Effect of surgeon-specific feedback on surgical outcomes: a systematic review of the literature.

BACKGROUND: Surgeon-specific outcome reporting provides an opportunity for quality assurance and improved surgical results. It is becoming increasingly prevalent and remains contentious amongst surgeons. The purpose of this systematic review was to evaluate the extent to which published literature supports the concept that feedback of surgeon-level outcomes reduces morbidity and/or mortality. No systematic reviews have previously been completed on this subject. METHODS: Medline and Embase were systematically searched for studies published prior to the 1st of January 2022. Feedback was defined as a summary of clinical performance over a specified period of time provided in written, electronic or verbal format. Studies were required to provide surgeon-specific feedback to multiple individual consultant surgeons with the primary purpose being to determine if feedback improved outcomes. Primary outcome(s) needed to relate to surgical outcomes as opposed to process measures only. All surgical specialties and procedures were eligible for inclusion. RESULTS: Seventeen studies were included in the review, traversing a wide range of specialties and procedures. Sixteen were non-randominsed and one randomized. Fifteen were before and after studies. The balance of the non-randomized studies support the concept that provision of surgeon-specific feedback can improve surgical outcomes, while the single randomized study suggests feedback may not be effective. CONCLUSIONS: This systematic review supports the use of surgeon-level feedback to improve outcomes. The strength of this finding is limited by reliance on before and after studies, further randomized studies on this subject would be insightful.

Immediate effect of caffeine on sympathetic nerve activity: why coffee is safe? A single-centre crossover study.

PURPOSES: Habitual coffee drinking is ubiquitous and generally considered to be safe despite its transient hypertensive effect. Our purpose was to determine the role of the sympathetic nervous system in the hypertensive response. METHODS: In a single-centre crossover study, medical caregivers were studied after consumption of standard coffee (espresso), water and decaffeinated coffee (decaff) given in random order at least 1 month apart. Plasma caffeine levels, mean arterial pressure, heart rate, total peripheral resistance and muscle sympathetic activity were recorded. Baroreflex activity was assessed using burst incidence and RR interval changes to spontaneous blood pressure fluctuations. RESULTS: A total of 16 subjects (mean [± standard error] age 34.4 ± 2 years; 44% female) were recruited to the study. Three agents were studied in ten subjects, and two agents were studied in six subjects. Over a 120-min period following the consumption of standard coffee, mean (± SE) plasma caffeine levels increased from 2.4 ± 0.8 to 21.0 ± 4 µmol/L and arterial pressure increased to 103 ± 1 mmHg compared to water (101 ± 1 mmHg; p = 0.066) and decaff (100 ± 1 mmHg; p = 0.016). Peripheral resistance in the same period following coffee increased to 120 ± 4% of the baseline level compared to water (107 ± 4; p = 0.01) and decaff (109 ± 4; p = 0.02). Heart rate was lower after both coffee and decaff consumption: 62 ± 1 bpm compared to water (64 bpm; p = 0.01 and p = 0.02, respectively). Cardio-vagal baroreflex activity remained stable after coffee, but sympathetic activity decreased, with burst frequency of 96 ± 3% versus water (106 ± 3%; p = 0.04) and decaff (112 ± 3%; p = 0.001) despite a fall in baroreflex activity from - 2.2 ± 0.1 to - 1.8 ± 0.1 bursts/100 beats/mmHg, compared to water (p = 0.009) and decaff (p = 0.004). CONCLUSION: The hypertensive response to coffee is secondary to peripheral vasoconstriction but this is not mediated by increased sympathetic nerve activity. These results may explain why habitual coffee drinking is safe.

Incorporating faecal haemoglobin measurement using the faecal immunochemical test (FIT) in the referral, triage and prioritisation pathway for patients with colorectal symptoms.

