Comparing different approaches in robotic-assisted surgery for unicompartmental knee arthroplasty: outcomes at a short-term follow-up of MAKO versus NAVIO system.

The popularity of unicompartmental knee arthroplasty (UKA) continues to grow among orthopaedic surgeons and robotic surgery may be helpful in obtaining a precise placement of the prosthetic components, thanks to the meticulous intra-operative computer study for simulating the prosthetic positioning. This may lead to longer implant survivorship as well as a reduction in intermediate and long-term prosthetic complications, despite the initial greater costs than those of manual UKA. In this preliminary study, from January 2017 and October 2017, 18 patients underwent UKA with MAKO robotic system assistance and 10 patients received UKA with NAVIO robotic system assistance. The two groups were homogeneous by age, BMI, degree of osteoarthritis involvement, and postoperative program. Patients were followed both clinically (Numeric Rating Scale NRS and Knee Injury Osteoarthritis Outcome Scores KOOS) and radiographically. At the end term follow up (2 years), no significant difference was observed for NRS and KOOS as well as for clinical parameters as an active range of motion. A significant discrepancy was detected regarding the duration of the surgery and time of using the robotic system, that appeared to be longer in the NAVIO group than that of MAKO group, likely due to the specific technical aspects that characterize these two different robotic systems. The main finding of this study is that favorable clinical and radiographical results may be obtained using a robotic approach (MAKO or NAVIO) for UKA positioning at a short follow up. Due to the lack of significant clinical differences observed between the two groups of patients at end term follow up, the "concept" of a robotic approach, more than a specific patented system, may be considered the key element for improving UKA technique and it is likely that in the near future the choice of a single specific robotic system will still be a "surgeon's preference". The results of the study add scientific evidence regarding the effective improvement of UKA results using different robotic approaches. They also show possible economic sustainability of this therapeutic strategy related to the optimal patients' performance obtained at short term follow up, suggesting that the robotic assistance may really become a key element for better long-term survivorship of unicompartmental knee arthroplasty.

Risk factors for postoperative complications in preterm infants with surgical necrotizing enterocolitis and associated outcomes.

BACKGROUND: We aim to determine clinical risk factors for postoperative complications in preterm infants with surgical necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). METHODS: A retrospective cohort study of preterm infants with surgical NEC or SIP to compare clinical factors between those with and without postoperative complications. RESULTS: 78/109 (71.5%) infants had any complication following surgical NEC. Adhesions (20/35, 57.1%) and wound infection (6/35, 17.1%) were the most common single surgical complications. Patients with a single surgical complication (35/66, 53%) were significantly less likely to be exposed to antenatal steroids, more frequently had a jejunostomy, needed a central line longer, and had a longer length of stay than those without any surgical complication. Infants with > 1 surgical complication (43/71, 60.5%) included mainly females, and had AKI more frequently at NEC onset, lower weight z-scores and lower weight for length z- scores at 36 weeks PMA than those without any complications.On multinomial logistic regression, antenatal steroids exposure (OR 0.23 [CI 0.06, 0.84]; p = 0.027) was independently associated with lower risk and jejunostomy 4.81 (1.29, 17.9) was independently associated with higher risk of developing a single complication. AKI following disease onset (OR 5.33 (1.38, 20.6), P = 0.015) was independently associated with > 1 complication in surgical NEC/SIP infants. CONCLUSION: Infants with postoperative complications following surgical NEC were more likely to be female, have additional morbidities, and demonstrate growth failure at 36 weeks PMA than those without surgical complications. There was no difference in mortality between those with and without surgical complications.

A cluster analysis-derived classification of psychological distress and illness behavior in the medically ill.

BACKGROUND: The classification of psychological distress and illness behavior in the setting of medical disease is still controversial. Current psychiatric nosology does not seem to cover the spectrum of disturbances. The aim of this investigation was to assess whether the joint use of DSM-IV categories and the Diagnostic Criteria for Psychosomatic Research (DCPR), that provide identification of syndromes related to somatization, abnormal illness behavior, irritable mood, type A behavior, demoralization and alexithymia, could yield subtyping of psychosocial variables in the medically ill. METHOD: A cross-sectional assessment using both DSM-IV and the DCPR was conducted in eight medical centers in the Italian Health System. Data were submitted to cluster analysis. Participants were consecutive medical out-patients and in-patients for whom a psychiatric consultation was requested. A total of 1700 subjects met eligibility criteria and 1560 agreed to participate. RESULTS: Three clusters were identified: non-specific psychological distress, irritability and affective disturbances with somatization. CONCLUSIONS: Two-step cluster analysis revealed clusters that were found to occur across clinical settings. The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, illness behavior and subclinical distress encompassed by the DCPR.

