A systematic review and meta-analysis of antibiotic-loaded bone cement for prevention of deep surgical site infections following primary total joint replacement.

BACKGROUND: The use of antibiotic-loaded bone cement (ALBC) as a mean for preventing deep surgical site infections (SSI) after total joint replacement is controversial. Therefore, we have conducted a meta-analysis to evaluate the prophylactic effect of ALBC for SSI prevention in patients undergoing arthroplasty. This study was conducted to revise treatment guidelines for MRSA infections in Japan. METHODS: PubMed (Medline), Scopus, Embase, Web of Science and Cochrane library were searched for relevant articles comparing preventive effect of ALBC for patients undergoing primary total joint arthroplasty by August 2022. Primary outcome was the incidence of deep SSI. Subgroup analyses by type of surgery (total hip (THA) or knee (TKA) arthroplasty) and by causative pathogen (methicillin-resistant Staphylococcus aureus (MRSA)) were performed. RESULTS: Of the 3379 studies identified for screening, six studies involving 5745 patients were included. The use of ALBC significantly reduced the incidence of deep SSI in overall patients (risk ratio [RR] 0.60, 95% confidential interval [CI] 0.39-0.92), but the evidence level was very low. There was no significant preventive effect for ALBC compared with non-ALBC in both THA and TKA (THA, RR 0.52, 95% CI 0.23-1.16; TKA, RR 0.64, 95% CI 0.38-1.06), and for preventing MRSA-SSI (RR 0.27, 95% CI 0.03-2.41). CONCLUSIONS: Although the overall preventive effect of ALBC was significant, the evidence level was very low. Thus, the routine use of ALBC as a mean to prevent SSI in arthroplasty may not be suggested.

[Relevance of the five-repetition sit-to-stand test for diagnosing sarcopenia in elderly inpatients with cardiac disease].

PURPOSE: The aim of this study was to determine the reference values for diagnosing sarcopenia using the five-repetition sit-to-stand test in elderly inpatients with cardiac disease. METHODS: We studied 71 inpatients with cardiac disease ≥65 years of age (mean age 78.0±7.9 years, 42.3% women) who were admitted between April 2015 and March 2016. Patients were assessed for sarcopenia, and we performed the five-repetition sit-to-stand test. We defined sarcopenia using the Asian Working Group for Sarcopenia-suggested diagnostic algorithm. A logistic regression analysis was performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of the relationship between sarcopenia and the five-repetition sit-to-stand test. A multivariate analysis showed that the age, admission diagnosis, the New York Heart Association classification, the Charlson comorbidity index, and the ratio of extracellular to total body water were relevant covariates. The cut-off value of the five-repetition sit-to-stand test to diagnose sarcopenia was determined using a receiver operating characteristic curve. RESULTS: Sarcopenia was diagnosed in 25 patients (35.2%). A multivariate logistic regression analysis showed that the five-repetition sit-to-stand test was significantly associated with sarcopenia (p=0.024), and the OR (95% CI) was 1.31 (1.04-1.65). The cut-off value of the five-repetition sit-to-stand test to diagnose sarcopenia was 10.9 s (sensitivity 80.0%, specificity 70.0%, area under the curve 0.83). CONCLUSIONS: The five-repetition sit-to-stand test is a useful screening tool for sarcopenia in elderly inpatients with cardiac disease. The cut-off value to diagnose sarcopenia was 10.9 s in this study.

[Prevention of surgical site infection for orthopaedic surgery in rheumatoid arthritis].

Rheumatoid arthritis (RA) is considered to be a risk factor of surgical site infection(SSI). RA patients have higher rates of nasal and oral carriage, which can cause endogenous infections. The decolonization strategy and good oral care may decrease the rate of SSI in RA patients. In the perioperative management of medications, methotrexate can be used continuously during the perioperative period. Biological agents should be withheld for an appropriate period considering the half-lives of each agent. If possible, withholding them for at least a week prior to and after surgery is preferred. Whether biological agents increase the rate of SSI in orthopaedic surgery is unclear. Several reports have indicated that biological agents can increase the risk of SSI in total joint replacements. This warrants attention.

