Debridement, Antibiotics, and Implant Retention in Unicompartmental Knee Arthroplasty Infection.

BACKGROUND: This multicenter study sought to further investigate the method and outcome of debridement, antibiotics, and implant retention (DAIR) for the management of unicompartmental knee periprosthetic joint infection (PJI). METHODS: This retrospective study was performed on 52 patients who underwent DAIR for PJI of a unicompartmental knee arthroplasty (UKA) across 4 academic medical centers, all performed by fellowship-trained arthroplasty surgeons. Patient demographics, American Society of Anesthesiologists score, infecting organism, operative data, antibiotic data, and success in infection control at 1 year were collected. RESULTS: The average time from index surgery to diagnosis of PJI was 11.1 weeks (range, 1.4 to 48). There was no correlation between time of diagnosis and success at 1 year (R = 0.09, P = .46). There was an association between surgical synovectomy and the eradication of infection (R = 0.28, P = .04). Overall, there was an 80.8% (42 of 52) infection-controlled success rate at 1 year from the DAIR procedure. All DAIR failures went on to require another procedure, either 1-stage (2 of 10) or 2-stage (8 of 10) revision to total knee arthroplasty (TKA). Of the DAIR successes, 6 (14.3%) went on to require conversion to TKA for progression of arthritis within 5 years. CONCLUSIONS: This study demonstrates that DAIR is a safe and moderately effective procedure in the setting of acute PJI of UKA across institutions, with a success rate consistent with DAIR for TKA. The data suggest that a wide exposure and thorough synovectomy be incorporated during the DAIR UKA to improve the likelihood of successful eradication of PJI at the 1-year mark. LEVEL OF EVIDENCE: Level III.

The electrostatic landscape of MHC-peptide binding revealed using inception networks.

Predictive modeling of macromolecular recognition and protein-protein complementarity represents one of the cornerstones of biophysical sciences. However, such models are often hindered by the combinatorial complexity of interactions at the molecular interfaces. Exemplary of this problem is peptide presentation by the highly polymorphic major histocompatibility complex class I (MHC-I) molecule, a principal component of immune recognition. We developed human leukocyte antigen (HLA)-Inception, a deep biophysical convolutional neural network, which integrates molecular electrostatics to capture non-bonded interactions for predicting peptide binding motifs across 5,821 MHC-I alleles. These predictions of generated motifs correlate strongly with experimental peptide binding and presentation data. Beyond molecular interactions, the study demonstrates the application of predicted motifs in analyzing MHC-I allele associations with HIV disease progression and patient response to immune checkpoint inhibitors. A record of this paper's transparent peer review process is included in the supplemental information.

An immunogenetic basis for lung cancer risk.

Cancer risk is influenced by inherited mutations, DNA replication errors, and environmental factors. However, the influence of genetic variation in immunosurveillance on cancer risk is not well understood. Leveraging population-level data from the UK Biobank and FinnGen, we show that heterozygosity at the human leukocyte antigen (HLA)-II loci is associated with reduced lung cancer risk in smokers. Fine-mapping implicated amino acid heterozygosity in the HLA-II peptide binding groove in reduced lung cancer risk, and single-cell analyses showed that smoking drives enrichment of proinflammatory lung macrophages and HLA-II+ epithelial cells. In lung cancer, widespread loss of HLA-II heterozygosity (LOH) favored loss of alleles with larger neopeptide repertoires. Thus, our findings nominate genetic variation in immunosurveillance as a critical risk factor for lung cancer.

Outpatient Total Knee Arthroplasty From a Stand-Alone Surgery Center: Safe as the Hospital?