Type A behaviour: a reappraisal of its characteristics in cardiovascular disease.

AIMS: The role of type A behaviour in cardiovascular disease is controversial and most of the research is based on self-rating scales. The aim of this study was to assess the prevalence of type A behaviour in cardiology and in other medical settings using reliable interview methods that reflect its original description. METHODS: A sample of 1398 consecutive medical patients (198 with heart transplantation, 153 with a myocardial infarction, 190 with functional gastrointestinal disorders, 104 with cancer, 545 with skin disorders and 208 referred for psychiatric consultation) was administered the Structured Clinical Interview for the DSM-IV and the Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) which identifies 12 clusters, including type A behaviour. RESULTS: A cardiac condition was present in 366 patients. There was a significant difference in the prevalence of type A behaviour in cardiovascular disease (36.1%) compared with other medical disorders (10.8%). Type A behaviour frequently occurred together with psychiatric and psychosomatic disturbances, particularly irritable mood, even though in the majority of cases it was not associated with DSM-IV diagnoses. Among cardiac patients, those with type A behaviour were less depressed, demoralised and worried about their illness. CONCLUSIONS: Type A behaviour was found to occur in about a third of cases of patients with cardiovascular disease. Only in a limited number of cases was it associated with depression. It has a lifestyle connotation that may have important clinical consequences as to stress vulnerability and illness behaviour.

Emotional symptoms, quality of life and cytokine profile in hemodialysis patients.

BACKGROUND: Mental disorders are frequent in hemodialysis (HD) patients. Depression and anxiety along with physical co-morbidity affect quality of life (QOL). Uremia is associated with inflammation and release of cytokines by lymphomonocytes. Inflammatory cytokines are relevant in depression. The aim of this study was to assess the psychological alterations and QOL in HD patients, and to correlate them with pattern of cytokine production. PATIENTS: 30 HD patients and 20 subjects with CKD Stage I-II K-DOQI. Psychometric tests were administered: 1) Hospital Anxiety and Depression Scale (HADS) composed of an anxiety subscale (HADS-A) and a depression subscale (HADS-D); 2) Kidney Disease Quality of Life (KDQOL) modified, including a cognitive function subscale (KDQOL-CF). Whole blood samples collected at beginning of HD session were diluted with RPMI/heparin and incubated for 24 h in presence of lipopolysaccharide (LPS). IL-1Gamma, IL-6, TNF-alpha and IL-10 were assayed on supernatants and results were normalized per number of lymphomonocytes (ng/106 cells). RESULTS: A depressive mood was more frequent in HD patients (50%) than controls (20%, p < 0.0001). No difference for anxiety (HD = 43%, controls = 45%) was observed. QOL score was significantly lower in HD than controls (p = 0.006) and correlated inversely with HADS total, HADS-A and HADS-D (p < 0.0001). Albumin, Kt/V and phosphate were comparable in patients with or without anxiety or depression. Cytokine production was significantly higher in HD patients than controls (IL-1beta p = 0.05; IL-6 p = 0.010; TNF-alpha p < 0.0001; IL-10, p = 0.0019). HD patients with the HADS-A positive for anxiety showed higher IL-6 production (p = 0.026), while IL-1beta levels were not associated with symptoms of depression. KDQOL-CF correlated inversely with levels of IL-6, TNF-alpha and IL-10. CONCLUSIONS: HD patients have symptoms of depression and anxiety that negatively affect QOL. These symptoms are independent of the efficiency of dialysis and nutritional status. On the contrary, IL-6 is linked to the presence of psychological discomfort in these patients.

The predictive role of pelvic magnetic resonance in the follow up of spontaneous or induced puberty in turner syndrome.

Puberty is a critical age for patients with Turner syndrome (TS): infertility is reported to be linked to karyotype and spontaneous puberty and menarche occur in approximately 30% of patients, especially in mosaicism. However, it is not always predictable considering hormonal pattern and pelvic transabdominal ultrasound scan (US).The aim of the study is to compare the accuracy of Magnetic Resonance Imaging (MRI) and US to evaluate uterine and gonads volume, to visualize the presence of follicles and to predict spontaneous puberty and menarche in girls with TS. In a retrospective study, we evaluated 19 TS patients (age: 9-16 years), who underwent transabdominal pelvic US and pelvic MRI as required by parents. We correlated pelvic imaging with karyotype, hormonal data and pubertal outcome, and we compared US resolution to MRI.MRI revealed a higher accuracy in the study of uterus and ovaries, and permitted to measure ovaries not visualized by US. Ovarian volume, the presence of follicles and the occurrence of spontaneous puberty were not related to the karyotype; spontaneous puberty started in one patient with a karyotype 45,X and in two patients with mosaicism (45,X/46,XX; 47,XXX/45, X). Ovarian follicles were relieved by MRI in patients with a spontaneous menarche and the persistence of menstrual cycles correlated with an ovarian volume corresponding to Tanner stage 3-4. We stress the role of MRI in the follow-up of TS adolescents, guide in the choice of the timing of treatment.