Incorporating faecal haemoglobin (FHb) measurement using the faecal immunochemical test (FIT) in the investigation pathway for patients with colorectal symptoms may improve access to colonoscopy for those at greatest risk of significant disease. AIM: To derive a colorectal symptom pathway incorporating standard clinical and FIT data to guide referral, triage, and prioritisation of cases in New Zealand. METHOD: Diagnostic accuracy of FIT to rule out colorectal cancer (CRC) was determined by meta-analysis. Thereafter, the risk of CRC after FIT was estimated for common clinical presentations by Bayesian methodology, using a specifically collated retrospective cohort of symptomatic cases. A symptom/FIT pathway was developed iteratively following multi-disciplinary engagement. RESULTS: Eighteen studies were included in meta-analysis. The sensitivity and specificity for CRC were 89.0% (95%CI 87.0-90.9%) and 80.1% (95%CI 77.7-82.4%) respectively, at a FHb threshold of >10mcg haemoglobin per gram stool, and 95.7% (95%CI 93.2-97.7%) and 60.5% (95%CI 53.8-67.0%) respectively, at the limit of detection. The final pathway was 97% sensitive for CRC, compared with 90% for the current direct access criteria, and requires 47% fewer colonoscopies. Estimated prevalence of CRC among those declined investigation was 0.23%. CONCLUSION: Incorporating FIT in the new patient symptomatic pathway as presented appears feasible, safe, and allows for resources to be targeted to those at greatest risk of disease. Further work is needed to ensure equity for Maori if this pathway were introduced nationally.

Augmentation of Natriuretic Peptide Bioactivity via Combined Inhibition of Neprilysin and Phosphodiesterase-9 in Heart Failure.

BACKGROUND: The natriuretic peptides (NPs) are potent natriuretic/diuretic and vasodilatory factors, and augmentation of their levels or signaling via inhibition of the enzymes neprilysin (NEP) and phosphodiesterase 9 (PDE9), respectively, has beneficial actions in heart failure (HF). OBJECTIVES: The authors investigated dual enhancement of NP bioactivity by combining PDE9 inhibition and NEP inhibition in HF using an ovine model. METHODS: Eight sheep with pacing-induced HF received on 4 separate days intravenous PDE9 inhibition (PF-04749982), NEP inhibition (SCH-32615), PDE9 inhibition + NEP inhibition (PI+NI), and vehicle control treatment. RESULTS: Compared with the control treatment, NEP inhibition significantly increased plasma NP concentrations with a corresponding rise in second messenger cyclic guanosine monophosphate (cGMP), whereas PDE9 inhibition increased circulating cGMP with a negligible effect on NP levels. Combined PI+NI elevated plasma NPs to an extent comparable to that seen with NEP inhibition alone but further increased cGMP, resulting in a rise in the cGMP-to-NP ratio. All active treatments reduced mean arterial pressure, left atrial pressure, pulmonary arterial pressure, and peripheral resistance, with combined PI+NI further reducing mean arterial pressure and left atrial pressure relative to either inhibitor separately. Active treatments increased urine volume and sodium, potassium and creatinine excretion, and creatinine clearance, in association with rises in urine cGMP levels. PI+NI induced a significantly greater natriuresis and increase in urinary cGMP relative to either inhibitor singly. CONCLUSIONS: The present study demonstrates for the first time that combined PI+NI has additional beneficial hemodynamic and renal effects when compared with either PDE9 inhibition or NEP inhibition alone. The superior efficacy of this 2-pronged augmentation of NP bioactivity supports PI+NI as a potential therapeutic strategy for HF.

The lifetime revision risk of unicompartmental knee arthroplasty.

AIMS: Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty (TKA), particularly for younger patients. The outcome of knee arthroplasty is typically defined as implant survival or revision incidence after a defined number of years. This can be difficult for patients to conceptualize. We aimed to calculate the 'lifetime risk' of revision for UKA as a more meaningful estimate of risk projection over a patient's remaining lifetime, and to compare this to TKA. METHODS: Incidence of revision and mortality for all primary UKAs performed from 1999 to 2019 (n = 13,481) was obtained from the New Zealand Joint Registry (NZJR). Lifetime risk of revision was calculated for patients and stratified by age, sex, and American Society of Anesthesiologists (ASA) grade. RESULTS: The lifetime risk of revision was highest in the youngest age group (46 to 50 years; 40.4%) and decreased sequentially to the oldest (86 to 90 years; 3.7%). Across all age groups, lifetime risk of revision was higher for females (ranging from 4.3% to 43.4% vs males 2.9% to 37.4%) and patients with a higher ASA grade (ASA 3 to 4, ranging from 8.8% to 41.2% vs ASA 1 1.8% to 29.8%). The lifetime risk of revision for UKA was double that of TKA across all age groups (ranging from 3.7% to 40.4% for UKA, and 1.6% to 22.4% for TKA). The higher risk of revision in younger patients was associated with aseptic loosening in both sexes and pain in females. Periprosthetic joint infection (PJI) accounted for 4% of all UKA revisions, in contrast with 27% for TKA; the risk of PJI was higher for males than females for both procedures. CONCLUSION: Lifetime risk of revision may be a more meaningful measure of arthroplasty outcomes than implant survival at defined time periods. This study highlights the higher lifetime risk of UKA revision for younger patients, females, and those with a higher ASA grade, which can aid with patient counselling prior to UKA. Cite this article: Bone Joint J 2022;104-B(6):672-679.

