with or without erythropoietin, plus restrictive transfusion protocol reduce the need for allogeneic blood after knee replacement surgery.

BACKGROUND: Unilateral total knee replacement (TKR) results in a substantial blood loss and 30 to 50 percent of patients receive allogeneic blood transfusion (ABT). Therefore, the effectiveness of a restrictive transfusion trigger (hemoglobin [Hb] level < 8 g/dL) plus stimulation of erythropoiesis was evaluated, with or without blood salvage, for reducing ABT in TKR patients. STUDY DESIGN AND METHODS: A series of 139 consecutive of primary TKR patients received perioperative iron sucrose (2 x 200 mg/48 hr, intravenously [IV]), plus preoperative erythropoietin (EPO; 1 x 40.000 UI, sc) if preoperative Hb level was less than 130 g per L (Group A). This protocol was applied to another series of 173 consecutive TKR patients who also received postoperative unwashed shed blood (USB) if preoperative Hb level was less than 130 g per L (Group B). Perioperative clinical and laboratory data were gathered. RESULTS: No adverse effects of iron sucrose, EPO, or USB administration were witnessed, and only 13 patients received ABT overall (4%). No major differences in perioperative blood counts or iron metabolism variables were observed between groups, but stimulation of erythropoiesis seemed to be more pronounced in those patients receiving EPO (p < 0.05). There were no differences in postoperative complications between groups, but length of hospital stay for patients with a preoperative Hb level of less than 130 g per L was shorter in Group B (p < 0.05). CONCLUSION: This blood saving protocol seems to be effective for reducing ABT in TKR patients. Which patients are more likely to benefit from either perioperative iron administration or selective addition of postoperative blood salvage to pharmacologic treatment, however, needs to be further evaluated.