BACKGROUND: Literature suggests that outpatient arthroplasty may result in low rates of complications and readmissions. There is, however, a dearth of information on the relative safety of total knee arthroplasty (TKA) performed at stand-alone ambulatory surgery centers (ASCs) versus hospital outpatient (HOP) settings. We aimed to compare safety profiles and 90-day adverse events of these 2 cohorts. METHODS: Prospectively collected data were reviewed on all patients who underwent outpatient TKA from 2015 to 2022. The ASC and HOP groups were compared, and differences in demographics, complications, reoperations, revisions, readmissions, and emergency department (ED) visits within 90 days of surgery were analyzed. There were 4 surgeons who performed 4,307 TKAs during the study period, including 740 outpatient cases (ASC = 157; HOP = 583). The ASC patients were younger than HOP patients (ASC = 61 versus HOP = 65; P < .001). Body mass index and sex did not differ significantly between groups. RESULTS: Within 90 days, 44 (6%) complications occurred. No differences were observed between groups in rates of 90-day complications (ASC = 9 of 157, 5.7% versus HOP = 35 of 583, 6.0%; P = .899), reoperations (ASC = 2 of 157, 1.3% versus HOP = 3 of 583, 0.5%; P = .303), revisions (ASC = 0 of 157 versus HOP = 3 of 583, 0.5%; P = 1), readmissions (ASC = 3 of 157, 1.9% versus HOP = 8 of 583, 1.4%; P = .625), and ED visits (ASC = 1 of 157, 0.6% versus HOP = 3 of 583, 0.5%; P = .853). CONCLUSION: These results suggest that in appropriately selected patients, outpatient TKA can be safely performed in both ASC and HOP settings with similar low rates of 90-day complications, reoperations, revisions, readmissions, and ED visits.

Timing and Factors Associated With Revision for Infection After Primary Total Knee Arthroplasty Based on American Joint Replacement Registry Data.

BACKGROUND: Infection following total knee arthroplasty (TKA) remains a challenging clinical problem. Using American Joint Replacement Registry data, this study examined factors related to the incidence and timing of infection. METHODS: Primary TKAs performed from January 2012 through December 2018 among patients ≥65 years of age at surgery were queried from the American Joint Replacement Registry and merged with Medicare data to enhance capture of revisions for infection. Multivariate Cox regressions incorporating patient, surgical, and institutional factors were used to produce hazard ratios (HRs) associated with revision for infection and mortality after revision for infection. RESULTS: Among 525,887 TKAs, 2,821 (0.54%) were revised for infection. Men had an increased risk of revision for infection at all-time intervals (≤90 days, HR = 2.06, 95% CI: 1.75-2.43, P < .0001; >90 days to 1 year, HR = 1.90, 95% CI: 1.58-2.28, P < .0001; >1 year, HR = 1.57, 95% CI: 1.37-1.79, P < .0001). TKAs performed for osteoarthritis had an increased risk of revision for infection at ≤90 days (HR = 2.01, 95% CI: 1.45-2.78, P < .0001) but not at later times. Mortality was more likely among patients who had a Charlson Comorbidity Index (CCI) ≥ 5 compared to those who had a CCI ≤ 2 (HR = 3.21, 95% CI: 1.35-7.63, P = .008). Mortality was also more likely among older patients (HR = 1.61 for each decade, 95% CI: 1.04-2.49, P = .03). CONCLUSION: Based on primary TKAs performed in the United States, men were found to have a persistently higher risk of revision for infection, while a diagnosis of osteoarthritis was associated with a significantly higher risk only during the first 90 days after surgery.

ChAdOx1 interacts with CAR and PF4 with implications for thrombosis with thrombocytopenia syndrome.

Vaccines derived from chimpanzee adenovirus Y25 (ChAdOx1), human adenovirus type 26 (HAdV-D26), and human adenovirus type 5 (HAdV-C5) are critical in combatting the severe acute respiratory coronavirus 2 (SARS-CoV-2) pandemic. As part of the largest vaccination campaign in history, ultrarare side effects not seen in phase 3 trials, including thrombosis with thrombocytopenia syndrome (TTS), a rare condition resembling heparin-induced thrombocytopenia (HIT), have been observed. This study demonstrates that all three adenoviruses deployed as vaccination vectors versus SARS-CoV-2 bind to platelet factor 4 (PF4), a protein implicated in the pathogenesis of HIT. We have determined the structure of the ChAdOx1 viral vector and used it in state-of-the-art computational simulations to demonstrate an electrostatic interaction mechanism with PF4, which was confirmed experimentally by surface plasmon resonance. These data confirm that PF4 is capable of forming stable complexes with clinically relevant adenoviruses, an important step in unraveling the mechanisms underlying TTS.