Sleep syncope: a prospective cohort study.

PURPOSE: Sleep syncope is defined as a form of vasovagal syncope which interrupts sleep. Long term follow-up has not been reported. METHODS: Between 1999 and 2013 we diagnosed vasovagal syncope in 1105 patients of whom 69 also had sleep syncope. We compared these 69 patients in the sleep syncope group to 118 patients with classical vasovagal syncope consecutively investigated between 1999 and 2003. We compared baseline demography, syncope history, tilt test results and follow-up findings. RESULTS: At baseline, age and gender distribution (mean ± standard deviation) of the classical VVS and sleep synocope groups were similar: 46 ± 21 vs. 47 ± 15 years (p = 0.53), and 55% versus 66% female (p = 0.28), respectively. Abdominal discomfort and vagotonia were more frequent in sleep syncope patients: 80% versus 8% and 33% versus 2% (p < 0.001). Childhood syncope and blood-needle phobia were also more frequent in sleep syncope patients: 58% versus 15% and 69% versus 19% (p < 0.001). Positive tilt test results were similar for the two groups (93% [classical VVS] vs. 91%; p = 0.56). Blood pressure, heart rate and stroke volume changed in a similar manner from baseline to syncope (p = 0.32, 0.34 and 0.18, respectively). Mean duration of follow-up for the classical VVS and sleep syncope groups, as recorded in the electronic records, were 17 (3-21) and 15 (7-27) years, respectively. Rates of mortality and of permanent pacemaker insertion were similar in the two groups: 16.2% (classical VVS) versus 7.6% (p = 0.09) and 3% (classical VVS) versus 3% (p = 0.9). Incidence of sleep episodes decreased from 1.9 ± 3 to 0.1 ± 0.3 episodes per year (p < 0.001). CONCLUSION: Sleep syncope is a subtype of vasovagal syncope with characteristic symptoms. Despite the severity of the sleep episodes, the prognosis is very good. Very few patients require permanent pacing, and nearly all respond to education and reassurance.

Surgical Helmet Systems Are Associated With a Lower Rate of Prosthetic Joint Infection After Total Knee Arthroplasty: Combined Results From the New Zealand Joint Registry and Surgical Site Infection Improvement Programme.

BACKGROUND: This study aimed to identify the risk factors, in particular the use of surgical helmet systems (SHSs), for prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Data recorded by the New Zealand Surgical Site Infection Improvement Programme (SSIIP) and the New Zealand Joint Registry (NZJR) were combined and analyzed. METHODS: Primary TKA procedures performed between July 2013 and June 2018 that were recorded by both the SSIIP and NZJR were analyzed. Two primary outcomes were measured: (1) PJI within 90 days as recorded by the SSIIP and (2) revision TKA for deep infection within 6 months as recorded by the NZJR. Univariate and multivariate analyses were performed to identify risk factors for both outcomes with results considered significant at P < .05. RESULTS: A total of 19,322 primary TKAs were recorded by both databases in which 97 patients had a PJI within 90 days as recorded by the SSIIP (0.50%), and 90 patients had a revision TKA for deep infection within 6 months (0.47%) as recorded by the NZJR. An SHS was associated with a lower rate of PJI (adjusted odds ratio [OR] = 0.50, P = .008) and revision for deep infection (adjusted OR = 0.55, P = .022) than conventional gowning. Male sex (adjusted OR = 2.6, P < .001) and an American Society of Anesthesiologists score >2 were patient risk factors for infection (OR = 2.63, P < .001 for PJI and OR = 1.75, P = .017 for revision for deep infection). CONCLUSION: Using contemporary data from the SSIIP and NZJR, the use of the SHS was associated with a lower rate of PJI after primary TKA than conventional surgical gowning. Male sex and a higher American Society of Anesthesiologists score continue to be risk factors for infection.

