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BACKGROUND AND AIM: Patients with autoimmune inflammatory rheumatic disease (AIIRD) are at higher risk of severe infections because of their underlying diseases and immunosuppression. Our objective was to elucidate the epidemiological and clinical characteristics of patients with AIIRD presenting with COVID-19 and their relation to disease severity. We explored whether variables, including underlying diagnosis, disease-modifying antirheumatic drugs (DMARDs) and COVID-19 vaccine status, were associated with more severe forms of COVID-19 infection. METHODS: Between 1 January 2020 and 30 June 2022, 151 patients with AIIRD and COVID-19 infection were analysed using a binary regression model and a multinomial regression model. RESULTS: The average age was 61.5 years, and average Charlson Comorbidity Index (CCI) was 2.1; 106 (70.2%) patients were diagnosed with rheumatoid arthritis (RA), and 70 (46.4%) patients were receiving prednisolone. In the multivariable logistic regression model, ages between 50 and 69 years (odds ratio (OR) = 5.85; 95% confidence interval (CI) = 1.35-25.25) and older than 70 years (OR = 5.29; 95% CI = 1.21-23.14), prior prednisolone treatment (OR = 7.09; 95% CI = 2.63-19.11) and vaccination status including one and two doses (OR = 0.19; 95% CI = 0.05-0.69) and three and four doses (OR = 0.09; 95% CI = 0.02-0.35) were all statistically significant factors related to changes in the severity level of COVID-19. CONCLUSION: Severity of COVID-19 infection in patients with AIIRD is affected by age, background steroid use and vaccination status. Factors including sex, comorbidity, diagnosis of AIIRDs and use of DMARDs, including conventional synthetic, biologics and targeted DMARDs, were not significantly associated with COVID-19 severity.
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Bilateral coordination is commonly impaired in neurodevelopmental conditions including cerebral palsy, developmental coordination disorder, and autism spectrum disorder. However, we lack objective clinical assessments that can quantify bilateral coordination in a clinically feasible manner and determine age-based norms to identify impairments. The objective of this study was to use augmented reality and computer vision to characterize bilateral reaching abilities in typically developing children. Typically developing children (n = 133) ages 6-17 years completed symmetric and asymmetric bilateral reaching tasks in an augmented reality game environment. We analyzed the number of target pairs they could reach in 50 s as well as the time lag between their hands reaching the targets. We found that performance on both tasks developed in parallel, with development slowing but not plateauing after age 12. Children performed better on the symmetric task than asymmetric, both in targets reached and with shorter hand lags. Variability between children in hand lag decreased with age. We also found gender differences with females outperforming males, which were most pronounced in the 10-11 year olds. Overall, this study demonstrates parallel development through childhood and adolescence of symmetric and asymmetric reaching abilities. Furthermore, it demonstrates the ability to quantify bilateral coordination using computer vision and augmented reality, which can be applied to assess clinical populations.
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Realidad Aumentada , Desempeño Psicomotor , Humanos , Niño , Masculino , Femenino , Adolescente , Desempeño Psicomotor/fisiología , Juegos de Video , Desarrollo Infantil/fisiología , Lateralidad Funcional , Destreza Motora/fisiología , Mano/fisiología , Factores SexualesRESUMEN
Antiviral agents with activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have played a critical role in disease management; however, little is known regarding the efficacy of these medications in the treatment of SARS-CoV-2 infection in immunocompromised patients, particularly in the management of persistent SARS-CoV-2 positivity. This narrative review discusses the management of persistent coronavirus disease 2019 in immunocompromised hosts, with a focus on antiviral therapies. We identified 84 cases from the literature describing a variety of approaches, including prolonged antiviral therapy (n = 11), combination antivirals (n = 13), and mixed therapy with antiviral and antibody treatments (n = 60). A high proportion had an underlying haematologic malignancy (n = 67, 80%), and were in receipt of anti-CD20 agents (n = 51, 60%). Success was reported in 70 cases (83%) which varied according to the therapy type. Combination therapies with antivirals may be an effective approach for individuals with persistent SARS-CoV-2 positivity, particularly those that incorporate treatments aimed at increasing neutralizing antibody levels. Any novel approaches taken to this difficult management dilemma should be mindful of the emergence of antiviral resistance.