Practice ordering guidance for neonatal parenteral nutrition.

OBJECTIVE: Neonatal parenteral nutrition (PN) is designed for very low birth weight infants (BW < or = 1500 g) for whom enteral feedings are inadequate. Evaluating the clinical practice guidance (CPG) content of printed paper order forms could provide a baseline for comparison and serve as a reference for electronic neonatal nutrition order design systems. METHODS: A scoring system for clinical practice guidance was developed and applied to nine institutions printed paper PN order forms. CPG scores were assigned as: (1) generic reminder only, (2) prompt with order entry space, (3) patient specific reminder only, (4) patient specific recommendation with order entry space. User-friendliness and form completion time were also recorded. RESULTS: The overall CPG score for the six most common PN components was 1.85+/-0.68 (mean+/-1s.d.), consistent with a generic reminder, but short of a specific nutrient dose order field. Amino acid received the highest CPG score, 2.05+/-0.64; vitamins rated the lowest. The institution of origin was an independent predictor of the CPG score. CONCLUSIONS: Paper neonatal PN order forms offer relatively little CPG. Significant form variation and format reflects the need to standardize neonatal PN design as the neonatal PN design moves from paper to electronic ordering systems.

A cross-cultural investigation of attachment style, catastrophizing, negative pain beliefs, and symptom severity in irritable bowel syndrome.

BACKGROUND: Little information exists regarding whether psychosocial variables in irritable bowel syndrome (IBS) vary by geographic location. Adult attachment is an important psychological concept rooted in childhood relationship experience that has not been previously studied in IBS. Catastrophizing and negative pain beliefs have been described in IBS and may be affected by attachment. AIMS: In this cross-cultural study, we determined: (i) whether attachment differs between IBS patients and controls, (ii) whether geographic location has a significant effect on attachment style, catastrophizing and negative pain beliefs, and (iii) how all three variables correlate with IBS symptom severity. METHODS: 463 IBS patients, with moderate to severe symptom scores, and 192 healthy controls completed validated questionnaires about attachment, catastrophizing, negative pain beliefs and IBS-SSS in nine locations, USA (New York, Los Angeles), Mexico, Italy (Rome, Bari), Romania, Iran, India, and China. KEY RESULTS: Attachment anxiety and avoidance scores were significantly higher in IBS patients than in controls (p < 0.001). This was particularly true for the fearful-avoidant attachment category, especially in China and Romania. Path analysis showed that attachment anxiety and avoidance had indirect effects on IBS-SSS through catastrophizing (p < 0.0001) and negative pain beliefs (p = 0.005). All three psychosocial measures varied significantly depending on location. CONCLUSIONS & INFERENCES: In the IBS population studied, attachment style was significantly different in IBS compared to a control population. Geographic differences in attachment, catastrophizing and negative pain beliefs were documented and their correlation with symptom severity and thus, research of psychosocial variables in IBS should take into account the location of the population studied.

Retinol (vitamin A) and riboflavin (vitamin B2) administration and metabolism in very low birth weight infants.

The combination of marginal hepatic retinol stores at delivery and the reduction of daily retinol dose due to complications with the delivery system places the VLBW infant receiving parenteral nutrition at high risk for retinol deficiency during the first month of life. This has serious health implications because retinol is essential during this period for normal growth and repair of the pulmonary tissue in VLBW infants. Enterally fed VLBW infants, on the other hand, receive relatively higher doses of retinol from vitamin-supplemented premature infant formula and fortified breast milk. Equally serious is the problem of monitoring vitamin A status in infants receiving supplemental doses of vitamin A. It seems clear that while plasma vitamin A levels are the most easily available method of monitoring vitamin A status, further studies are necessary to determine if these levels correlate with hepatic content. This is of particular concern since liver disease is common in VLBW infants and vitamin A hepatotoxicity has been described in a cohort of 41 patients receiving therapeutic doses of the vitamin. While further research of daily enteral and parenteral retinol requirements of VLBW infants should continue, formulation of a specific VLBW parenteral vitamin supplement should also be developed.

