Drug eluting bioactive glass ceramics for fusion in spondylodiscitis: a pilot study.

Retrospective observational study. To determine the efficacy and safety of bioactive glass ceramics mixed with autograft in the treatment of spondylodiscitis. Thirty-four patients with spondylodiscitis underwent surgery using autologous bone graft augmented by antibiotic loaded bioactive glass ceramic granules. Twenty-five patients aging 6 to 77, completed 1-year follow-up. The lumbosacral junction was affected in 3, lumbar spine in 13, one each in the dorso-lumbar junction and sacrum, and 7 dorsal spines. The organism isolated was Mycobacterium tuberculosis in 15, Methicillin sensitive Staphylococcus aureus (MSSA) in 4, Pseudomonas aeruginosa in 4, Klebsiella pneumoniae in one, Burkholderia pseudomallei in 1, and mixed infections in 2. All patients had appropriate antibiotic therapy based on culture and sensitivity. Clinical and radiological evaluation of all the patients was done at 6 weeks, 3 months, 6 months, and 12 months after the surgery. Twenty-three patients improved clinically and showed radiographic fusion between 6 and 9 months. The patient with Burkholderia infection died due to fulminant septicemia with multi organ failure while another patient died at 9 months due to an unrelated cardiac event. The mean Visual Analogue Score (VAS) at the end of 1-year was 2 with radiological evidence of fusion in all patients. There were no re-infections or discharging wounds, and the 30-day re-admission rate was 0. Bioactive glass ceramics is a safe and effective graft expander in cases of spondylodiscitis. The absorption of antibiotics into the ceramic appears to help the elimination of infection.

Does Femoral Notching During Total Knee Arthroplasty Influence Periprosthetic Fracture. A Prospective Study.

BACKGROUND: Notching of the anterior femoral cortex during total knee arthroplasty (TKA) has been attributed to cause supracondylar fractures of the femur. Anatomic variations in the femur bone in different races make notching inevitable when standard designs of prostheses are used. The objective of this study is to determine the prevalence of notching when a PFC Sigma knee was used in an Indian population sample using the anterior referencing system and to assess the frequency of femoral shaft fractures in these cases. METHODS: This is a single-center, prospective study. All patients undergoing TKA were recruited and followed up for a minimum of 2 years. All patients had a PFC Sigma knee (DePuy Synthes), and the anterior referencing system was used for implantation. The Knee Society Score was used for outcome scoring and the Gujarathi's schema for the grading of notching. Radiological outcomes were evaluated by an independent observer. Linear regression analysis assessed the effect of notching on range of motion and final score. RESULTS: Of the 200 cases, 21% had varying degrees of notching. Grade I was seen in 13%, grade II in 6.5%, grade III in 1%, and grade IV in 0.5% in this series. There was no supracondylar fracture in 2 years. Notching had no bearing on the range of movement or outcome scores. CONCLUSION: Although notching is best avoided, this study has shown no correlation between notching and supracondylar fracture of the femur following TKA. It does not appear to have any bearing on the range of movement or final outcome scores.

Electrolyte imbalance after total joint arthroplasty: risk factors and impact on length of hospital stay.

BACKGROUND: Clinical as well as subclinical hyponatremia is frequently seen after orthopedic surgery. The study was aimed to determine the frequency and severity of hyponatremia in a cohort of total joint arthroplasty cases and identify the risk factors and their impact. METHODS: This is a retrospective observational study of 546 consecutive cases of total joint arthroplasty patients from a single institution. Only primary hip and knee replacements were included. The study was approved by the institutional review board. Preoperative and postoperative serum electrolytes were recorded till 45-day review. This was correlated with the age, gender, BMI, drug intake, and comorbidities. RESULTS: We identified 84.9% postsurgical hyponatremia in our cohort. Of these 80% were mild, 16% moderate and 4% severe. Preoperative hyponatremia was a consistent finding in most severe cases. Thaizides, ACE inhibitors, and longer surgeries like bilateral TKRs had more hyponatremia. Hospital stay was not impacted in this study for reasons discussed. There were no deaths in this series during the follow-up period, but two patients were rehospitalized. CONCLUSION: Postsurgical hyponatremia occurs in up to 85% of primary hip and knee arthroplasty patients. The most consistent predictor of severe electrolyte disturbance postsurgery is preoperative hyponatremia. Older age, female gender, longer surgery, and drugs like thiazides and ACE inhibitors seemed contributory.