Total predicted MHC-I epitope load is inversely associated with population mortality from SARS-CoV-2.

Polymorphisms in MHC-I protein sequences across human populations significantly affect viral peptide binding capacity, and thus alter T cell immunity to infection. In the present study, we assess the relationship between observed SARS-CoV-2 population mortality and the predicted viral binding capacities of 52 common MHC-I alleles. Potential SARS-CoV-2 MHC-I peptides are identified using a consensus MHC-I binding and presentation prediction algorithm called EnsembleMHC. Starting with nearly 3.5 million candidates, we resolve a few hundred highly probable MHC-I peptides. By weighing individual MHC allele-specific SARS-CoV-2 binding capacity with population frequency in 23 countries, we discover a strong inverse correlation between predicted population SARS-CoV-2 peptide binding capacity and mortality rate. Our computations reveal that peptides derived from the structural proteins of the virus produce a stronger association with observed mortality rate, highlighting the importance of S, N, M, and E proteins in driving productive immune responses.

S043 mythbuster: truncal vagotomy and gastric drainage procedures.

INTRODUCTION: You are sitting for your oral surgery board exam and the examiner asks what you do when you realize that you have accidentally cut the posterior vagus nerve during a hiatal hernia repair. Is the answer to proceed with a gastric drainage procedure correct? The prevailing dogma seems to be that inadvertent vagotomy will produce gastric stasis/paresis and the stomach will not empty and hence should be accompanied by a gastric drainage procedure. This report presents clinical outcomes of 49 patients who underwent truncal vagotomy without a drainage procedure (pyloroplasty or gastrojejunostomy). METHODS: 49 patients underwent truncal vagotomy with laparoscopic adjustable gastric banding in an IRB (Investigational Review Board)-approved clinical trial to determine if the addition of a vagotomy would increase achieved weight loss when compared to gastric banding alone. The details of this trial were presented at SAGES (Martin and Earle in Surg Endosc 25:2522-2525, 2011) in 2010. The patients in this study have been followed for over ten years and their histories were examined to look for evidence of gastric stasis or intractable diarrhea or if they required further surgery for these complaints. RESULTS: 49 patients have been followed for a mean of 10.9 years. All except one have experienced a loss of hunger and cessation of gastric borborygmus. One patient showed mild delayed gastric emptying after developing diabetes. Two other patients with DM carry a diagnosis of gastroparesis. No patient has experienced intractable diarrhea. Five patients have had revisions to sleeve gastrectomy or gastric bypass for weight loss failure or esophageal dilatation and GERD. CONCLUSIONS: Review of these truncal vagotomy patients without drainage procedures at 10 years does not support the myth that the stomach will not empty after vagotomy and a gastric drainage procedure should always accompany truncal vagotomy.

Gqα/G11α deficiency in dorsomedial hypothalamus leads to obesity resulting from decreased energy expenditure and impaired sympathetic nerve activity.

