No Differences in Major In-Hospital Outcome Metrics When Comparing the Direct Lateral Approach to the Posterior Approach for Hemiarthroplasties After Traumatic Displaced Femoral Neck Fractures.

Introduction: The surgical approach of hemiarthroplasty for displaced femoral neck fractures remains debated. The study objective was to compare in-hospital outcomes for geriatric displaced femoral neck fractures treated with hemiarthroplasty based on surgical approach (direct lateral vs. posterior approach). Materials and Methods: This retrospective cohort study included geriatric patients (≥60 y/o) admitted 7/1/2016-3/31/2020 treated with hemiarthroplasty. Outcomes included: operative time (incision to closure), length of stay (HLOS), and blood loss volume (mL). The Harding direct lateral approach was compared to the posterior approach; P < .05. Results: There were 164 patients (59% direct lateral, 41% posterior). Patients treated with the direct lateral approach had an advanced directive (P = .03), dementia, (P = .03), or were functionally dependent (P = .03) more often than patients treated with the posterior approach. Time to surgery was comparable between groups (P = .52). The direct lateral approach was associated with a shorter operative time (2.3 vs. 2.8 h, P = .03), a longer HLOS (5.0 vs. 4.0 days, P < .01), and a lower median volume of blood loss (50 vs. 100 mL, P = .01), than the posterior approach, respectively. In a stratified analysis, for those who were not functionally dependent, did not have dementia or an advanced directive, the direct lateral approach led to a longer HLOS (P = .03) and shorter operative time (P = .04) than the posterior approach. Whereas among those who were functionally dependent, had dementia or had an advanced directive, the direct lateral approach led to less blood loss (P = .02) than the posterior approach. Discussion: While those treated with the direct lateral approach lost significantly less blood, they had a significantly longer HLOS than those treated with the posterior approach. Comorbidities significantly modified outcomes, which may suggest their presence could assist with treatment decisions. Conclusions: This study found neither approach, the direct lateral nor posterior, to be superior. Surgical approach could remain physician preference.

Displaced Geriatric Femoral Neck Fractures: A Retrospective Comparison of Total Hip Arthroplasties Versus Hemiarthroplasty.

Introduction: Controversary exists around the best surgical management for traumatic geriatric displaced femoral neck fractures. The study objective was to compare outcomes among those managed with a total hip arthroplasty (THA) to those managed with a hemiarthroplasty (HA). Methods: This retrospective matched cohort study included geriatric hip fractures (≥65 y/o) admitted 7/1/16-3/31/20. Patients were matched on having an advanced directive, pre-existing dementia, and age. Outcomes included: time to surgery, length of stay (LOS), blood loss volume, and discharge destination. THAs were compared to HAs; an alpha of <.05 indicated statistical significance. Results: There were 191 patients: 86% were treated with HA and 14% with THA. Most (40%) were 80-89 years old, 66% were female, and 92% were white. After matching, the groups were well balanced on demographics and baseline characteristics with 27 patients/arm. The median time to surgery was 23 hours for both arms, P = .38. The LOS was significantly longer for those managed with a HA when compared to those managed with a THA, 5.6 vs 4.0 days, P = .001. The median blood loss volume was significantly lower for HAs than for THAs, but the difference was small, 100 vs 120 mL, P = .02. Patients managed with a HA were less likely to be discharged home than those managed with a THA, 22% vs 70%, P = .005. Conclusions: While patients managed with a THA had significantly more blood loss than those managed with a HA, the difference in blood loss was small and not clinically relevant. Those managed with a THA experienced a significantly shorter LOS and were more likely to be discharged home than patients managed with a HA. Among a healthier, younger geriatric population, THA may lead to shortened LOS and improved discharge destinations when compared to HA for treatment of femoral neck fractures.

A Systematic Review of the Long-Term Clinical Success of Gastric Peroral Endoscopic Myotomy for Refractory Gastroparesis.

Gastroparesis is a chronic and debilitating gastrointestinal disorder with few medical treatment options. Traditional surgical management has involved laparoscopic pyloromyotomy or gastric stimulation. In recent years, gastric peroral endoscopic myotomy (GPOEM) has become an attractive, less invasive option for patients with refractory gastroparesis. There is little information on the long-term clinical success of GPOEM in patients with refractory gastroparesis. This systematic review aims to evaluate the data on this procedure's long-term clinical efficacy and safety. A comprehensive literature review was done in PubMed, EMBASE, Ovid, and Google Scholar databases from the date of earliest entry in May 2017 up to August 15, 2022. The Gastroparesis Cardinal Symptom Index (GCSI) score, adverse reaction, and length of stay were analyzed. Eleven studies were eligible for inclusion (900 patients), seven of the studies were retrospective, while four were prospective. The GCSI is a 6-point Likert scale questionnaire that assesses improvement in gastroparesis. An average decrease of GCSI by 1 point compared to baseline GCSI for all patients (described as clinical success) was found in 662 patients out of 713 (92.8%) at one-year follow-up, 421 out of 460 (91.5%) at two-year follow-up, 270 out of 270 (100%) at three-year follow-up, and 102 out of 102 (100%) at four-year follow-up. Adverse events occurred in 62 out of 835 patients (in nine studies), with two of the most frequent being bleeding and mucosal tears. GPOEM is an effective and safe treatment option for patients with refractory gastroparesis, with symptom improvement noted up to four years postoperatively.