Effect of 4 % chlorhexidine on cord colonization among hospital and community births in India: a randomized controlled study.

BACKGROUND: Infections are the single most important cause of neonatal mortality in developing countries. Results from trials in Asia evaluating the effect of chlorhexidine on neonatal mortality have been encouraging but limited data are available on the impact of cord cleansing on bacterial colonization. Further, no data from facility deliveries and impact with time is available. This pilot study was aimed to evaluate the impact of 4 % commercially prepared chlorhexidine on cord colonization and density of colonization among newborns in India. METHODS: Three hundred twenty-six newborns (hospital-247; community-79) were enrolled within 24 h of birth and randomly assigned to one of three groups: chlorhexidine, placebo or dry cord care. Umbilical swabs were collected at baseline, 2- and 48- hours after intervention application. RESULTS: At baseline, growth positivity (any bacterial growth) was 20 % (50 of 247 swabs) and 81 % (64 of 79 swabs) among hospital and community born neonates, respectively. In both settings, chlorhexidine compared to placebo and dry cord care, reduced colonization following 2- and 48-hour post application. Chlorhexidine significantly reduced 48-hour post application colony counts in comparison to placebo [Hospital: mean difference = -1.01; 95 % CI: -1.72, -0.30 Community: mean difference = -1.76; 95 % CI: -2.60, -0.93] and dry cord care [Hospital: mean difference = -1.16; 95 % CI: -1.93, -0.39 Community: mean difference = -2.23; 95 % CI: -3.18, -1.29]. Differences were similar for gram-positive and gram-negative bacteria. CONCLUSIONS: Cord cleansing with 4 % chlorhexidine soon after birth reduced colonization as well as density of colonization significantly; however this pilot study does not address the impact of chlorhexidine on mortality. The control preparation neither increased or decreased colonization. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov: NCT01528852, Registered February 7, 2012.

Assessment of the clinical effects of cholesteryl ester transfer protein inhibition with evacetrapib in patients at high-risk for vascular outcomes: Rationale and design of the ACCELERATE trial.

BACKGROUND: Potent pharmacologic inhibition of cholesteryl ester transferase protein by the investigational agent evacetrapib increases high-density lipoprotein cholesterol by 54% to 129%, reduces low-density lipoprotein cholesterol by 14% to 36%, and enhances cellular cholesterol efflux capacity. The ACCELERATE trial examines whether the addition of evacetrapib to standard medical therapy reduces the risk of cardiovascular (CV) morbidity and mortality in patients with high-risk vascular disease. STUDY DESIGN: ACCELERATE is a phase 3, multicenter, randomized, double-blind, placebo-controlled trial. Patients qualified for enrollment if they have experienced an acute coronary syndrome within the prior 30 to 365 days, cerebrovascular accident, or transient ischemic attack; if they have peripheral vascular disease; or they have diabetes with coronary artery disease. A total of 12,092 patients were randomized to evacetrapib 130 mg or placebo daily in addition to standard medical therapy. The primary efficacy end point is time to first event of CV death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. Treatment will continue until 1,670 patients reached the primary end point; at least 700 patients reach the key secondary efficacy end point of CV death, myocardial infarction, and stroke, and the last patient randomized has been followed up for at least 1.5 years. CONCLUSIONS: ACCELERATE will establish whether the cholesteryl ester transfer protein inhibition by evacetrapib improves CV outcomes in patients with high-risk vascular disease.