The G-protein subunits Gqα and G11α (Gq/11α) couple receptors to phospholipase C, leading to increased intracellular calcium. In this study we investigated the consequences of Gq/11α deficiency in the dorsomedial hypothalamus (DMH), a critical site for the control of energy homeostasis. Mice with DMH-specific deletion of Gq/11α (DMHGq/11KO) were generated by stereotaxic injection of adeno-associated virus (AAV)-Cre-green fluorescent protein (GFP) into the DMH of Gqαflox/flox:G11α-/- mice. Compared with control mice that received DMH injection of AAV-GFP, DMHGq/11KO mice developed obesity associated with reduced energy expenditure without significant changes in food intake or physical activity. DMHGq/11KO mice showed no defects in the ability of the melanocortin agonist melanotan II to acutely stimulate energy expenditure or to inhibit food intake. At room temperature (22°C), DMHGq/11KO mice showed reduced sympathetic nervous system activity in brown adipose tissue (BAT) and heart, accompanied with decreased basal BAT uncoupling protein 1 (Ucp1) gene expression and lower heart rates. These mice were cold intolerant when acutely exposed to cold (6°C for 5 h) and had decreased cold-stimulated BAT Ucp1 gene expression. DMHGq/11KO mice also failed to adapt to gradually declining ambient temperatures and to develop adipocyte browning in inguinal white adipose tissue although their BAT Ucp1 was proportionally stimulated. Consistent with impaired cold-induced thermogenesis, the onset of obesity in DMHGq/11KO mice was significantly delayed when housed under thermoneutral conditions (30°C). Thus our results show that Gqα and G11α in the DMH are required for the control of energy homeostasis by stimulating energy expenditure and thermoregulation.NEW & NOTEWORTHY This paper demonstrates that signaling within the dorsomedial hypothalamus via the G proteins Gqα and G11α, which couple cell surface receptors to the stimulation of phospholipase C, is critical for regulation of energy expenditure, thermoregulation by brown adipose tissue and the induction of white adipose tissue browning.

Gsα deficiency in the dorsomedial hypothalamus leads to obesity, hyperphagia, and reduced thermogenesis associated with impaired leptin signaling.

OBJECTIVE: Gsα couples multiple receptors, including the melanocortin 4 receptor (MC4R), to intracellular cAMP generation. Germline inactivating Gsα mutations lead to obesity in humans and mice. Mice with brain-specific Gsα deficiency also develop obesity with reduced energy expenditure and locomotor activity, and impaired adaptive thermogenesis, but the underlying mechanisms remain unclear. METHODS: We created mice (DMHGsKO) with Gsα deficiency limited to the dorsomedial hypothalamus (DMH) and examined the effects on energy balance and thermogenesis. RESULTS: DMHGsKO mice developed severe, early-onset obesity associated with hyperphagia and reduced energy expenditure and locomotor activity, along with impaired brown adipose tissue thermogenesis. Studies in mice with loss of MC4R in the DMH suggest that defective DMH MC4R/Gsα signaling contributes to abnormal energy balance but not to abnormal locomotor activity or cold-induced thermogenesis. Instead, DMHGsKO mice had impaired leptin signaling along with increased expression of the leptin signaling inhibitor protein tyrosine phosphatase 1B in the DMH, which likely contributes to the observed hyperphagia and reductions in energy expenditure, locomotor activity, and cold-induced thermogenesis. CONCLUSIONS: DMH Gsα signaling is critical for energy balance, thermogenesis, and leptin signaling. This study provides insight into how distinct signaling pathways can interact to regulate energy homeostasis and temperature regulation.

Lost in the crowd: identifying targetable MHC class I neoepitopes for cancer immunotherapy.

INTRODUCTION: The recent development of checkpoint blockade immunotherapy for cancer has led to impressive clinical results across multiple tumor types. There is mounting evidence that immune recognition of tumor derived MHC class I (MHC-I) restricted epitopes bearing cancer specific mutations and alterations is a crucial mechanism in successfully triggering immune-mediated tumor rejection. Therapeutic targeting of these cancer specific epitopes (neoepitopes) is emerging as a promising opportunity for the generation of personalized cancer vaccines and adoptive T cell therapies. However, one major obstacle limiting the broader application of neoepitope based therapies is the difficulty of selecting highly immunogenic neoepitopes among the wide array of presented non-immunogenic HLA ligands derived from self-proteins. Areas covered: In this review, we present an overview of the MHC-I processing and presentation pathway, as well as highlight key areas that contribute to the complexity of the associated MHC-I peptidome. We cover recent technological advances that simplify and optimize the identification of targetable neoepitopes for cancer immunotherapeutic applications. Expert commentary: Recent advances in computational modeling, bioinformatics, and mass spectrometry are unlocking the underlying mechanisms governing antigen processing and presentation of tumor-derived neoepitopes.

Human Papilloma Virus Specific Immunogenicity and Dysfunction of CD8+ T Cells in Head and Neck Cancer.