Plasma Clearance of B-Type Natriuretic Peptide (BNP) before and after Bariatric Surgery for Morbid Obesity.

BACKGROUND: Obese patients have lower plasma concentrations of the cardiac natriuretic peptides (NPs) than their age- and sex-matched counterparts. This may reflect lower production and/or increased peptide clearance. It is unclear whether NP bioactivity is affected by obesity. METHODS: We studied the effects of obesity on B-type natriuretic peptide (BNP) clearance and bioactivity by comparing results from standardized intravenous infusions of BNP administered 2 weeks before and 6 months after bariatric surgery in 12 consecutive patients with morbid obesity (body mass index, BMI > 35 kg/m2). Anthropometric, clinical, neurohormonal, renal, and echocardiographic variables were obtained pre- and postsurgery. Pre- vs postsurgery calculated intrainfusion peptide clearances were compared. RESULTS: BMI (44.3 ± 5.0 vs 33.9 ± 5.2 kg/m2, P < 0.001) and waist circumference (130.3 ± 11.9 vs 107.5 ± 14.7 cm, P < 0.001) decreased substantially after bariatric surgery. Calculated plasma clearance of BNP was reduced (approximately 30%) after surgery. Though not controlled for, sodium intake was presumably lower after bariatric surgery. Despite this, preinfusion endogenous plasma NP concentrations did not significantly differ between pre- and postsurgery studies. The ratio of plasma N-terminal (NT)-proBNP to 24 h urine sodium excretion was higher postsurgery (P = 0.046; with similar nonsignificant findings for BNP, atrial NP (ANP) and NT-proANP), indicating increased circulating NPs for a given sodium status. Mean plasma NP concentrations for given calculated end-systolic wall stress and cardiac filling pressures (as assessed by echocardiographic E/e') rose slightly, but not significantly postsurgery. Second messenger, hemodynamic, renal, and neurohormonal responses to BNP were not altered between studies. CONCLUSION: Obesity is associated with increased clearance, but preserved bioactivity, of BNP.

The lifetime risk of revision following total hip arthroplasty.

AIMS: Joint registries typically use revision of an implant as an endpoint and report survival rates after a defined number of years. However, reporting lifetime risk of revision may be more meaningful, especially in younger patients. We aimed to assess lifetime risk of revision for patients in defined age groups at the time of primary surgery. METHODS: The New Zealand Joint Registry (NZJR) was used to obtain rates and causes of revision for all primary total hip arthroplasties (THAs) performed between January 1999 and December 2016. The NZJR is linked to the New Zealand Registry of Births, Deaths and Marriages to obtain complete and accurate data. Patients were stratified by age at primary surgery, and lifetime risk of revision calculated according to age, sex, and American Society of Anesthesiologists (ASA) classification. The most common causes for revision were also analyzed for each age group. RESULTS: The overall, ten-year implant survival rate was 93.6% (95% confidence interval (CI) 93.4% to 93.8%). It was lowest in the youngest age group (46 to 50 years), rising sequentially with increasing age to 97.5% in the oldest group (90 to 95 years). Lifetime risk of revision surgery was 27.6% (95% CI 27.3% to 27.8%) in those aged 46 to 50 years, decreasing with age to 1.1% (95% CI 0.0% to 5.8%) in those aged 90 to 95 years at the time of primary surgery. Higher ASA grades were associated with an increased lifetime risk of revision across all ages. The commonest causes for revision THA were aseptic loosening, infection, periprosthetic fracture, and dislocation. CONCLUSION: When counselling patients preoperatively, the lifetime risk of revision may be a more meaningful and useful measure of longer-term outcome than implant survival at defined time periods. This study highlights the considerably increased likelihood of subsequent revision surgery in younger age groups. Cite this article: Bone Joint J 2021;103-B(3):479-485.

Completeness and capture rate of publicly funded arthroplasty procedures in the New Zealand Joint Registry.