Presentation of metastatic breast cancer as a large bowel obstruction in an elderly female with resultant diverting ileostomy: case report.

Background: Breast cancer metastases generally occur in the lymph nodes, bone, lungs, or liver. Very rarely does a primary breast cancer metastasize to the colon, and even more rarely does the metastasis cause a large bowel obstruction. To our knowledge, there are no reports in the literature of the surgical management of elderly patients presenting with metastatic breast cancer as a large bowel obstruction. Here we present an unusual case of breast cancer metastasis of an elderly female, years after initial diagnosis and treatment of the primary breast cancer, that metastasized to the ascending colon and presented as a large bowel obstruction, ultimately treated with diverting ileostomy. The patient's rare presentation illustrates the necessity to consider metastatic breast cancer among patients with large bowel obstruction, and the consideration for palliation of symptoms with diversion. Case Description: The patient is an 84-year-old otherwise healthy female with history of right breast invasive lobular carcinoma, who underwent bilateral mastectomy, right axillary lymph node dissection, and adjuvant chemotherapy, radiation, and letrozole in 2017. In March of 2022, the patient presented with radiographic evidence of a proximal large bowel obstruction. On exploratory laparotomy she was found to have an ascending colon mass as well as widespread intra-abdominal carcinomatosis consistent with metastatic breast cancer. She underwent a diverting loop ileostomy for palliation of her obstructive symptoms and later followed with oncology for palliative chemotherapy and anti-hormone therapy. She overall recovered well without any future plans for surgical intervention. Conclusions: Although uncommon, it is important to consider metastatic disease when evaluating patients with history of breast cancer for large bowel obstruction. Failure to do so can result in a delay in recognition of metastatic tumor biology or even a misdiagnosis. This may impede appropriate treatment and may contribute to significant morbidity or even mortality for patients.

Early life stress and chronic variable stress in adulthood interact to influence methamphetamine self-administration in male rats.

Early life stress interacts with adult stress to differentially modulate neural systems and vulnerability to various psychiatric illnesses. However, the effects of early life stress and adult stress on addictive behaviors have not been sufficiently investigated. We examined the effects of early life stress in the form of prolonged maternal separation, followed in early adulthood by either 10 days of chronic variable stress or no stress, on methamphetamine self-administration, extinction, and cue-induced reinstatement. We observed that chronic variable stress in adulthood reduced methamphetamine self-administration in rats with a history of early life stress. These findings add to an emerging body of literature suggesting interactions between early life and early adulthood stressors on adult behavioral phenotypes.

The Effects of Maternal Separation on Adult Methamphetamine Self-Administration, Extinction, Reinstatement, and MeCP2 Immunoreactivity in the Nucleus Accumbens.

The maternal separation (MS) paradigm is an animal model of early life stress. Animals subjected to MS during the first 2 weeks of life display altered behavioral and neuroendocrinological stress responses as adults. MS also produces altered responsiveness to and self-administration (SA) of various drugs of abuse including cocaine, ethanol, and amphetamine. However, no studies have yet examined the effects of MS on methamphetamine (METH) SA. This study was performed to examine the effects of MS on the acquisition of METH SA, extinction, and reinstatement of METH-seeking behavior in adulthood. Given the known influence of early life stress and drug exposure on epigenetic processes, we also investigated group differences in levels of the epigenetic marker methyl CpG binding protein 2 (MeCP2) in the nucleus accumbens (NAc) core. Long-Evans pups and dams were separated on postnatal days (PND) 2-14 for either 180 (MS180) or 15 min (MS15). Male offspring were allowed to acquire METH SA (0.05 mg/kg/infusion) in 15 2-h daily sessions starting at PND67, followed by extinction training and cue-induced reinstatement of METH-seeking behavior. Rats were then assessed for MeCP2 levels in the NAc core by immunohistochemistry. The MS180 group self-administered significantly more METH and acquired SA earlier than the MS15 group. No group differences in extinction or cue-induced reinstatement were observed. MS15 rats had significantly elevated MeCP2-immunoreactive cells in the NAc core as compared to MS180 rats. Together, these data suggest that MS has lasting influences on METH SA as well as epigenetic processes in the brain reward circuitry.