Human papillomavirus subtype 16 (HPV16) is the primary cause of an increasing number of head and neck squamous cell carcinomas (HNSCC), providing strong rationale for T-cell immune therapies against HPV+ HNSCC. Here we assess immunogenicity of HPV16-specific CD8+ T cells (CTL) and characterize HPV-specific mechanisms of T-cell dysfunction. We identified 16 strong and 29 moderately immunogenic CTL-epitopes from HPV16 E2, E6, and E7 antigens restricted by 12 common HLA class I alleles. E2-specific CTL-reactivity was higher in patients with HPV+ HNSCC than in healthy controls (>3-fold; P = 0.026). Patient-derived E2, E6, and E7 peripheral CTLs exhibited heterogeneity in dysfunctional phenotypes. Immunogenomic analyses of 119 HNSCC transcriptomes revealed high T-cell infiltration and dysfunction in HPV+ HNSCC and correlation of HPV antigen expression with T-cell exhaustion gene signatures. Indoleamine 2,3-dioxygenase (IDO-1) was strongly expressed in HPV+ HNSCC versus HPV- HNSCC (P = 0.001) and correlated with E7 expression (R 2 = 0.84; P = 0.033). Combination treatment with PD-1 blockade and IDO-1 inhibition overcame profound CTL-dysfunction, enhancing HPV+ HNSCC sensitivity to CTL-cytotoxicity in vitro (up to 10-fold in E7-CTLs, P = 0.011). Our findings implicate mechanisms of T-cell escape in HPV+ HNSCC, wherein high tumoral HPV-antigen load results in high expression of immune dysfunction genes on tumor cells (e.g., IDO-1), and dysfunction of HPV-specific CTLs (e.g., E7, E2-CTLs). The HPV16 CTL-epitopes identified in this study, in combination with blockade of HPV+ HNSCC-specific PD-1/IDO-1 checkpoints, may be useful for targeted immunotherapy.Significance: This study evaluates the HPV antigen T-cell immunogenicity role of inhibitory receptors and other exhaustion markers in the cytotoxic function of HPV antigen-specific CTLs and identifies combined inhibition of PD-1/IDO-1 as a strategy to enhance CTL targeting of HPV+ HNSCC. Cancer Res; 78(21); 6159-70. ©2018 AACR.

Physical Screening Predictors for Success in Completing Air Force Phase II Air Liaison Officer Aptitude Assessment.

OBJECTIVES: Air Liaison Officer Aptitude Assessment (AAA) attrition is often associated with a lack of candidate physical preparation. The Functional Movement Screen, Tactical Fitness Assessment, and fitness metrics were collected (n = 29 candidates) to determine what physical factors could predict a candidate s success in completing AAA. METHODS: Between-group comparisons were made between candidates completing AAA versus those who did not (p < 0.05). Upper 50% thresholds were established for all variables with R2 < 0.8 and the data were converted to a binary form (0 = did not attain threshold, 1 = attained threshold). Odds-ratios, pre/post-test probabilities and positive likelihood ratios were computed and logistic regression applied to explain model variance. RESULTS: The following variables provided the most predictive value for AAA completion: Pull-ups (p = 0.01), Sit-ups (p = 0.002), Relative Powerball Toss (p = 0.017), and Pull-ups × Sit-ups interaction (p = 0.016). CONCLUSION: Minimum recommended guidelines for AAA screening are Pull-ups (10 maximum), Sit-ups (76/2 minutes), and a Relative Powerball Toss of 0.6980 ft × lb/BW. Associated benefits could be higher graduation rates, and a cost-savings associated from temporary duty and possible injury care for nonselected candidates. Recommended guidelines should be validated in future class cycles.

Comparison of radiographic osteoarthritis scores in dogs less than 24 months or greater than 24 months following tibial plateau leveling osteotomy.

