Expedited surgery does not increase transfusion rates for patients with geriatric hip fracture taking factor Xa inhibitors.

Objectives: Geriatric patients who sustain hip fractures and are taking factor Xa inhibitors (Xa-I) experience surgical delay. Our institution developed a pharmacokinetic protocol to formally guide and expedite surgical timing for these patients. The protocol is based on the patient's renal function and timing of last Xa-I dose. For patients with impaired renal function, longer wait times are recommended. The purpose of this study was to determine the effects of this protocol for patients with geriatric hip fracture taking Xa-I. Design: Retrospective cohort study. Setting: Level 1 trauma center. Patients/Participants: A total of 164 patients aged 65 and older who were taking Xa-I before admission and underwent hip fracture surgery; 68 patients in the Standard group (2014-2018) and 96 patients in the Expedited group (2020-2022, after protocol implementation). Intervention: Hip fracture surgery. Main Outcome Measurements: Time to surgery (TTS), transfusion rate, blood loss, 90-day complication rates. Results: The median TTS was significantly shorter in the Expedited group (28.6 hours, interquartile range 21.3 hours) than in the Standard group (44.8 hours, interquartile range 21.1 hours) (P < .001). There were no differences in overall transfusion rates. Multivariable regression analysis demonstrated that time to surgery was not predictive of transfusion rate in all patients (OR 1.00, 95% CI 0.99-1.02, P = .652). There were no differences in blood loss or rates of 90-day complications. Conclusion: Geriatric patients with hip fractures and taking factor Xa inhibitors may warrant earlier surgery without an increased risk of transfusion or bleeding. Level of Evidence: Therapeutic Level III.

Thermal Degradation Characteristics of Styrene-Butadiene-Styrene Copolymer Asphalt Binder Filled with an Inorganic Flame-Retarding Agent.

Asphalt binder is a complex mixture of dark brown polymers composed of hydrocarbons with generally poor fire resistance. To improve its flame retardancy when used in tunnel asphalt pavements, a new inorganic flame-retardant filler (FR) containing magnesium hydroxide, aluminum hydroxide, inorganic phosphate, and melamine salt was explored. Thereafter, limiting oxygen index (LOI) and smoke suppression tests for the flame-retarded asphalt binder (FRA) mastics mixed with FR and styrene-butadiene-styrene (SBS) copolymer asphalt binder were conducted. Thermogravimetric (TG) and differential scanning calorimetry (DSC) curves for the FRA were correspondingly generated. Based on the TG data, the reaction function g(α), apparent activation energy Ea, and pre-exponential factor A were quantitatively evaluated using kinetic analysis. In addition, a Fourier transform infrared spectrometry (FTIR) test was utilized to assess the effects of the presence of FR on the chemical composition of the asphalt binder. Dynamic shear rheometer (DSR) tests were also performed to evaluate the rheological behavior of FRA. Results show that the presence of the FR significantly reduced the LOI and improved the smoke suppression during combustion of the asphalt binder mastics. The presence of FR was found to increase the Ea and the complexity of the combustion reaction, thereby improving the flame retardancy of the asphalt binder. FTIR analysis indicated that the presence of FR did not induce any strong chemical reactions to significantly impact or alter the functional groups of the asphalt binder. Furthermore, it was also observed that the rutting parameter and critical failure temperature of FRA increased with the addition of FR due to the stiffening effect of the solid FR particles.

COVID-19 Shelter-In-Place Orders Associated With Delayed Presentation and Deep Venous Thrombosis in Geriatric Hip Fractures.

Geriatric hip fractures benefit from timely surgery. At the onset of the corona-virus disease 2019 (COVID-19) pandemic, shelter-in-place (SIP) orders were mandated in high-risk cities. The authors hypothesized that geriatric patients with hip fractures were more likely to present to the hospital greater than 24 hours after injury during SIP orders. They retrospectively reviewed patients 65 years or older who presented with hip fractures between March 20, 2020, and May 24, 2020 (SIP group), and between March 20, 2019, and May 24, 2019 (historical group). Primary outcomes were incidence of presentation greater than 24 hours after injury and mean number of days between injury and presentation. Secondary outcomes were incidence of preoperative deep venous thrombosis (DVT) and 30- and 90-day mortality rates. Thirty-three patients comprised the SIP group, and 50 patients comprised the historical group. There were no significant differences in their demographics or medical comorbidities. The SIP group was more likely to present greater than 24 hours after injury (P=.05) and presented a greater number of days after injury (P=.02). There was a significant difference in the incidence of preoperative DVT (P=.03). There were no significant differences in 30- and 90-day mortality rates. Geriatric patients who sustained hip fractures during SIP restrictions for COVID-19 were more likely to present greater than 24 hours after injury, have a greater number of days between injury and presentation, and be diagnosed with a preoperative DVT. [Orthopedics. 2021;44(4):223-228.].

Sports Participation Is an Appropriate Expectation for Recreational Athletes Undergoing Shoulder Arthroplasty.