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Antivirales , Tratamiento Farmacológico de COVID-19 , COVID-19 , Huésped Inmunocomprometido , SARS-CoV-2 , Humanos , Antivirales/uso terapéutico , SARS-CoV-2/inmunología , COVID-19/inmunología , Quimioterapia Combinada , Anticuerpos Neutralizantes/uso terapéuticoRESUMEN
BACKGROUND: Staphylococcus aureus bloodstream infection (bacteraemia) is traditionally treated with at least two weeks of IV antibiotics in adults, 3-7 days in children, and often longer for those with complicated disease. The current practice of treating S. aureus bacteraemia (SAB) with prolonged IV antibiotics (rather than oral antibiotics) is based on historical observational research and expert opinion. Prolonged IV antibiotic therapy has significant disadvantages for patients and healthcare systems, and there is growing interest in whether a switch to oral antibiotics following an initial period of IV therapy is a safe alternative for clinically stable patients. PROTOCOL: The early oral switch (EOS) domain of the S. aureus Network Adaptive Platform (SNAP) trial will assess early switch to oral antibiotics compared with continued IV treatment in clinically stable patients with SAB. The primary endpoint is 90-day all-cause mortality. Hospitalised SAB patients are assessed at platform day 7 +/- 2 (uncomplicated SAB) and day 14 +/-2 (complicated SAB) to determine their eligibility for randomisation to EOS (intervention) or continued IV treatment (current standard of care). DISCUSSION: Recruitment is occurring to the EOS domain of the SNAP trial. As of August 2023, 21% of all SNAP participants had been randomised to the EOS domain, a total of 264 participants across 77 centres, with an aim to recruit at least 1000 participants. We describe challenges and facilitators to enrolment in this domain to aid those planning similar trials.
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Coronavirus disease 2019 (COVID-19) in immunocompromised patients can lead to severe and prolonged illness. Data are limited with regard to management of COVID-19 in this setting, particularly in persistent or recrudescent infection. The authors conducted an online survey among infectious diseases doctors to determine current approaches to treatment across Australasia. There was marked variability in responses relating to the diagnostic modalities and use of antiviral agents in patients with immunocompromise, highlighting the need for high-quality studies to guide treatment decisions in this group.
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COVID-19 , Humanos , Antivirales/uso terapéutico , Huésped Inmunocomprometido , Encuestas y Cuestionarios , Australasia/epidemiologíaRESUMEN
INTRODUCTION AND IMPORTANCE: Parastomal evisceration is a very uncommon complication of a stoma, with only a few cases currently published in the literature. It may occur either early or late following either ileostomy or colostomy and has been reported in both the emergency and elective setting. The aetiology is likely multifactorial, but a few risk factors have been identified that predispose to its occurrence. Early recognition and prompt surgical evaluation is necessary, and management depends on patient, pathologic and environmental factors. CASE PRESENTATION: A 50-year-old man with an obstructing rectal cancer underwent elective surgery for the creation of a temporary loop ileostomy prior to commencement of neoadjuvant chemotherapy (capecitabine and oxaliplatin). His background included obesity, alcohol excess and he was a current smoker. His postoperative course was complicated by a non-obstructing parastomal hernia which was managed non-operatively in the context of his neoadjuvant therapy. Seven months after his loop ileostomy and three days post his sixth cycle of chemotherapy, he presented to the emergency department with signs of shock and evisceration of small bowel via a dehiscence of the mucocutaneous junction at the superior aspect of the loop ileostomy. We discuss this unusual case of late parastomal evisceration. CLINICAL DISCUSSION: Parastomal evisceration is caused by a mucocutaneous dehiscence. Risk factors such as coughing, increased intra-abdominal pressure, emergency surgery, and stomal prolapse or hernia can all be predisposing factors. CONCLUSION: Parastomal evisceration is a life-threatening complication that requires urgent assessment, resuscitation, and early referral to the surgical team for intervention.
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BACKGROUND: Performing lumbar punctures carries a risk of harm to the patient, but the information cerebrospinal fluid provides often makes this procedure necessary. Clinicians in the Australian setting would benefit from having more information on these procedures, in order to help them in a risk versus benefit analysis. AIMS: To describe the contemporary indications, cerebrospinal fluid findings and complications of lumbar punctures in a metropolitan Australian health service. METHODS: Retrospective electronic medical records audit of lumbar punctures performed on 525 adults within three acute hospitals between 1 July 2018 and 30 June 2019. Main outcome measures include frequency of indication for lumbar puncture by category, normal versus abnormal cerebrospinal fluid for each category, and frequency, severity and type of complications of lumbar punctures. RESULTS: Of 525 adult lumbar punctures that were assessed in this study, 466 were performed for a diagnostic indication. The most common diagnostic indications were acute severe headache (156 procedures; 33.5%) and encephalopathy (128 procedures; 27.5%). The yield of abnormal results varied by indication category, with the above indications yielding abnormal results in 85 (54.5%) and 72 (56.3%) cases respectively. A complication was recorded in 54 (10.3% of total) procedures. The majority (45; 8.6%) of complications were minor in severity and most frequently consisted of post-dural puncture headache (PDPH). CONCLUSIONS: In the era of an increased reliance on high quality neuroimaging, lumbar puncture has a high diagnostic yield with a low rate of major complications. The most common complication is PDPH, which is mild and self-limiting in most cases.