MRI morphology of surgically treated lumbar canal stenosis: a retrospective study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to identify morphologic features on magnetic resonance imaging that might correlate with lumbar canal stenosis severe enough to warrant surgery. SUMMARY OF BACKGROUND DATA: None of the quantitative parameters measured on x-rays, CT scans, or magnetic resonance imaging correlates well with the severity of clinical symptoms in lumbar canal stenosis (LCS). In a patient with neurogenic claudication, we need to define what would constitute radiologic LCS and whether he needs surgical intervention. This paper attempts to define MRI features of LCS addressing the morphology rather than canal dimensions in any direction. MATERIALS AND METHODS: A total of 64 consecutive patients who were operated at 113 levels of LCS were reviewed retrospectively. Their clinical notes and MRI were analyzed. Only the axial T2-weighted images were utilized for this study. The images were reviewed by 1 orthopedic surgeon and 1 radiologist and segregated into morphologic categories. No interobserver and intraobserver studies were undertaken. RESULTS: Two types of axial image features were identified in LCS symmetrical and asymmetrical with 5 subtypes. They were trefoil, triangular, "cat's eye," "pinhole," and complete obliteration. Several subtypes were also described. Of the operated cases, 70.8% had a triangular configuration of the canal with symmetrical large triangular canal shape occurring in 49/80 levels. It was impossible to correlate the severity of symptoms, their duration, and the presence of objective neurological deficits with the morphologic picture from the documentation available. CONCLUSIONS: LCS seems to produce predictable patterns on T2 axial MRI. The triangular configuration correlates most frequently with surgical LCS. Further studies are needed in normal individuals, in prospective patients, and to determine the outcome of treatment based on MRI morphology.

Efficiency of red cell distribution width in identification of children aged 1-3 years with iron deficiency anemia against traditional hematological markers.

BACKGROUND: Current strategy to identify iron deficiency anemia relies on markers involving high costs. Reports have suggested red cell distribution width (RDW) as a potential screening test for identifying iron deficiency anemia (IDA) but studies in pediatric populations are lacking. Our study elucidates the discriminative ability of RDW for detecting IDA among young children. METHODS: 2091 blood reports of children aged 1-3 years from an urban low socio-economic population of Delhi were analyzed to evaluate the sensitivity of RDW in discriminating IDA using receiver's operating characteristic curve. Hemoglobin and RDW were estimated using coulter, zinc protoporphyrin with AVIV fluorometer and serum ferritin by enzyme linked immunosorbent assay. RESULTS: A total of 1026 samples were classified as iron deficient anemia using gold standard. As a marker of overall efficiency, area under the curve for RDW was 0.83 (95% CI, 0.81- 0.84; p < 0.001). Sensitivity of RDW at cut-off of 18% to detect iron deficiency anemia was 76.5% and specificity 73.1% yielding a positive predictive value of 73% and negative predictive value of 76%. At a cut-off of RDW 16.4%, the sensitivity was 94% and at a cut-off of 21%, the specificity was 95%. Combination of hemoglobin ≤ 10 g/dL and RDW >15%, yielded a sensitivity of 99% and specificity of 90%. These data suggest that simple coulter analysis estimating hemoglobin and RDW can be used for identification of children in need for iron therapy. CONCLUSIONS: In India and similar settings, RDW >15% with hemoglobin ≤ 10.0 g/dL identifies iron deficient anemic children without need for iron status markers which could help reduce cost of management especially in poor settings. TRIAL REGISTRATION: Clinicaltrials.gov NCT00255385.

Compliance with home-based fortification strategies for delivery of iron and zinc: its effect on haematological and growth markers among 6-24 months old children in north India.