Healthcare resources attributable to methicillin-resistant Staphylococcus aureus orthopedic surgical site infections.

The number of orthopedic surgeries is increasing as populations steadily age, but surgical site infection (SSI) rates remain relatively consistent. This study aimed to quantify the healthcare resources attributable to methicillin-resistant Staphylococcus aureus (MRSA) SSIs in orthopedic surgical patients. The analysis was conducted using a national claims database comprising data from almost all Japanese residents. We examined patients who underwent any of the following surgeries between April 2012 and March 2018: amputation (AMP), spinal fusion (FUSN), open reduction of fracture (FX), hip prosthesis (HPRO), knee prosthesis (KPRO), and laminectomy (LAM). Propensity score matching was performed to identify non-SSI control patients, and generalized estimating equations were used to estimate the differences in outcomes between the case and control groups. The numbers of MRSA SSI cases (infection rates) ranged from 64 (0.03%) to 1,152 (2.33%). MRSA SSI-attributable increases in healthcare expenditure ranged from $11,630 ($21,151 vs. $9,521) for LAM to $35,693 ($50,122 vs. $14,429) for FX, and increases in hospital stay ranged from 40.6 days (59.2 vs. 18.6) for LAM to 89.5 days (122.0 vs. 32.5) for FX. In conclusion, MRSA SSIs contribute to substantial increases in healthcare resource utilization, emphasizing the need to implement effective infection prevention measures for orthopedic surgeries.

A splice variant of ASC regulates IL-1beta release and aggregates differently from intact ASC.

The apoptosis-associated speck-like protein containing a caspase recruit domain (ASC) is involved in apoptosis and innate immunity and is a major adaptor molecule responsible for procaspase-1 activation. ASC mRNA is encoded by three exons: exons 1 and 3 encode a pyrin domain (PYD) and caspase recruit domain (CARD), respectively, and exon 2 encodes a proline and glycine-rich (PGR) domain. Here, we identified a variant ASC protein (vASC) lacking the PGR domain that was smaller than full length ASC (fASC) derived from fully transcribed mRNA and searched for differences in biochemical and biological nature. Both fASC and vASC were found to activate procaspase-1 to a similar degree, but the efficiency of IL-1beta excretion was significantly higher for vASC. There was also a marked structural difference observed in the fibrous aggregates formed by fASC and vASC. These results suggest that although the PGR domain is dispensable for procaspase-1 activation, it plays an important role in the regulation of the molecular structure and activity of ASC.

A resected case of solitary pancreatic metastasis from adenocarcinoma of the lung.

CONTEXT: Primary lung cancer frequently metastasizes to distant organs; however, the pancreas is a relatively infrequent site of metastasis. Because most metastatic cases in the pancreas tend to be discovered in patients only after malignant disease has become widely disseminated, it is extremely rare that a metachronous metastatic lesion limited to the pancreas is discovered with postoperative imaging and is surgically resectable. Most patients demonstrate accompanying metastases to other organs, especially in cases of lung cancer, which prove to be surgically unresectable when diagnosed. Although several cases have been reported of patients who underwent pancreatic resection for curative intent, most patients died from recurrent disease. CASE REPORT: We report herein an unusual case of secondary tumor of the pancreas (primary tumor: adenocarcinoma of the lung) with hopefully curative resection. The interval between the surgical treatment of lung cancer and the metachronous pancreatic metastasis was 22 months; there has been no recurrence of disease during the 24 months of follow-up after a pylorus-preserving pancreaticoduodenectomy. CONCLUSION: Surgical treatment should be considered in patients with pancreatic metastasis from other organs if the disease is localized in the pancreas or if metastasis in other organs is controlled with chemotherapy and/or radiotherapy.

[Bone and joint infection].

Older adults are at risk for the immune dysfunction associated with advanced age, which contribute to their increased risk of infection. Hematogenous osteomyelitis occurs not only in children, but also in older adults. Iatrogenic septic arthritis can be occured after the intraarticular injection for the osteoarthritis in aging society. Tuberculous spondylitis occurs in older adults and the differential diagnosis with pyogenic spondylitis and vertebral metastasis is important.