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Cefalea Pospunción de la Duramadre , Punción Espinal , Adulto , Humanos , Punción Espinal/efectos adversos , Estudios Retrospectivos , Australia/epidemiología , Cefalea Pospunción de la Duramadre/etiología , Cefalea Pospunción de la Duramadre/complicaciones , Cefalea/etiologíaRESUMEN
BACKGROUND/OBJECTIVE: Advice given to patients on driving resumption after total hip arthroplasty (THA) is inconsistent. Due to a lack of clear guidelines, surgeons' recommendations range between 4-8 weeks after surgery to resume driving. Delays in driving return can have detrimental social and economic impact. However, it is important to ensure patients only resume driving once safe. This study presents a systematic review and meta-analysis of driving simulation studies after THA to establish when patients can safely return to driving postoperatively. METHODS: A systematic review and meta-analysis using PRISMA guidelines was undertaken. Titles and abstracts were screened for inclusion, data was extracted, and studies assessed for bias risk. Review Manager, was used for statistical analysis. Values for brake reaction time (BRT) were included for meta-analysis. RESULTS: 14 articles met the inclusion criteria. Of these, 7 measured BRT and were included in the meta-analysis. Pooled means of both right and left THA showed BRT around or above preoperative baseline at 1 week, 2 weeks and 3 weeks, and below baseline at 6 weeks, 12 weeks, 32 weeks and 52 weeks. Of these, the pooled means at 6, 32, and 52 weeks were significant (p < 0.05).Studies not meeting meta-analysis inclusion criteria were included in a qualitative analysis, examining self-reported postoperative driving return times which ranged from 6 days to over a year or in rare cases, never. Majority of patients (n = 960) self-reported driving return within approximately 6 weeks (pooling of mean values 32.9 days). CONCLUSIONS: The mean return to driving time recommended in the literature was 4.5 weeks. Based upon BRT meta-analysis, a return to baseline braking performance was noted at 6 weeks postoperatively. However, driving is a complex skill, and patient recommendation should be individualised based on factors such as vehicle transmission type, THA technique, surgical side, medication and comorbidities.
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Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Conducción de Automóvil , Humanos , Tiempo de Reacción , Periodo PosoperatorioRESUMEN
OBJECTIVES: To determine the negative predictive value (NPV) of the FebriDx point-of-care host response device in patients presenting with symptoms suggestive of COVID-19 infection in a mostly immunised Australian emergency department (ED) population during the late 2021 phase of the COVID-19 pandemic. DESIGN: Observational diagnostic accuracy study comparing FebriDx point-of-care test to SARS-CoV-2 PCR. SETTING: An ED in Melbourne, Australia, with 63 000 annual presentations in 2021. PARTICIPANTS: Patients aged 16 and over who met the Victorian Department of Health case definition for suspected COVID-19 infection PCR testing. Patients meeting any of the following criteria were excluded: <16 years of age; acute respiratory symptom(s) with onset>14 days prior to testing; current immunosuppressive or interferon therapy; live immunisation within the last 30 days; fever lasting>7 days; antibiotic or antiviral use in the preceding 14 days; experience of major trauma, major surgical intervention or severe burns within the last 30 days. PRIMARY AND SECONDARY OUTCOME MEASURES: COVID-19 PCR results (detected, not detected) and FebriDx results (bacterial positive, viral negative, viral positive). RESULTS: 94 participants were enrolled (female: 46; male: 48), 34% of participants (tested positive for COVID-19 according to PCR results, with a background incidence among all adult ED attenders of 2.5%. The sensitivity of FebriDx for detection of COVID-19 was 56% (95% CI 40% to 100%) and specificity was 92% (95% CI 84% to 100%). For the population tested, this resulted in an NPV of 80% (95% CI 71% to 100%) and a positive predictive value of 78% (95% CI 60% to 100%). CONCLUSIONS: In the context of a population with low COVID-19 infection rates, an evolved variant of COVID-19 and a very high community COVID-19 vaccination rate, FebriDx demonstrated reduced sensitivity and NPV relative to results from earlier international tests. These contextual factors should be considered during any attempt to generalise the current results. TRIAL REGISTRATION NUMBER: ACTRN12620001029987 (Australian Clinical Trials).