BACKGROUND: Several studies have investigated sports participation in patients who undergo total shoulder arthroplasty (TSA). However, there are limited data in the setting of hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA), particularly regarding the frequency of participation in common sports. HYPOTHESIS: The majority of patients who undergo TSA or HA will be able to maintain active lifestyles with high levels of sports participation after their procedure, while patients who undergo rTSA will have lower levels of sports participation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We identified patients who underwent TSA, rTSA, stemmed HA, or humeral head resurfacing (the latter 2 were defined collectively as the HA group) by surgeons within our department since January 2004. We excluded patients who (1) underwent revision arthroplasty, (2) had a history of chronic pain syndrome, (3) experienced septic arthritis of the involved shoulder, and/or (4) were deceased at the time of follow-up. The minimum follow-up from the time of surgery was 2 years. Qualified patients were sent a questionnaire that asked about sports participation and the frequency of participation at the time of follow-up. Frequency was rated as 0, 1 to 3, or 4 to 7 times a week. Sports were defined as lower extremity sport, volleyball, tennis, skiing, bowling, swimming, weight lifting, golf, and other sport. RESULTS: Overall, 95% of the TSA group, 40% of the rTSA group, and 76% of the HA group who had participated in at least 1 sport before surgery indicated that they were doing so at the time of follow-up. Among active patients in the TSA and HA groups, the most common sports at the time of follow-up were weight lifting (52%), swimming (36%), and golf (25%). For the 2 active patients in the rTSA group, 1 participated in swimming and hunting and fishing, while the other participated in weight lifting. For the active patients in the TSA and HA groups who were participating in at least 1 of the 3 most common sports, most patients indicated that they were doing so 1 to 3 times a week at the time of completing the questionnaire. CONCLUSION: Patients undergoing shoulder arthroplasty can maintain an active lifestyle with moderate to high frequencies of participation after surgery, particularly regarding weight lifting, swimming, and golf.

Feasibility and safety comparison of laparoscopy-assisted versus open gastrectomy for advanced gastric carcinoma with D2 lymphadenectomy.

OBJECTIVE: Laparoscopy-assisted gastrectomy for advanced gastric cancer still remains controversial. The aim of this study is to compare oncologic feasibility and technical safety of laparoscopic versus open gastrectomy for advanced gastric cancer with D2 lymphadenectomy by comparing patients' short-term postoperative outcomes. METHODS: One hundred and one patients with laparoscopy-assisted gastrectomy and 101 patients with open gastrectomy were one-to-one matched and then compared in terms of operative outcomes and hospital courses. RESULTS: The laparoscopic group showed significantly longer operating time (297.4 vs. 198.1 min, P < 0.001), earlier first flatus time (2.8 vs. 3.6 days, P < 0.001), earlier diet start time (3.8 vs. 4.6 days, P < 0.001), shorter hospital stay (10.5 vs. 11.9 days, P < 0.001) and less morbidity (21.8 vs. 37.6%, P = 0.019). However, retrieval lymph nodes, intraoperative blood loss, transfused patients, postoperative fever and mortality were similar in the two groups. As for complications, incision infection (1.0 vs. 8.9%, P = 0.021) was significantly more common in the open group than in the laparoscopic group. In the subgroup comparisons of outcomes of laparoscopy-assisted gastrectomy, the tumor, node, metastasis III group showed significantly increased retrieval lymph nodes (37.2 vs. 31.0, P < 0.001), increased intraoperative blood loss (147.2 vs. 120.5 ml, P = 0.010), increased length of hospital stay (11.1 vs. 9.9 days, P < 0.001) and increased morbidity (32.6 vs. 13.8%, P = 0.024) when compared with the tumor, node, metastasis II group. CONCLUSIONS: Laparoscopy-assisted gastrectomy is feasible and safe for the treatment of advanced gastric cancer with D2 lymphadenectomy compared with open gastrectomy. Higher-level tumor stage (tumor, node, metastasis III) may increase the operative risk and should be performed with caution by surgeons with considerable experience of laparoscopic gastrectomy.

Improving the systemic drug delivery efficacy of nanoparticles using a transferrin variant for targeting.

Targeted therapy for the treatment of cancers using nanoparticles (NPs) decorated with transferrin (Tf) has been relatively successful, as several such nanocarriers are currently undergoing clinical trials. However, since native Tf has a low probability of delivering its payload due to its short residence time in the cell, or low cellular association, there is room to significantly improve the potency of current systems. We pioneered the redesign of this targeting ligand by altering the ligand-metal interaction, as suggested by our mathematical model, and here we present the first study to investigate the enhanced therapeutic efficacy of NPs conjugated to our engineered oxalate Tf. Our mathematical model was first used to predict that NPs conjugated to oxalate Tf will exhibit a higher degree of cellular association compared to native Tf-conjugated NPs. Our in vitro trafficking experiments validated the model prediction, and subsequent in vitro and in vivo efficacy studies demonstrated that this increase in cellular association further translates into an enhanced ability to deliver chemotherapeutics. Our findings signify the importance of the cellular trafficking properties of targeting ligands, as they may significantly influence therapeutic potency when such ligands are conjugated to NPs. Given the early success of a number of native Tf-conjugated NPs in clinical trials, there is potential for using Tf-variant based therapeutics in systemic drug delivery applications for cancer treatment.

Mathematical modeling of vesicle drug delivery systems 2: targeted vesicle interactions with cells, tumors, and the body.

Vesicles have been studied for several years in their ability to deliver drugs. Mathematical models have much potential in reducing time and resources required to engineer optimal vesicles, and this review article summarizes these models that aid in understanding the ability of targeted vesicles to bind and internalize into cancer cells, diffuse into tumors, and distribute in the body. With regard to binding and internalization, radiolabeling and surface plasmon resonance experiments can be performed to determine optimal vesicle size and the number and type of ligands conjugated. Binding and internalization properties are also inputs into a mathematical model of vesicle diffusion into tumor spheroids, which highlights the importance of the vesicle diffusion coefficient and the binding affinity of the targeting ligand. Biodistribution of vesicles in the body, along with their half-life, can be predicted with compartmental models for pharmacokinetics that include the effect of targeting ligands, and these predictions can be used in conjunction with in vivo models to aid in the design of drug carriers. Mathematical models can prove to be very useful in drug carrier design, and our hope is that this review will encourage more investigators to combine modeling with quantitative experimentation in the field of vesicle-based drug delivery.