Clinical application of double dorsal plates for the distal radius fractures.

The purpose of this study was to develop plates that fit the contour of the distal radius of the Japanese and can be inserted less invasively. Three-dimensional models of 36 radii of 18 volunteers were prepared. Using these models, the shape of the cortical bone on the radial margin of the distal radius and just below the dorsal fourth compartment of the wrist, to which the plates were expected to be applied, was measured, and the curves of the plates were determined. The functions of approximated curves of the plates were: [y = -2 x 10(-8) x5 - 2 x 10(-6) x(4) + 0.0006 x3 - 0.0312 x2 + 0.3274 x + 15.224 on the radial margin of the distal radius and [y = 7 x 10(-7) x5 - 0.0001 x4 + 0.0078 x3 - 0.2355 x2 + 3.1815 x - 5.6383 just below the fourth compartment. The clinical results of the application of double dorsal plates were satisfactory in clinical cases for the distal radius fractures.

[Interstitial pneumonia associated with chronic thyroiditis].

A 56-year-old woman was initially seen in March 1998 with a complaint of back pain. Her thyroid gland was swollen and the level of TSH was elevated at 10 microU/ml. Chronic thyroiditis with hypothyroidism was diagnosed. Negative reactions were obtained for both anti-thyroglobulin and anti-thyroid peroxidase antibodies. Daily treatment with thyroxine 50 mg was started. A cough developed in August 1998, and her chest radiographs revealed multiple bilateral consolidation shadows. A transbronchial lung biopsy specimen demonstrated mononuclear cells infiltration in the alveolar septa with fibrosis, consistent with nonspecific interstitial pneumonia (NSIP). There were no findings clinically or serologically suggestive of collagen-vascular diseases. Ultimately interstitial pneumonia compatible with the NSIP pattern in association with chronic thyroiditis was diagnosed. Oral prednisolone (30 mg/day) and azathioprine (50 mg/day) administration was initiated. The cough and the shadows on the chest radiographs improved. However, one year after completion of the treatment, interstitial pneumonia recurred. Retreatment with prednisolone and azathioprine has resulted in its improvement.

Pulmonary embolism caused by intimal sarcoma of the pulmonary artery.

We herein report the case of a 39-year-old woman with a pulmonary embolism caused by intimal sarcoma of the pulmonary artery. She presented with shortness of breath and leg edema. Computed tomography showed a low density area that extended from the main pulmonary artery to the bilateral pulmonary arteries. We diagnosed her to have a pulmonary thromboembolism. The thrombosis did not decrease after the administration of anti-coagulant therapy, and she underwent resection of the thrombotic tissue. Histopathologically, the surgical specimen was not found to be thrombotic tissue but rather an intimal sarcoma of the pulmonary artery. After undergoing surgery, she received radiation therapy and chemotherapy; however, she died 31 months after being diagnosed.

Extrarenal multiorgan metastases of collecting duct carcinoma of the kidney: a case series.

INTRODUCTION: Collecting duct carcinoma is a rare type of renal cell carcinoma. The primary is difficult to diagnose on imaging, and metastases are often present on initial presentation. Extensive multiorgan metastases can result in complex presentations that can be difficult to diagnose. CASE PRESENTATION: We present two case reports of multiorgan metastases of collecting duct carcinoma that were autopsy confirmed. The first case was a 55-year-old man who presented with fever and abdominal pain. Abdominal computed tomography showed enlargement of the right kidney. Pyelonephritis was considered on the basis of laboratory test results and imaging findings. However, multiple cavitary lesions were found on routine chest radiography. These lesions were biopsied, resulting in a histological diagnosis of metastatic adenocarcinoma. A renal tumor was considered. Transitional cell carcinoma was suspected, which proved to be misdiagnosed and chemotherapy was given accordingly. However, this was not effective and the patient died after 2 months. Autopsy demonstrated the primary tumor to be collecting duct carcinoma, with metastases to lung, liver, spleen, bone marrow, right adrenal gland, and para-aortic lymph node. Computed tomography done while the patient was alive detected lung, liver, and para-aortic lymph node metastases. The second case was a 77-year-old man who presented with fever. Pyelonephritis was considered on the basis of the laboratory test results and imaging findings. Antibiotic therapy improved his symptoms and laboratory indicators of inflammation. One year later, he developed backache. Computed tomography revealed a progressively enlarging right renal lesion, multiple liver masses, enlargement of the para-aortic lymph nodes, and multiple osteoblastic and osteoclastic lesions. A renal tumor with multiple metastases was diagnosed. Chemotherapy was given without effect, and the patient died of cardiac failure 1 year later. Autopsy revealed a primary tumor of collecting duct carcinoma with metastases to the liver, right adrenal gland, right upper ureter, bone marrow, para-aortic and mediastinal lymph nodes, and bone. CONCLUSION: We present the radiological findings of lung, liver, lymph node, and bone metastases in two patients with collecting duct carcinoma.