Compliance is a key component in successful implementation of the delivery of micronutrients among children. The present study evaluates the compliance with two home-based food fortification strategies (fortified complementary food or sprinkle) for providing iron and zinc among children aged 6-24 months. A total of 292 children were randomly allocated to receive either rice-based fortified complementary food and nutrition education (Cf = 101), sprinkle and nutrition education (Mp = 97), or nutrition education alone as control (Ed = 94). All the enrolled children were breastfed at the beginning of the study and were advised to continue breastfeeding. Biweekly information on compliance and anthropometry was collected. Complete haemogram estimation was conducted at baseline and end of the study. Compliance with the fortified complementary food was higher compared to sprinkle (Cf = 81%, Mp = 64% child-days). Consumption of the fortified complementary food for 6 months resulted in a significant increase in mean haemoglobin in the intervention group compared to control group (Cf 1.29 +/- 1.6 g/dL; Ed 0.23 +/- 1.3 g/dL; p < 0.001). Our results showed that fortified complementary food had higher compliance than sprinkle and is a suitable delivery mechanism for iron and zinc in preschool children.

Fourteen-Year Follow-Up of a Patient With a Hydroxyapatite Ceramic Matrix Reconstruction of and a Bone Graft for a Critical-Size Cortical Bone Defect: A Case Report.

A 42-year-old man diagnosed with chondrosarcoma of the proximal femur underwent limb salvage by compartmental excision of the lesion and reconstruction with a custom-made hip prosthesis. The critical-size defect in the proximal femur was reconstructed with ceramic hemicylinders that were tied in place with sutures and augmented with two fibular strut grafts and an autologous cancellous iliac crest bone graft. A fourteen-year follow-up of the same case revealed that substituted ceramic matrices can be converted into dynamic, metabolically active, living bone.

Protective role of ferulic acid on carbon tetrachloride-induced hyperlipidemia and histological alterations in experimental rats.

BACKGROUND: The present study aimed to evaluate the antihyperlipidemic effect of ferulic acid (FA) on carbon tetrachloride (CCl4)-treated rats. METHODS: Female albino rats of the Wistar strain were used in the present study. The rats were divided into four groups: groups 1 and 4 received physiological saline (3 mL/kg body weight/week) by subcutaneous injection, whereas groups 2 and 3 received a subcutaneous injection of CCl4 (3 mL/kg body weight/week) for a total period of 12 weeks. In addition, groups 3 and 4 were administered FA (20 mL/kg body weight) every day for the last 90 days. RESULTS: The results showed significantly (p≤0.05) elevated levels of cholesterol, triglycerides (TG), and free fatty acids (FFA) in the liver and kidney of CCl4-treated rats as compared with those of the controls. In addition, the levels of cholesterol, FFA, phospholipids (PL), and TG were elevated significantly in the circulation. Administration of FA effectively reduced these levels of lipids in the plasma, liver, and kidney of CCl4-treated rats. The PL level was significantly decreased in the liver and kidney of CCl4-treated rats and was positively modulated by FA treatment. Our histopathological observations were also in correlation with the biochemical parameters. CONCLUSIONS: From the results obtained, we could conclude that FA effectively protects the system against hyperlipidemia and may be an effective therapeutic agent for the treatment of this disorder.

Acetabular cup positioning in primary routine total hip arthroplasty-a review of current concepts and technologies.