Radiographic osteoarthritis scores were determined in 60 dogs up to 3 years following tibial plateau leveling osteotomy. Radiographs taken immediately following surgery and at long-term follow-up 1 to 3 years later were evaluated by 2 certified radiologists using a modified 32-point osteoarthritis scale. Changes in osteoarthritis scores were evaluated by paired t-tests and regression analysis. Sub-groups of dogs were formed to evaluate if osteoarthritis scores changed differently for follow-up periods of < 24 months compared with those > 24 months. There was a significant increase in osteoarthritis score from post-operative to follow-up evaluations for all dogs studied. Regression analysis of the relationship of months after surgery to change in osteoarthritis score was not significant. These results indicate that osteoarthritis did progress following tibial plateau leveling osteotomy, but not in a linear fashion over time.

Comparaison des cotes radiographiques pour l'ostéoarthrite chez les chiens âgés de moins de 24 mois ou de plus de 24 mois après une ostéotomie de stabilisation du plateau tibial. Les cotes radiographiques d'ostéoarthrite ont été déterminées chez 60 chiens jusqu'à 3 ans après une ostéotomie de stabilisation du plateau tibial. Les radiographies prises immédiatement après la chirurgie et au suivi à long terme, de 1 à 3 ans plus tard, ont été évaluées par 2 radiologistes certifiés à l'aide d'une échelle d'ostéoarthrite modifiée de 32 points. Les changements des cotes d'ostéoarthrite ont été évalués à l'aide de tests de t pairés et d'analyses de régression. Des sous-groupes de chiens ont été formés afin d'évaluer si les cotes d'ostéoarthrite avaient évolué différemment pour les périodes de suivi de < 24 mois comparativement à celles de > 24 mois. Il y a eu une hausse importante de la cote d'ostéoarthrite entre les évaluations postopératoires et les évaluations de suivi pour tous les chiens examinés. L'analyse de régression de la relation entre le nombre de mois après la chirurgie et le changement de la cote d'ostéoarthrite n'était pas significative. Les résultats indiquent que l'ostéoarthrite a progressé après l'ostéotomie de stabilisation du plateau tibial, mais non d'une manière linéaire au fil du temps.(Traduit par Isabelle Vallières).

Testing the effectiveness of the Amputee Mobility Protocol: a pilot study.

We studied prolonged length of stay (LOS) in the acute care setting on a medical-surgical vascular unit, related to loss of functional mobility status after lower extremity amputation, and implementation of the Amputee Mobility Protocol (AMP) as a standard of care for all patients pre- and post-lower extremity amputation who were admitted to the medical-surgical vascular unit. A comparative pre-post observational study evaluated the effect of AMP on level of functional mobility and LOS after lower extremity amputation in the patient population on the medical-surgical vascular unit. Data was collected retrospectively from patient chart reviews from November of 2004 to March of 2005 for the pre-AMP group and through concurrent patient chart reviews from November of 2005 to March of 2006 for the post-AMP group. Dependent variables included functional mobility and LOS, which were evaluated by a modified Functional Independence Measure (FIM) score and the hospital LOS. Forty-four eligible patients were enrolled in the AMP pilot study during a 5-month period. The sample population consisted of 30 patients pre-AMP and 14 patients post-AMP. LOS for transmetatarsal amputations decreased by 0.7 days, whereas functional mobility increased by a minimum of one level in the modified FIM score. Functional mobility increased for transtibial amputations by one level and transfemoral amputations by 2 levels using the modified FIM score. LOS increased for patients undergoing transtibial (7.1 days) and transfemoral (2.7 days) amputations. This quality improvement project heightened staff awareness regarding ambulation and its impact on functional mobility and early discharge. Vascular nurses were able to affect patients' functional mobility and LOS by implementing a standardized AMP. Data showed that using the standardized AMP increased patients' functional mobility but did not significantly decrease acute care setting LOS. The AMP continues to be used for this patient population because of its impact on functional mobility and independence. This pilot study relates to 3 of the top 20 vascular research priorities: 1) an interdisciplinary strategy to improve the patient's level of functional independence and thereby decrease LOS and cost; 2) the nursing intervention of early, predetermined ambulation schedules will increase the nursing knowledge of strategies that facilitate recovery after vascular surgery in this population; and 3) factors that affect patient outcomes after these three major vascular procedures will be addressed in pilot outcomes. Limitations of the AMP pilot study included the small sample size, staff turnover, and lack of a concurrent control group. The next phase of this project will create and implement a similar activity protocol for patients after abdominal aortic aneurysm repair and various types of lower extremity bypass procedures.