Development of the upper-body dressing scale for a buttoned shirt: a preliminary correlational study.

OBJECTIVES: A patient with poststroke hemiparesis learns to use the nonparetic arm to compensate for the weakness of the paretic arm to achieve independence in dressing. This is the learning process of new component actions on dressing. The purpose of this study was to develop the Upper-Body Dressing Scale (UBDS) for buttoned shirt dressing, which evaluates the component actions of upper-body dressing, and to provide preliminary data on internal consistency of the UBDS, as well as its reproducibility, validity, and sensitivity to clinical change. DESIGN: Correlational study of concurrent validity and reliability in which 63 consecutive stroke patients were enrolled in the study and were assessed repeatedly by the UBDS and the dressing item of Functional Independent Measure (FIM). RESULTS: Fifty-one patients completed the 3-wk study. The Cronbach's coefficient alpha of UBDS was 0.88. The principal component analysis extracted two components, which explained 62.3% of total variance. All items of the scale had high loading on the first component (0.65-0.83). Actions on the paralytic side were the positive loadings and actions on the healthy side were the negative loadings on the second component. Intraclass correlation coefficient was 0.87. The level of correlation between UBDS score and FIM dressing item scores was -0.72. Logistic regression analysis showed that only the score of UBDS on the first day of evaluation was a significant independent predictor of dressing ability (odds ratio, 0.82; 95% confidence interval, 0.71-0.95). The UBDS scores for paralytic hand passed into the sleeve, sleeve pulled up beyond the elbow joint, and sleeve pulled up beyond the shoulder joint were worse than the score for the other components of the task. These component actions had positive loading on the second component, which was identified by the principal component analysis. CONCLUSIONS: The UBDS has good internal consistency, reproducibility, validity, and sensitivity to clinical changes of patients with poststroke hemiparesis. This detailed UBDS assessment enables us to document the most difficult stages in dressing and to assess motor and process skills for independence of dressing.

Predicting recovery of upper-body dressing ability after stroke.

OBJECTIVE: To identify predictors of the recovery of independent dressing ability after stroke. DESIGN: Prospective cohort study. SETTING: Rehabilitation unit at a university hospital. PARTICIPANTS: Sixty-three consecutive stroke patients were enrolled in the study. Twelve patients were not able to complete the study because they were discharged or transferred to another hospital before study completion. INTERVENTION: Fifty-one patients underwent and completed 15 days of dressing training based on the time-delay method, which included the 10 component actions of upper-body dressing and 4 cues given by therapists. MAIN OUTCOME MEASURES: The dressing item of the FIM instrument, Brunnstrom motor recovery stages, presence or absence of deep and tactile sensation, Rey-Osterrieth complex figure test, Kohs block design test, body image test, Weintraub cancellation task, and presence or absence of the visual extinction phenomenon and the motor impersistence phenomenon. RESULTS: The FIM upper-body dressing item score and the cancellation task score at the start of training were significantly better in patients who achieved independence in dressing within 15 training days than in patients who did not (P < .05). The motor impersistence phenomenon was found less frequently among patients who achieved independence in upper-body dressing than among patients who did not (P < .05). However, logistic regression analysis showed that only the FIM score for upper-body dressing on the first day of training was a significant independent predictor of dressing ability at the end of training (odds ratio, 4.33; 95% confidence interval, 1.51-12.37). The receiver operating characteristic curve indicated that a cutoff score of 3 would provide the best balance between sensitivity and specificity for the FIM upper-body dressing item. The positive predictive value of this cutoff score was .90, and the negative predictive value was .70. CONCLUSIONS: Our findings indicate that the FIM upper-body dressing score on the first day of dressing training is an independent predictor of recovery of upper-body dressing ability after stroke.