BACKGROUND: Registry-based studies have become more common due to the availability of a large study cohort. However, the validity of findings is dependent on the completeness of the registry. This study aimed to validate the capture rate of the New Zealand Joint Registry (NZJR) by matching procedures that have been recorded separately via clinical coding by the New Zealand Government's National Surgical Site Infection Improvement Programme (SSIIP). METHODS: The National Health Index, a unique identification code for all patients, was combined with the arthroplasty procedure performed (primary total knee arthroplasty (TKA), primary total hip arthroplasty (THA), revision TKA or revision THA) and operation side. Publicly funded procedures recorded in the NZJR were matched with procedures recorded by the SSIIP on a record-by-record basis. This identified the total number of arthroplasty procedures performed in New Zealand, which was used as the denominator value to calculate the procedure capture rate of the NZJR. RESULTS: Between 2013 and 2018, 24 556 primary TKA, 28 970 primary THA, 2107 revision TKA and 4263 revision THA procedures were recorded by both datasets. The NZJR recorded 95.5% of primary TKA procedures, 96.3% of primary THA procedures, 97.1% of revision TKA procedures and 95.2% of revision THA procedures. CONCLUSION: The NZJR recorded >95% of publicly funded arthroplasty procedures. In contrast, there were inaccuracies in clinical coding by hospitals, particularly with revision procedures, demonstrating the benefits of an arthroplasty registry. However, data recorded by an infection surveillance programme may supplement arthroplasty registry data to strengthen the quality of research.

Outcomes of Computer-Assisted Surgery Compared with Conventional Instrumentation in 19,221 Total Knee Arthroplasties: Results After a Mean of 4.5 Years of Follow-Up.

BACKGROUND: Studies have shown improved alignment in association with the use of computer-assisted surgery (CAS) as compared with conventional instrumentation during total knee arthroplasty (TKA) but have failed to show a consistent clinical benefit. The aim of the present study was to compare the revision rates and functional outcomes following TKA performed with either CAS or conventional instrumentation. Recognizing that selection bias may arise from the preferential use of CAS in difficult or complex cases, the implant survival data and postoperative functional scores were analyzed with reference to whether the surgeon routinely performed TKA with use of CAS or conventional instrumentation. METHODS: Revision rates and functional data in terms of the Oxford Knee Score (OKS) at 6 months, 5 years, and 10 years were obtained from the New Zealand Joint Registry (NZJR) for 19,221 TKAs performed from 2006 to 2018.These data were analyzed by comparing 2 cohorts of patients: those managed by high-volume surgeons who routinely used CAS ("routine CAS" surgeons) and those managed by high-volume surgeons who routinely used conventional instrumentation ("routine conventional" surgeons). The mean duration of follow-up was 4.5 years (range, 0 to 12 years). RESULTS: The revision rate per 100 component-years was 0.437 for the "routine CAS" surgeons, compared with 0.440 for the "routine conventional" surgeons (p = 0.724). For patients <65 years of age, the revision rate per 100 component-years was equivalent for the "routine CAS" and "routine conventional" surgeons (0.585 compared with 0.508; p = 0.524). The OKS scores were similar at 6 months (38.88 compared with 38.52; p = 0.172), 5 years (42.26 compared with 41.77; p = 0.206), and 10 years (41.59 compared with 41.74; p = 0.893) when comparing the 2 cohorts. Surgeons who had performed >50 TKAs with use of CAS took 10 minutes longer on average than those who used conventional instrumentation (92 compared with 82 minutes; p = 0.012). CONCLUSIONS: The present study demonstrated no difference in survivorship or functional outcome scores to support using CAS for TKA. Experienced surgeons using CAS had longer operative durations than comparable surgeons using conventional instrumentation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Despite Improved Survivorship of Uncemented Fixation in Total Knee Arthroplasty for Osteoarthritis, Cemented Fixation Remains the Gold Standard: An Analysis of a National Joint Registry.