A longitudinal study of alexithymia and psychological distress in inflammatory bowel disease.

A group of 104 patients with inflammatory bowel disease (IBD) was followed longitudinally for 6 months. While anxiety and depression scores were influenced over time by changes in the level of disease activity, there was no significant change in alexithymia scores. The findings support the contention that alexithymia is a stable personality characteristic in some IBD patients, in contrast to anxiety and depression which are state phenomena influenced by the level of disease activity.

[Psychological disorders in patients with enterostomy. The influence of age]. / Disturbi psicologici in pazienti portatori di enterostomia. Influenza dell'età.

A retrospective study of patients who had undergone enterostomy and subsequent follow-up in the past 9 years was carried out with the aim of identifying differences with relation to symptoms of depression, the deterioration of social relations and sexual disturbances between elderly (age greater than or equal to 65) and non-elderly patients (age less than 65). Depressive symptoms were present to a greater extent in elderly (48.6%) than in non-elderly patients (34.8%), whereas sexual disturbances were experienced more in non-elderly (34.8%) than elderly (21.6%) patients. No striking differences were noted with regard to the deterioration of social relations. The differences observed, although marked in terms of percentage, were not statistically significant given the relatively small number of cases examined.

Effects of different psychophysiological stressors on the cutaneous electrogastrogram in healthy subjects.

To evaluate the effect of psychophysiological stress on the gastric electrical activity, the cutaneous electrogastrography (EGG), a non-invasive technique, was performed in ten healthy subjects. Three different stressful (cold pressor test, arithmetic task, and Stroop color-word test) tests and a non-stressful (reading a booklet) task were administered, and EGG parameters (dominant frequency, coefficient of variation of dominant frequency, and gastric power) were recorded during baseline, task and rest periods. Neutral task did not affect EGG parameters. During stressful stimulations, a slight decrease in the dominant frequency and an increase in the coefficient of variation of the dominant frequency were found. During arithmetic task, the gastric power significantly increased (baseline vs stimulus P = 0.008; stimulus vs rest P = 0.015; baseline vs rest P = 0.011), and a statistically significant difference between gastric power during arithmetic and neutral task was observed (P = 0.007). During Stroop test, the gastric power showed only a trend toward significance (baseline vs stimulus P = 0.018; stimulus vs rest P = 0.018). A wide interindividual variability was recorded during the stress period. Therefore, the individual susceptibility to psychological stress may influence the EGG response and gastric electrical activity. In conclusion, cutaneous electrogastrography may be used as a non-invasive technique to study the effects of acute stressors on the gastric electrical activity.

[Disabling outcomes and psychological disorders in the patient with an enterostomy]. / Esiti invalidanti e disturbi psicologici nel paziente portatore di enterostomia.

The authors carried out a retrospective study of patients undergoing enterostomy during the past 9 years. From 1981 to present a total of 60 patients (39 males and 21 females) were operated and subsequently followed-up. The aim of the study was to examine the following factors: the diagnosis which led to operation, the type of stoma used, early and late complications, the behaviour of the alvus, psychological disorders and Karnofsky's Performance-Status Index. After having presented the findings, the surgical results obtained are discussed together with the patient's psychological reactions to stoma. All types of early surgical complications were absent in 66.6% of patients, whereas late complications were absent in 41.6%. Even in those cases where surgical techniques and prostheses permitted a satisfactory post-operative outcome, the sociopsychological and sexual problems relating to the wound and the perceived difference between the real and ideal Ego are highlighted.

A review of medication reconciliation issues and experiences with clinical staff and information systems.

Medication reconciliation was developed to reduce medical mistakes and injuries through a process of creating and comparing a current medication list from independent patient information sources, and resolving discrepancies. The structure and clinician assignments of medication reconciliation varies between institutions, but usually includes physicians, nurses and pharmacists. The Joint Commission has recognized the value of medication reconciliation and mandated implementation in 2006; however, a variety of issues have prevented simple, easy, and universal implementation. This review references issues related to the development and the implementation of medication reconciliation including: - the need of a system or standard for accurate drug identification to create a definitive 'gold standard' patient medication list, - identifying stakeholders of medication reconciliation within the institution and contrasting staff interest and participation with institutional resources, - observations and opportunities of integrating medication reconciliation with the electronic patient health record, and - summarizing a series of institutions experiences developing and implementing medication reconciliation. Last, as medication reconciliation becomes a regular process within medical centers, key concepts for effective implementation are discussed.