Motor apparatus in human spermatozoa that lack central pair microtubules.

Electron microscopic examination of the spermatozoa from a man suffering from asthenozoospermia (poor or low sperm motility) showed that approximately 92% of the sperm flagella lacked central pair microtubules but possessed dynein arms and radial spokes while a small percentage of the spermatozoa had complete flagella. The characteristics of the motor apparatus of the spermatozoa and the effects of caffeine on the sperm motility were examined, as were the reactivation of demembranated spermatozoa and the sliding of doublet microtubules. Almost all spermatozoa were immotile in a Tyrode solution while only a small percentage of spermatozoa showed slow forward movement or feeble flagellar vibration, whereas addition of caffeine to the sperm suspension induced forward swimming of approximately half of the spermatozoa. The reactivation of demembranated spermatozoa with MgATP(2-) could not succeed because of disintegration of the demembranated flagella. However, when the demembranated spermatozoa were exposed to MgATP(2-) and then treated with elastase, the microtubular doublets of approximately half the number of the flagella slid from the end or middle of the flagella. These results suggest that the motor apparatus in the sperm flagella that lack the central pair microtubules is functionally assembled and intrinsically capable of undergoing flagellar movement but not strong enough to beat normally.

Pyothorax-associated T-cell lymphoma: a case report.

We present a case of pyothorax-associated T-cell lymphoma in which Epstein-Barr virus (EBV) genome is not detected in the tumor cells. An 80-year-old male came to our hospital because of a left chest pain. Chest computed tomography (CT) showed a mass at the lower-dorsal part of the pyothorax wall, which involved the adjacent chest wall. The surgical biopsy specimen showed a predominant infiltration of atypical lymphocytes. Results of immunohistochemical analysis were as follows: CD3+, CD4-, CD8+, CD20-, CD30-, CD45RO+ and CD79a-. We diagnosed this case as a type of peripheral T-cell lymphoma. In situ hybridization using EBV-encoded RNA-1 (EBER-1) did not reveal the positive signals in the nucleus of tumor cells. Polymerase chain reaction (PCR) analysis yielded a negative result for human herpesvirus 8 (HHV8). Radiation therapy at 54 Gy reduced the tumor size by 90%. Visual and hearing disturbances of unknown etiology developed just before the completion of radiotherapy. The symptoms progressively worsened and the patient became bedridden. He died of pneumonia 2 months after the completion of radiotherapy. Autopsy did not reveal abnormalities to which the neurological disturbances were attributable.

[Rheumatoid arthritis in patients aged above 75 years old at onset].

Elderly onset rheumatoid arthritis (RA) is difficult to diagnose definitively when the patients note their first symptoms of arthritis above the age of 75 years old. In this report, we reviewed the clinical features of elderly onset RA and its diagnosis. The subjects included 4 females, aged 78, 83, 84 and 93 years, respectively. The onsets were abrupt in 2 cases and more slowly arriving in the other 2. Shoulder joints and wrist joints were involved in all cases. Knee joints, finger joints and foot joints were involved in 3 cases and the elbow was involved in one case. Anti-RA treatment quickly attenuated the acute and severe arthritis and brought down the high CRP level associated with vivid inflammatory activity of RA. The RAPA value was very high in all but one of the cases. Severe destructive findings in radiography was undetectable in the major joints (e.g. shoulder, hip and knee joints). Radiographic findings in wrist and finger joints were also very difficult to differentiate from arthrosis and osteoporosis. On the other hand, RA involvement in the cervical spine was certain in the radiographs; 1 case had anterior atlantoaxial subluxation and 2 cases had subaxial intervertebral erosion. Pathological radiographic findings in the cervical spine are useful for the diagnosis of elderly onset RA.