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COVID-19 , Adulto , Humanos , Masculino , Femenino , Adolescente , COVID-19/diagnóstico , COVID-19/epidemiología , Valor Predictivo de las Pruebas , SARS-CoV-2 , Pandemias , Vacunas contra la COVID-19 , Australia/epidemiología , Pruebas en el Punto de Atención , Servicio de Urgencia en HospitalRESUMEN
Background: COVID-19 has affected many healthcare workers (HCWs) globally. We performed state-wide SARS-CoV-2 genomic epidemiological investigations to identify HCW transmission dynamics and provide recommendations to optimise healthcare system preparedness for future outbreaks. Methods: Genome sequencing was attempted on all COVID-19 cases in Victoria, Australia. We combined genomic and epidemiologic data to investigate the source of HCW infections across multiple healthcare facilities (HCFs) in the state. Phylogenetic analysis and fine-scale hierarchical clustering were performed for the entire dataset including community and healthcare cases. Facilities provided standardised epidemiological data and putative transmission links. Findings: Between March-October 2020, approximately 1,240 HCW COVID-19 infection cases were identified; 765 are included here, requested for hospital investigations. Genomic sequencing was successful for 612 (80%) cases. Thirty-six investigations were undertaken across 12 HCFs. Genomic analysis revealed that multiple introductions of COVID-19 into facilities (31/36) were more common than single introductions (5/36). Major contributors to HCW acquisitions included mobility of staff and patients between wards and facilities, and characteristics and behaviours of patients that generated numerous secondary infections. Key limitations at the HCF level were identified. Interpretation: Genomic epidemiological analyses enhanced understanding of HCW infections, revealing unsuspected clusters and transmission networks. Combined analysis of all HCWs and patients in a HCF should be conducted, supported by high rates of sequencing coverage for all cases in the population. Established systems for integrated genomic epidemiological investigations in healthcare settings will improve HCW safety in future pandemics. Funding: The Victorian Government, the National Health and Medical Research Council Australia, and the Medical Research Future Fund.
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This audit reviewed the impact on access to routine medical care and adverse outcomes in patients with suspected SARS-CoV-2 infection managed on a 'COVID-19' (CV) ward compared with a general medicine ward at Box Hill Hospital, Victoria. Data were collected at two time points to capture changes associated with onsite testing. We found no healthcare delays from admission to CV wards and observed faster exits from CV wards with improved testing efficiency. This critical finding is relevant as Victoria manages a third wave of infections.
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COVID-19 , SARS-CoV-2 , Hospitales , Humanos , Control de Infecciones , Pacientes InternosRESUMEN
BACKGROUND: There is limited evidence available on return to driving for patients undergoing knee arthroplasty (KA). Primarily, surgeons have used brake reaction time as a surrogate measure of safe return to driving. The purpose of this study was to review existing literature and provide guidance on the recovery of braking performance following knee arthroplasty. METHODS: A literature search was performed for prospective studies on driving after KA. Two reviewers screened citations for inclusion, assessed methodological quality, and extracted data. Values for total brake reaction-time (TBRT), movement-time (MT), reaction-time (RT), and braking-force (BF) were included for meta-analysis. RESULTS: Twelve studies with 368 subjects were identified. TBRT, RT, MT, and BF relative to preoperative baseline were assessed. Meta-analysis of TBRT showed a significant improvement from preoperative baseline at 3â¯months & 1â¯year (pâ¯=â¯0.003 & pâ¯=â¯0.0001). MT showed a significant increase at 2 and 4â¯weeks (pâ¯=â¯0.00001 & pâ¯=â¯0.03) before returning to no being significantly different at 6â¯weeks and beyond. In contrast RTs were noted to improve significantly 2â¯weeks (pâ¯=â¯0.006), 4â¯weeks (pâ¯=â¯0.03), and 1â¯year (pâ¯=â¯0.0002). CONCLUSION: Meta-analysis showed no significant difference in TBRT up until 3â¯months. RT increased significantly post-operatively suggesting it is not a reliable indicator. MT in contrast was significantly decreased post KA and may represent a more reliable measure of braking performance post KA. Surgeons should consider these recommendations and other patient factors that determine fitness to drive prior to advising their patients on a safe to return to driving.