An electronic documentation system increases diagnostic code capture for very low birth weight infants.

INTRODUCTION: Information describing medical interventions and patient outcome of very low birth weight (VLBW; BW <1500 grams) infants who receive neonatal intensive care is necessary to evaluate the quality of health care. We developed an electronic patient documentation system (EDS) called PCode to identify and select patient diagnostic (DX) codes and compared EDS to the previous paper-based documentation system (PDS). Our hypothesis was that EDS would capture more patient diagnostic codes than PDS. METHODS: PDS was originally developed as a two page 'code sheet' which listed all 275 neonatal diagnoses/management options and corresponding 3-4 character diagnostic (DX) codes, organized by organ system. PDS code sheets were manually completed by one of three trained 'coders' for every neonatal patient. EDS was developed as a Java application with the 'coder' selecting DX codes from drop lists also categorized by organ system. The study intervention was patient code selection using either the PDS or the EDS system. Both systems produced a paper DX code summary. PDS data capture occurred from 11/1997-3/1999 followed by EDS data capture until 8/2000. The primary outcome variable was DX codes captured per patient. Data were analyzed using independent t-test and linear regression. RESULTS: The number of diagnoses increased with decreasing birth weight. After linear regression was applied to control for birth weight, the number of DX codes was 31% greater in the EDS group, 7.2 +/- 2.9 DX codes/patient, p=0.008. There was a trend towards fewer erroneous DX codes in the EDS group. The most common DX codes were hyaline membrane disease, sepsis evaluation and hyperbilirubinemia, as expected for this patient population. CONCLUSIONS: EDS captured more VLBW infant DX codes compared to PDS. These results support the transition toward electronic data documentation for the neonatal clinical environment. Electronically linking PCode to the patient database has been initiated and should reduce manual coding errors.

Increased parenteral nutrition calcium and phosphorus for very-low-birth-weight infants using computer software assisted ordering.

BACKGROUND: Providing adequate calcium (Ca) and phosphorus (P) in an appropriate ratio to preterm very-low-birth-weight (VLBW: BW < 1500 g) infants receiving parenteral nutrition (PN) is difficult because Ca:P solubility in PN is relatively low. Computer software assisted ordering (CSAO) was developed to integrate PN Ca:P solubility with clinical data to improve parenteral Ca and P administration. Our hypothesis was that CSAO would improve the system of designing PN by increasing the amount of Ca and P ordered without Ca:P precipitation. METHODS: Control PN orders were designed using proprietary preprinted PN forms which incorporated predefined PN Ca and P concentrations to prevent precipitation, independent of patient Ca or P administration. CSAO assessed total daily fluids and correlated parenteral volume with Ca:P solubility during order entry to recommend daily Ca and P doses. PN orders which provided > or = 80% of total nutrition volume as PN were analyzed. RESULTS: PN was designed with more Ca (60.3 +/- 16.7 mg/k/day, mean +/- 1 SD) and P (32.8 +/- 13.9 mg/k/day) using CSAO compared to control group Ca (50.0 +/- 17.1 mg/k/day) and P (25.1 +/- 9.1 mg/k/day), both Ca and P, p < 0.001, CSAO provided > or = 80% of the minimum recommended daily Ca in 82% of PN orders compared to 51% of the control orders, p < 0.001. No PN mixture demonstrated Ca:P precipitation. CONCLUSION: The system of designing PN was improved using computer software assisted ordering indicated by increased PN Ca and P content without Ca:P precipitation.

A prospective study of the relationship between disease activity and psychologic distress in patients with inflammatory bowel disease.

BACKGROUND: The evaluation of psychologic states is very useful in the management of inflammatory bowel disease (IBD) patients, particularly when related to disease activity (DA). Our aim was to prospectively evaluate the relationship between psychologic distress and DA. METHODS: DA and psychologic distress were evaluated in 104 IBD outpatients by means of clinical criteria and the Hospital Anxiety and Depression Scale (HADS) at base line and after 6 months. Patients were grouped in unchanged, improved, and worsened DA from base line to follow-up. RESULTS: Repeated-measures ANOVA showed a significant group-by-time interaction for HADS anxiety (F = 89.6, P = 0.0001) and depression (F = 3.67, P = 0.03) subscales. CONCLUSIONS: Over time changes in DA significantly affect psychologic distress and are closely related to corresponding increases and decreases in anxiety and depression in IBD patients. Our findings therefore suggest that the assessment of psychologic distress, particularly anxiety, should be included in the clinical management of IBD patients.