BACKGROUND: Total knee arthroplasty (TKA) numbers are increasing worldwide. While cement fixation for both femoral and tibial components is commonly used, alternatives include hybrid and uncemented TKAs. This study aimed to evaluate survivorship, revision rates, and patient-reported outcomes for cemented, hybrid, and uncemented TKAs using New Zealand Joint Registry (NZJR) data. METHODS: NZJR data relating to all TKAs performed during the 19 years up to the end of December 2017 were analyzed. Outcomes were assessed using prosthesis survivorship data (including reasons for revision) and Oxford scores at 6 months, 5 years, and 10 years postoperatively. RESULTS: A total 96,519 primary TKAs were performed during the period examined. Most (91.5%) were fully cemented with 4.8% hybrid and 3.7% uncemented. Mean Oxford scores at 6 months were highest in cemented and lowest in uncemented TKAs (P < .001). However, this was not clinically significant. There was no difference at 5 or 10 years. Ten-year survival rates were 97%, 94.5%, and 95.8% for cemented, uncemented, and hybrid TKAs, respectively. Revision rates were 0.47, 0.74, and 0.52 per 100 component years for cemented, uncemented, and hybrid prostheses, respectively. The revision rate for uncemented prostheses compared with cemented was higher (P < .001). When stratified by age group, there were differences in survival rates between cemented and uncemented groups (P = .001) and hybrid and uncemented groups (P = .038) in patients aged <55 years; between cemented and uncemented groups in those aged 55-64 years (P = .031); and between cemented and hybrid groups in those aged >75 years (P = .004). CONCLUSION: Uncemented TKAs had similar patient-reported outcomes but higher revision rates and worse survivorship compared with hybrid or fully cemented TKAs.

Usually, Selectively, or Rarely Resurfacing the Patella During Primary Total Knee Arthroplasty: Determining the Best Strategy.

BACKGROUND: Surgeons may "usually" resurface the patella during total knee arthroplasty (TKA), "rarely" resurface, or "selectively" resurface on the basis of certain criteria. It is unknown which of these 3 strategies yields superior outcomes. Utilizing New Zealand Joint Registry data, we investigated (1) what proportion of surgeons employs each of the 3 patellar resurfacing strategies, (2) which strategy is associated with the lowest overall revision rate, and (3) which strategy is associated with the highest 6-month and 5-year Oxford Knee Score (OKS). METHODS: Two hundred and three surgeons who performed a total of 57,766 primary TKAs from 1999 to 2015 were categorized into the 3 surgeon strategies on the basis of how often they resurfaced the patella during primary total knee arthroplasty; with "rarely" defined as <10% of the time, "selectively" as ≥10% to ≤90%, and "usually" as >90%. For each strategy, the cumulative incidence of all-cause revision was calculated and utilized to construct Kaplan-Meier survival curves. The mean 6-month and 5-year postoperative OKS for each group were utilized for comparison. RESULTS: Overall, 57% of surgeons selectively resurfaced, 37% rarely resurfaced, and 7% usually resurfaced. The usually resurfacing group was associated with the highest mean OKS at both 6 months (38.57; p < 0.001) and 5 years postoperatively (41.34; p = 0.029), followed by the selectively resurfacing group (6-month OKS, 37.79; 5-year OKS, 40.87) and the rarely resurfacing group (6-month OKS, 36.92; 5-year OKS, 40.02). Overall, there was no difference in the revision rate per 100 component years among the rarely (0.46), selectively (0.52), or usually (0.46) resurfacing groups (p = 0.587). Posterior-stabilized TKAs that were performed by surgeons who selectively resurfaced had a lower revision rate (0.54) than those by surgeons who usually resurfaced (0.64) or rarely resurfaced (0.74; p < 0.001). CONCLUSIONS: Usually resurfacing the patella was associated with improved patient-reported outcomes, but there was no difference in overall revision rates among the 3 strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Transient elastography to assess liver stiffness in patients with inflammatory bowel disease.

BACKGROUND: Liver injury during inflammatory bowel disease (IBD) is primarily diagnosed by liver biopsy, which has a small but serious risk of severe complications. The aim of this study was to assess liver stiffness, and subsequently the prevalence and associations of liver fibrosis in IBD patients with thiopurine therapy and other clinical factors, by using transient elastography (TE). METHODS: In this prospective, international two-center study, included IBD-patients underwent TE measurements. Laboratory results and medication reports, radiology results and historical liver biopsy results were extracted from the patient charts. RESULTS: Transient elastography results of 168 patients were presented. Moderate and severe fibrosis were detected in 4% (7/168) and 1% (1/168) of the cohort, respectively. Factors contributing to lower liver stiffness were female gender and (historical) exposure to azathioprine. Further, there was a statistical trend towards lower liver stiffness in patients using thiopurines overall (4.7 vs. 5.2kPa, p=0.07). Liver stiffness correlated positively with waist circumference, liver enzyme tests, hemoglobin and 6-methylmercaptopurine concentration and negatively with platelet count. CONCLUSION: Exposure to thiopurine therapy was not associated with higher liver stiffness, although no clinical difference in severity of fibrosis was detected. Further research should robustly determine the accuracy of TE as an evaluation of liver fibrosis in IBD patients.

Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures.

BACKGROUND: Complex proximal humeral fractures may require prosthetic replacement of the humeral head. Surgical options include reverse shoulder arthroplasty (RSA) and shoulder hemiarthroplasty; however, the optimal technique remains controversial. The goal of this study was to compare functional outcomes and revision rates of RSA with hemiarthroplasty in patients with acute proximal humeral fractures. MATERIALS AND METHODS: Between January 1, 1999, and December 31, 2014, there were 218 patients who underwent RSA and 427 who underwent hemiarthroplasty for acute proximal humeral fractures identified through New Zealand Joint Registry records. Study groups were compared with regard to baseline characteristics, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS], revision rate, mortality rate) at 6 months and 5 years after surgery. RESULTS: RSA patients were significantly older (mean age, 78.2 vs. 71.6 years; P < .001), with a higher proportion of female patients (90% vs. 77%; P < .001) than in the hemiarthroplasty group. No statistically significant difference existed in revision rate per 100 component-years (0.58 [RSA] vs. 1.16 [hemiarthroplasty]; P = .137) or 1-year mortality (3.8% vs. 3.4%; P = .805) between both groups. There was no significant difference in 6-month OSS (29.6 vs. 28.4; P = .305). The RSA group demonstrated a superior mean 5-year OSS (37.6 vs. 32.7; P = .078); however, the difference did not achieve statistical significance. CONCLUSIONS: Although our results suggest that RSA patients may experience superior 5-year functional scores, we have identified no significant difference in functional outcomes and revision rates between RSA and hemiarthroplasty in the treatment of acute proximal humeral fractures.

Introduction of the Pill Pruner to acute medical care: a simple medication guide to control polypharmacy.

AIM: To assess the effect of a simple medication guide (the Pill Pruner) on the number of regular medications taken by older patients following medical admission. METHODS: In July 2009, following introduction of the Pill Pruner, we audited 500 consecutive older patients, recording the number of regular medications being taken on admission and discharge. Safety data included 90-day mortality and readmission rates. Medication numbers were compared to a similar audit undertaken in September 2008 and to a repeat audit in December 2009. RESULTS: The mean number of medications on admission (± SD) was 6.3 ± 3 versus 6.5 ± 3 at discharge (P = 0.13). Number of discharge medications was decreased compared to September 2008 (7.7 ± 4; P = 0.001) but similar to that for the repeat audit. No change in mortality or readmission rate was seen. CONCLUSION: Use of the Pill Pruner reduced the number of regular medications prescribed to older patients without affecting safety.

Betaine and Trimethylamine-N-Oxide as Predictors of Cardiovascular Outcomes Show Different Patterns in Diabetes Mellitus: An Observational Study.

BACKGROUND: Betaine is a major osmolyte, also important in methyl group metabolism. Concentrations of betaine, its metabolite dimethylglycine and analog trimethylamine-N-oxide (TMAO) in blood are cardiovascular risk markers. Diabetes disturbs betaine: does diabetes alter associations between betaine-related measures and cardiovascular risk? METHODS: Plasma samples were collected from 475 subjects four months after discharge following an acute coronary admission. Death (n = 81), secondary acute MI (n = 87), admission for heart failure (n = 85), unstable angina (n = 72) and all cardiovascular events (n = 283) were recorded (median follow-up: 1804 days). RESULTS: High and low metabolite concentrations were defined as top or bottom quintile of the total cohort. In subjects with diabetes (n = 79), high plasma betaine was associated with increased frequencies of events; significantly for heart failure, hazard ratio 3.1 (1.2-8.2) and all cardiovascular events, HR 2.8 (1.4-5.5). In subjects without diabetes (n = 396), low plasma betaine was associated with events; significantly for secondary myocardial infarction, HR 2.1 (1.2-3.6), unstable angina, HR 2.3 (1.3-4.0), and all cardiovascular events, HR 1.4 (1.0-1.9). In diabetes, high TMAO was a marker of all outcomes, HR 2.7 (1.1-7.1) for death, 4.0 (1.6-9.8) for myocardial infarction, 4.6 (2.0-10.7) for heart failure, 9.1 (2.8-29.7) for unstable angina and 2.0 (1.1-3.6) for all cardiovascular events. In subjects without diabetes TMAO was only significant for death, HR 2.7 (1.6-4.8) and heart failure, HR 1.9 (1.1-3.4). Adding the estimated glomerular filtration rate to Cox regression models tended to increase the apparent risks associated with low betaine. CONCLUSIONS: Elevated plasma betaine concentration is a marker of cardiovascular risk in diabetes; conversely low plasma betaine concentrations indicate increased risk in the absence of diabetes. We speculate that the difference reflects control of osmolyte retention in tissues. Elevated plasma TMAO is a strong risk marker in diabetes.