INTRODUCTION: Total hip arthroplasty (THA) has revolutionized the treatment of hip joint arthritis. With the increased popularity and success of the procedure, research has focused on improving implant survival and reducing surgical complications. Optimal component orientation has been a constant focus with various philosophies proposed. Regardless of the philosophy, achieving an accurate acetabular position for each clinical scenario is crucial. In this paper, we review the recent developments in improving the accuracy and ideal positioning of the acetabular cup in routine primary THA. METHODOLOGY: A review of the recent scientific literature for acetabular cup placement in primary THA was performed, with available evidence for safe zones, spinopelvic relationship, preoperative planning, patient-specific instrumentation, navigation THA and robotic THA. CONCLUSION: Though the applicability of Lewinnek safe zones has been questioned with an improved understanding of spinopelvic relationships, its role remains in positioning the acetabular cup in a patient with normal spinopelvic alignment and mobility. Evaluation of spinopelvic relationships and accordingly adjusting acetabular anteversion and inclination can significantly reduce the incidence of dislocation in patients with a rigid spine. In using preoperative radiography, the acetabular inclination, anteversion and intraoperative pelvic position should be evaluated. With improving technology and the advent of artificial intelligence, superior and more accurate preoperative planning is possible. Patient-specific instrumentation, navigated and robotic THA have been reported to improve accuracy in acetabular cup positioning as decided preoperatively but any significant clinical advantage over conventional THA is yet to be elucidated.

Ischemic or Coronary Evaluations in Patients With Monomorphic VT Electrical Storm Undergoing VT Ablation.

BACKGROUND: Monomorphic ventricular tachycardia (VT) electrical storm (ES) in patients with coronary artery disease is dependent on scarred myocardium. The role of routine ischemic or coronary evaluations before ablation in patients presenting with monomorphic VT storm, without acute coronary syndrome (ACS), remains unknown. OBJECTIVES: This study sought to assess the impact of ischemic or coronary evaluations on procedural outcomes and post-ablation mortality in monomorphic VT storm patients. METHODS: All patients undergoing VT ablation at the Cleveland Clinic from 2014 to 2020 after presenting with monomorphic VT storm were enrolled in a prospectively maintained registry. The associations among ischemic or coronary evaluations and short-term procedural efficacy, acute outcomes, and mortality during follow-up were assessed. RESULTS: A total of 97 consecutive patients with monomorphic VT storm in the absence of ACS underwent VT ablations. This cohort was characterized by severe LV systolic dysfunction (mean left ventricular ejection fraction 30.3%, 67% with known ischemic cardiomyopathy) with moderately severe heart failure (median NYHA functional class II); 45% of patients underwent ischemic or coronary evaluations via coronary angiography (10%), noninvasive myocardial perfusion (26%), or both (9%). The yield of these evaluations was low: No acute coronary occlusions were identified. There was no association between ischemic evaluation and acute ablation outcomes or mortality during follow-up. Similarly, in a secondary analysis, the yield of ischemic or coronary evaluations in patients with monomorphic VT storm and known coronary disease (regardless of ablation status) was found to be low. CONCLUSIONS: Ischemic evaluations in patients with monomorphic VT storm without ACS may not improve procedural outcomes or mortality after ablation.

Anti-inflammatory role of naringenin in rats with ethanol induced liver injury.

The aim of the study was to investigate the antiinflammatory effects of naringenin in rats induced liver damage by exposure to ethanol. Rats were divided into four groups, groups 1 and 2 received isocaloric glucose; groups 3 and 4 received 20% ethanol equivalent to 6 g/kg body weight everyday for the total experimental period of 60 days. In addition, groups 2 and 4 were supplemented with naringenin (50 mg/kg p.o.) everyday for the last 30 days of the experiment. The results showed significantly elevated levels/activities/expression of serum aspartate and alanine transaminases, iron, ferritin, transforming growth factor-alpha (TNF-α), interleukin-6 (IL-6), nuclear factor-kappa B (NF-κB), cyclooxygenase-2 (COX-2), macrophage inflammatory protein 2 (MIP-2) and CD14 in ethanol fed rats as compared to those of the control. Ethanol-fed rats exhibited increased staining for the presence of inducible nitric oxide (iNOS) protein adducts in the liver. Supplementation with naringenin for the last 30 days to ethanol-fed rats, significantly decreased the levels/activities/expression of serum aspartate and alanine transaminases, iron, ferritin, TNF-α, IL-6, NF-κB, COX-2, MIP-2, CD14 and iNOS protein adducts in the liver as compared to the untreated ethanol fed rats. The inhibition of TNF-α, IL-6, NF-κB, COX-2, MIP-2, iNOS and CD14 by naringenin may contribute to its antiinflammatory activity in ethanol fed rats.