The effect of beta-blocker dosing strategy on regulation of perioperative heart rate and clinical outcomes in patients undergoing vascular surgery: a randomized comparison.

The optimal dosing strategy for perioperative beta-blockers to safely achieve recommended target heart rates (HRs) by current guidelines is not well defined. An HR-titrated perioperative beta-blocker dosing regimen versus a fixed-dose regimen was assessed by clinical outcomes, postoperative heart rate, and beta-blocker-related complications. Patients (n = 64) scheduled to undergo moderate- to high-risk vascular surgery and without contraindications to beta-blockade were randomized to either a fixed-dose or HR-titrated beta-blocker dosing schedule. Clinical outcomes and HRs were followed immediately preoperatively to 24 hr postoperatively. A difference in mean HR between the two dosing arms was significant immediately postoperatively (70.1 vs. 58.2 bpm for fixed dose and HR-titrated arms, respectively; p = 0.012) but at no other time points. However, the HR-titrated strategy led to a significant reduction in the percentage of HR measurements >80 bpm (34.5% vs. 16.1%, p < 0.001) and to a significant reduction in absolute HR change (17.5 vs. 22.5 bpm, p = 0.034). There were no significant differences in the occurrence of asymptomatic hypotension between the two study arms, and no beta-blocker-related adverse events occurred in either study arm. An aggressive, HR-titrated perioperative beta-blocker dosing strategy was associated with more consistent maintenance of postoperative HRs within the range recommended by current guidelines and did not result in increased drug-related adverse events. The question of what is the best perioperative beta-blocker dosing regimen warrants further evaluation in a large-scale clinical trial.

First-year results of a community peripheral vascular screening program at an academic community hospital.

Disease associated with the vascular system, including peripheral arterial disease, poses a serious health problem with incidence growing annually. Recognizing this, several health care organizations across the United States have developed programs for public education and community awareness, and for screening individuals at risk for vascular disease. Lehigh Valley Hospital developed and implemented a screening program that evaluated more than 160 individuals during a 12-month period. Results suggest that screening should be limited to patients at high risk; however, the intrinsic value of patient education and patient peace of mind is worth proceeding with the screening effort because patients reported a positive experience.

The reliability of digital imaging in the remote assessment of wounds: defining a standard.

CONTEXT: Telemedicine has been used for remote management of many medical problems. Given the ever-expanding demands to provide increasing service with increasingly limited resources, quality care and practice efficiency can be enhanced by telemedicine. OBJECTIVE: This study was undertaken to explore the reliability of wound assessment using computer-transmitted digital imagery compared with a traditional bedside evaluation and also to assess its potential role in healthcare delivery. DESIGN/SETTING/PATIENTS: In the hospital setting, rounding vascular surgeons and a surgical resident evaluated the wounds on the service. A digital photograph was obtained with a 3.3 megapixel camera, and a wound-assessment tool was completed. A plastic surgery attending then reviewed the images at a later date and completed the same data tool. MAIN OUTCOME MEASURES: Wounds were rated for eschar, exposed bone, cellulitis, purulence, swelling, granulation tissue, granulation color, and depth using a standardized data collection tool. kappa statistics were computed for all variables, between raters. RESULTS: There were 2 phases of the study. In both phases, there was 100% agreement by the rounding physicians that the digital image was representative of the wound. Phase 1 agreement between evaluators was moderate to almost perfect, as demonstrated by kappa values (range, 0.50-0.87). In phase 2, all variable kappa values were rated as almost perfect, except the ability to evaluate depth of the wound to the millimeter, which was rated as substantial. CONCLUSIONS: The ability to accurately evaluate a wound on the basis of a digital image is possible. However, it requires training of participants and is facilitated by use of an assessment tool. With these caveats, evaluation of wounds using digital images is equivalent to bedside examination. This technology can improve practice efficiency, provide needed expertise at remote sites, and is an acceptable alternative method of wound assessment.