Comparison of two plasma urate assays in patients receiving vitamin C supplementation.

The aim of this study was to compare plasma urate (PU) concentrations using two different assays in patients receiving vitamin C supplementation. PU was measured using two routinely available enzymatic uricase methods: (1) uric acid plus method (ascorbate oxidase assay), and (2) uric acid method (non-ascorbate oxidase assay). Twenty patients receiving allopurinol were randomised to an increase in allopurinol dose or commence vitamin C 500  mg/d on a 1:1 ratio. Twenty patients not receiving allopurinol were randomised to start allopurinol or vitamin C 500  mg/d on a 1:1 ratio. Trough fasting samples for plasma ascorbate and urate were measured weekly until week 8. There was no significant difference in the mean PU measured by the two assays. In patients not receiving supplemental vitamin C the mean PU concentrations were identical for both assays. For patients receiving supplemental vitamin C the mean PU concentrations for the ascorbate oxidase assay was 0.525  mmol/L (SE 0.034) and for the non-ascorbate oxidase assay 0.510  mmol/L (SE 0.033), p = 0.079.There is a small non-significant difference in measured PU in patients receiving supplemental vitamin C between the two assays. The assay which does not include ascorbate oxidase results in consistently lower PU concentrations compared to the assay which includes ascorbate oxidase.

Does speed matter? Revision rates and functional outcomes in TKA in relation to duration of surgery.

Longer operative times may be required in complex total knee arthroplasty (TKA), however little is known about outcomes in procedures performed rapidly. We analysed 58,009 primary TKAs from the New Zealand National Joint Registry. The mean surgical duration was 89 minutes, and 50% of procedures lasted between 60 and 89 minutes. There was no difference in adjusted revision rates for groups lasting between 40 and 120 minutes, however procedures lasting >120 minutes had significantly higher revision rates. There was a higher revision rate in TKAs lasting <40 minutes (0.71 vs 0.48 revisions per 100 component years) but this was not statistically significant (P = 0.1). For primary TKAs lasting less than 120 minutes, further shortening operative time did not improve outcome, and very rapid procedures (<40 minutes) may lead to an increased risk of revision.

Effect of glenoid cementation on total shoulder arthroplasty for degenerative arthritis of the shoulder: a review of the New Zealand National Joint Registry.

BACKGROUND: Despite the lack of literature showing improved results compared with cemented designs, uncemented glenoid components are still commonly used in total shoulder arthroplasty (TSA). Most studies comparing cemented with uncemented glenoids involve small numbers or include patients with inflammatory arthritis. METHODS: New Zealand National Joint Registry data was used to compare the outcomes of uncemented and cemented glenoids in TSA performed for degenerative arthritis. Measured variables were the revision rate and the Oxford Shoulder Score (OSS). RESULTS: Data were retrieved on 1596 patients, with a mean follow-up 3.5 years (range 2-10.7 years), 1065 of whom had a cemented glenoid. There were no significant differences in any preoperative factors between the 2 groups. The revision rate for uncemented glenoids was 4.4 times higher than for cemented glenoids (1.92 vs. 0.44 revisions per 100 component-years, P < .001). Age <55 years was an independent risk factor for revision (P < .001). The most common reason for revision was rotator cuff wear (35.5%) in the uncemented glenoids and loosening (36.3%) in the cemented glenoids. The difference in the mean OSS between the 2 groups was less than 1 point at 6 months (P = .109) and at 5 years (P = .377). CONCLUSION: Uncemented glenoids had a markedly higher revision rate. Patients aged <55 years have the highest revision rate regardless of glenoid fixation method. The higher revision rate in the uncemented glenoid group persisted when the effect of young age was corrected for. There was no clinically or statistically significant difference in the OSS results for clinical outcome between the two groups. LEVEL OF EVIDENCE: Level III, retrospective cohort, treatment study.