A Comprehensive Appraisal of Risk Prediction Models for Cardiogenic Shock.

ABSTRACT: Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.

Factors Affecting the Decision to Initiate Anticoagulation After Spine Surgery: Findings From the AOSpine Anticoagulation Global Initiative.

STUDY DESIGN: Cross-sectional, international survey. OBJECTIVES: To identify factors influencing pharmacologic anticoagulation initiation after spine surgery based on the AOSpine Anticoagulation Global Survey. METHODS: This survey was distributed to the international membership of AOSpine (n = 3805). A Likert-type scale described grade practice-specific factors on a scale from low (1) to high (5) importance, and patient-specific factors a scale from low (0) to high (3) importance. Analysis was performed to determine which factors were significant in the decision making surrounding the initiation of pharmacologic anticoagulation. RESULTS: A total of 316 spine surgeons from 64 countries completed the survey. In terms of practice-specific factors considered to initiate treatment, expert opinion was graded the highest (mean grade ± SD = 3.2 ± 1.3), followed by fellowship training (3.2 ± 1.3). Conversely, previous studies (2.7 ± 1.2) and unspecified guidelines were considered least important (2.6 ± 1.6). Patient body mass index (2.0 ± 1.0) and postoperative mobilization (2.3 ± 1.0) were deemed most important and graded highly overall. Those who rated estimated blood loss with greater importance in anticoagulation initiation decision making were more likely to administer thromboprophylaxis at later times (hazard ratio [HR] = 0.68-0.71), while those who rated drain output with greater importance were likely to administer thromboprophylaxis at earlier times (HR = 1.32-1.43). CONCLUSION: Among our global cohort of spine surgeons, certain patient factors (ie, patient mobilization and body mass index) and practice-specific factors (ie, expert opinion and fellowship training) were considered to be most important when considering anticoagulation start times.

Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association.

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post-cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

Bartonella infective endocarditis of a prosthetic aortic valve with a subvalvular abscess.

A patient with a prosthetic aortic valve, and culture negative endocarditis caused by Bartonella henselae presented with nonspecific constitutional symptoms, skin rash, and then later developed acute renal failure. The patient underwent redo sternotomy, aortic root, and ascending aorta replacement with a homograft, which resolved his symptoms and the renal failure.

Comparative and combined effect of chlorogenic acid and tetrahydrocurcumin on antioxidant disparities in chemical induced experimental diabetes.

The present study evaluates the combined effect of tetrahydrocurcumin and chlorogenic acid on oxidative stress in streptozotocin-nicotinamide-induced diabetic rats. Rats were rendered diabetic by a single intraperitoneal injection (i.p) of streptozotocin (45 mg/kg BW), 15 min after an i.p injection of nicotinamide (110 mg/kg BW). The levels of fasting plasma glucose and insulin were estimated. As an index of oxidative stress, the levels of enzymic antioxidants and lipid peroxidation products were analyzed in liver and kidney. Diabetic rats showed an increase in the levels of fasting plasma glucose, lipid peroxidative products such as thiobarbituric acid reactive substances and lipid hydroperoxides and a decrease in plasma insulin, and enzymic antioxidants viz., superoxide dismutase, catalase, glutathione peroxidase and glutathione-S-transferase. Combined administration of tetrahydrocurcumin (80 mg/kg BW) and chlorogenic acid (5 mg/kg BW) to diabetic rats for 45 days, reversed the biochemical changes to near normal. The above findings were supported by histological observations of the liver and kidney. Together the present study clearly reflects that combined dosage of tetrahydrocurcumin and chlorogenic acid augments enzymic antioxidants with a concomitant decrease in lipid peroxidation and protects against streptozotocin-nicotinamide-induced type 2 diabetes in experimental rats.