The Adult Carbohydrate Perception Questionnaire Identifies Patients with Lactose or Fructose Intolerance Who Respond to Diet.

INTRODUCTION: There is no evidence that a positive breath test is a good predictor of the success of a carbohydrate-restricted diet. Our objective was to investigate whether patients in whom lactose intolerance (LIT) or fructose intolerance (FIT) is diagnosed by validated symptom measurement respond to diet. METHODS: Patients referred for evaluation of LIT or FIT underwent hydrogen/methane breath testing (malabsorption test) and symptom measurement with the adult Carbohydrate Perception Questionnaire (aCPQ, intolerance test) before and after 50 g lactose or 25 g fructose. Patients with a positive aCPQ received instructions on specific diets and supplements. Severity of abdominal pain, bloating, diarrhoea, flatulence, and nausea were measured using a visual analogue scale (VAS) before (VAS1, mm) and after (VAS2, mm) diet. The change in VAS for individual symptoms and overall symptoms after diet is expressed as deltaVAS (mm) and as change relative to VAS1 (%). RESULTS: Forty-one patients were included (23 LIT, 8 FIT, 10 LIT+FIT). Eight patients had negative breath tests (no malabsorption). After 2 months of diet, the overall VAS and the individual symptoms decreased (p < 0.001). Overall VAS1 and the VAS1 for individual symptoms correlated significantly with the decrease in deltaVAS (mm) after diet. Nineteen patients (46%) had total recovery, and additional 13 patients (32%) had improvement of >50%. Response to diet was independent of breath test results. CONCLUSION: This uncontrolled and unblinded study suggests that patients with carbohydrate intolerance diagnosed by aCPQ benefit significantly from diet, independent of the presence of malabsorption. Controlled studies are required to confirm these results in larger patient groups.

A 5-Year Review of Hospital Costs and Reimbursement in the Surgical Management of Degenerative Spondylolisthesis.

BACKGROUND: To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis. METHODS: A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions. All charges, expenses, reimbursement, and margins were obtained through financial auditing. A multivariate linear regression model was used to compare demographics, charges, etc. A 1-way analysis of variance with Tukey post hoc analysis was used to analyze reimbursements and margins based upon insurances. RESULTS: Two hundred thirty-three patients met inclusion criteria. The overall charges and expenses for PLF were significantly less compared to both types of instrumented fusions (P < .0001). Medicare and private insurance were the most common insurance types; Medicare and private insurance mean reimbursements for PLF were $36,903 and $47,086, respectively; for PPS, $37,450 and $53,851, and for PLIF $40,171 and $51,640. Hospital margins for PPS and PLIF in Medicaid patients were negative (-$3,702 and -$6,456). Hospital margins were largest for both worker's compensation and private insurance patients in all fusion groups. Hospital margins with Medicare for PLF, PPS, and PLIF were $24,347, $19,205, and $23,046, respectively. Hospital margins for private insurance for PLF, PPS, and PLIF were $37,569, $36,834, and $33,134, respectively. CONCLUSIONS: As more instrumentation is used, the more it costs both the hospital and the insurance companies; hospital margins did not increase correspondingly. CLINICAL RELEVANCE: Improved understanding of related costs and margins associated with lumbar fusions to help transition to more cost effective spine centers.

Proximal tibiofibular osteoarthritis presenting as pain after total knee arthroplasty treated successfully with fusion of the proximal tibial-fibular joint.

Total knee arthroplasty (TKA) is a common treatment option for end-stage osteoarthritis of the tibiofemoral and patellafemoral joints. Diagnosis and treatment of the painful TKA can pose a significant challenge. In this report, we present the unusual case of a patient 12 years after total knee replacement presenting with isolated proximal tibial-fibular osteoarthritis as a cause of lateral knee pain. Proximal tibiofibular osteoarthritis is not typically on the differential diagnosis for a painful TKA but can be a rare cause of lateral knee pain. Proximal tibiofibular fusion may provide relief of pain and restoration of function.

Prognostic Factors for Success After Irrigation and Debridement With Modular Component Exchange for Infected Total Knee Arthroplasty.

BACKGROUND: Irrigation and debridement with modular component exchange (IDMCE) can treat prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Compared to 2-stage revision, IDMCE is associated with lower morbidity but may carry higher infection recurrence rates. We aimed to identify prognostic factors associated with successful IDMCE in patients with PJI. METHODS: We identified 99 consecutive patients who underwent IDMCE following TKA PJI at a tertiary academic medical center from November 2009 through January 2016. Examined variables included age, gender, symptom duration, body mass index, Charlson comorbidity index, total protein, albumin, hemoglobin A1c, erythrocyte sedimentation rate (ESR), C-reactive protein, white blood cell count, gram stain results, final cultures, and use of long-term antibiotic suppression. Success was defined as no further operation on the ipsilateral knee. We used t tests and chi-square analyses to determine whether each preoperative factor was associated with IDMCE reoperation. RESULTS: At mean follow-up of 2.6 years, 64 patients who underwent IDMCE were defined as successful. Thirty-five patients required one or more additional procedures for recurrent infection; of these, 20 patients underwent 2-stage revision. Patients with symptom duration of less than 2 days avoided additional surgery in 88% of cases. Elevated ESR >47 mm/h was the only variable associated with reoperation (P = .005). There were no associations among the other examined variables. CONCLUSION: Using IDMCE for PJI after TKA required reoperation in 35% of cases. Elevated preoperative ESR laboratory values and duration of symptoms >2 days were associated with reoperation.