Computer-Assisted Total Knee Arthroplasty: Is There a Difference Between Image-Based and Imageless Techniques?

BACKGROUND: Image-based and imageless computer-assisted total knee arthroplasty (CATKA) has become increasingly popular. This study aims to compare outcomes, including perioperative complications and transfusion rate, between CATKA and conventional total knee arthroplasty (TKA), as well as between image-based and imageless CATKA. METHODS: Using the 9th revision of the International Classification of Diseases codes, we queried the Nationwide Inpatient Sample database from 2005 to 2011 to identify unilateral conventional TKA, image-based, and imageless CATKAs as well as in-hospital complications and transfusion rates. RESULTS: A total of 787,809 conventional TKAs and 13,246 CATKAs (1055 image-based and 12,191 imageless) were identified. The rate of CATKA increased 23.13% per year from 2005 to 2011. Transfusion rates in conventional TKA and CATKA cases were 11.73% and 8.20% respectively (P < .001) and 6.92% in image-based vs 8.27% in imageless (P = .023). Perioperative complications occurred in 4.50%, 3.47%, and 3.41% of cases after conventional, imageless, and imaged-based CATKAs, respectively. Using multivariate analysis, perioperative complications were significantly higher in conventional TKA compared to CATKA (odds ratio = 1.17, 95% confidence interval 1.03-1.33, P = .01). There was no significant difference between imageless and image-based CATKA (P = .34). Length of hospital stay and hospital charges were not significantly different between groups (P > .05). CONCLUSION: CATKA has low complication rates and may improve patient outcomes after TKA. CATKA, especially the image-based technique, may reduce in-hospital complications and transfusion without increasing hospital charges and length of hospital stay significantly. Large prospective studies with long follow-up are required to verify potential benefits of CATKA.

Severe presentation of antibody-negative, postinfectious steroid-responsive encephalitis and atonic bladder after herpes simplex encephalitis.

A 75-year-old woman presented with new onset of confusion, intense episodic dizziness and formed visual hallucinations. Herpes simplex encephalitis and non-convulsive temporal lobe seizures were confirmed with cerebrospinal fluid (CSF) and electroencephalography testing. In addition, her hospital course was complicated by syndrome of inappropriate antidiuretic hormone secretion and atonic bladder contributing to an episode of urinary tract infection. After completing 3 weeks of acyclovir treatment, the patient became obtunded with right arm choreiform movements and persistent inflammatory CSF findings not attributable to persistent herpes simplex virus infection or other confounding factors. The patient responded to steroid treatment. Repeated autoimmune and paraneoplastic evaluations were negative. Both clinical (cognitive testing and atonic bladder) and CSF inflammatory finding improved in the follow-up period.

Differences in opioid prescribing in low back pain patients with and without depression: a cross-sectional study of a national sample from the United States.

INTRODUCTION: Low back pain (LBP) is among the leading indications for the prescription of opioid analgesics in clinical practice. There is increasing evidence suggesting that these agents may have diminished efficacy in the treatment of LBP. OBJECTIVES: We evaluated the relationship between depression, the probability of receiving an opioid prescription, and the amount of morphine equivalent amounts prescribed per year among patients with LBP using nationwide data. METHODS: A cross-sectional analysis was performed on existing data from the Medical Expenditure Panel Survey data set from the period 2004 to 2009. Demographic, medical condition, Patient Health Questionnaire-2 responses, and prescription drug information were obtained on 56,811,864 weighted person-years of data from individuals aged 18 to 65 with an ICD-9 code specific to LBP. RESULTS: Increases in PHQ-2 score, as well a positive screen for depression, were associated with an increased probability of being prescribed opioid therapy and more morphine equivalents per year. CONCLUSION: Analysis of a nationwide sample of patients with LBP shows an association between depression and higher rates of opioid prescribing after controlling for several known cofounders. Clinicians prescribing opioids in LBP populations that rely on clinical trial results that exclude depressed patients may misjudge the risks and benefits of this class of therapy.

Loss of feedback inhibition via D2 autoreceptors enhances acquisition of cocaine taking and reactivity to drug-paired cues.

A prominent aspect of drug addiction is the ability of drug-associated cues to elicit craving and facilitate relapse. Understanding the factors that regulate cue reactivity will be vital for improving treatment of addictive disorders. Low availability of dopamine (DA) D2 receptors (D2Rs) in the striatum is associated with high cocaine intake and compulsive use. However, the role of D2Rs of nonstriatal origin in cocaine seeking and taking behavior and cue reactivity is less understood and possibly underestimated. D2Rs expressed by midbrain DA neurons function as autoreceptors, exerting inhibitory feedback on DA synthesis and release. Here, we show that selective loss of D2 autoreceptors impairs the feedback inhibition of DA release and amplifies the effect of cocaine on DA transmission in the nucleus accumbens (NAc) in vitro. Mice lacking D2 autoreceptors acquire a cued-operant self-administration task for cocaine faster than littermate control mice but acquire similarly for a natural reward. Furthermore, although mice lacking D2 autoreceptors were able to extinguish self-administration behavior in the absence of cocaine and paired cues, they exhibited perseverative responding when cocaine-paired cues were present. This enhanced cue reactivity was selective for cocaine and was not seen during extinction of sucrose self-administration. We conclude that low levels of D2 autoreceptors enhance the salience of cocaine-paired cues and can contribute to the vulnerability for cocaine use and relapse.

Demonstrated brain insulin resistance in Alzheimer's disease patients is associated with IGF-1 resistance, IRS-1 dysregulation, and cognitive decline.

While a potential causal factor in Alzheimer's disease (AD), brain insulin resistance has not been demonstrated directly in that disorder. We provide such a demonstration here by showing that the hippocampal formation (HF) and, to a lesser degree, the cerebellar cortex in AD cases without diabetes exhibit markedly reduced responses to insulin signaling in the IR→IRS-1→PI3K signaling pathway with greatly reduced responses to IGF-1 in the IGF-1R→IRS-2→PI3K signaling pathway. Reduced insulin responses were maximal at the level of IRS-1 and were consistently associated with basal elevations in IRS-1 phosphorylated at serine 616 (IRS-1 pS6¹6) and IRS-1 pS6³6/6³9. In the HF, these candidate biomarkers of brain insulin resistance increased commonly and progressively from normal cases to mild cognitively impaired cases to AD cases regardless of diabetes or APOE ε4 status. Levels of IRS-1 pS6¹6 and IRS-1 pS6³6/6³9 and their activated kinases correlated positively with those of oligomeric Aß plaques and were negatively associated with episodic and working memory, even after adjusting for Aß plaques, neurofibrillary tangles, and APOE ε4. Brain insulin resistance thus appears to be an early and common feature of AD, a phenomenon accompanied by IGF-1 resistance and closely associated with IRS-1 dysfunction potentially triggered by Aß oligomers and yet promoting cognitive decline independent of classic AD pathology.