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Artroplastia de Reemplazo de Rodilla , Conducción de Automóvil , Tiempo de Reacción/fisiología , Artroplastia de Reemplazo de Rodilla/rehabilitación , Humanos , Aptitud Física , Periodo Posoperatorio , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Delays to diagnosis of anterior cruciate ligament (ACL) injury and specialist consultation continue to place patients at risk of early onset osteoarthritis. Incorporating acute knee clinics within a streamlined accident and emergency (A&E) pathway have shown potential in reducing delay but specific evaluative research is lacking. The aim of this service evaluation was to investigate the effectiveness of an acute knee clinic at one NHS Trust in the United Kingdom (UK), on reducing the delay to diagnosis of ACL injury and specialist consultation compared to a standard A&E pathway. METHODS: An uncontrolled before and after design was utilised for this service evaluation. Data were collected from historical electronic patient records over a 1-year period with analysed results compared against previously collected data from the same NHS Trust. RESULTS: 81 records met the criteria for the streamlined A&E pathway and were compared against 50 from the standard A&E pathway. For the streamlined A&E pathway median delay to diagnosis reduced from 97 to 14 days and delay to specialist consultation reduced from 158.5 to 45 days and were of statistical significance. The incorporation of an acute knee clinic was identified as the most influential factor on delay in addition to the location of presentation and mechanism of injury. CONCLUSIONS: Introducing an acute knee clinic within a streamlined A&E pathway has a clinically relevant effect on reducing delay to diagnosis and specialist consultation and allows findings to be extrapolated and implemented to all UK based NHS Trust A&E departments.
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Lesiones del Ligamento Cruzado Anterior/diagnóstico , Medicina de Emergencia/organización & administración , Adulto , Lesiones del Ligamento Cruzado Anterior/diagnóstico por imagen , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Derivación y Consulta , Reino Unido , Adulto JovenRESUMEN
BACKGROUND: Surgical site infections (SSIs) are morbid and costly complications after elective colorectal surgery. SSI prevention bundles have been shown to reduce SSI in colorectal surgery, but their impact on organ space infections (OSI) is variable. Adoption of an evidence-based practice without an implementation strategy is often unsuccessful. Our aim was to successfully implement an OSI prevention bundle and to achieve a cost-effective reduction in OSI following elective left-sided colorectal operations. METHODS: The Translating Research into Practice model was used to implement an OSI prevention bundle in all patients undergoing elective left-sided colorectal resections by a single unit from November 2018 to September 2019. The new components included oral antibiotics with mechanical bowel preparation, when required, and use of impermeable surgical gowns. Other standardised components included alcoholic chlorhexidine skin preparation, glove change after bowel handling prior to wound closure with clean instruments. The primary outcome was OSI. Secondary outcomes included bundle compliance, unintended consequences and total patient costs. Outcomes were compared with all patients undergoing elective left-sided colorectal resections at the same institution in 2017. RESULTS: Elective colorectal resections were performed in 173 patients across two cohorts. The compliance rate with bundle items was 63% for all items and 93% for one omitted item. There was a reduction in OSI from 12.9% (11 of 85) to 3.4% (3 of 88, p<0.05) after implementation of the OSI prevention bundle. The average cost of an OSI was $A36 900. The estimated savings for preventing eight OSIs by using the OSI bundle in the second cohort was $A295 198. CONCLUSION: Successful implementation of an OSI prevention bundle was associated with a reduced rate of OSI after elective colorectal surgery. The OSI bundle and its implementation were cost-effective. Further study is required to investigate the sustainability of the OSI prevention bundle.
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Cirugía Colorrectal , Antibacterianos/uso terapéutico , Estudios de Cohortes , Cirugía Colorrectal/efectos adversos , Procedimientos Quirúrgicos Electivos/efectos adversos , Humanos , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
BACKGROUND: Healthcare workers (HCW) are exposed to an increased risk of COVID-19 through direct contact with patients and patient environments. We calculated the; seroprevalence of SARS-CoV-2 in HCW at Eastern Health, a tertiary healthcare network in Victoria, and assessed associations with demographics, work location and role. METHODS: A cross-sectional cohort study of HCW at Eastern Health was conducted. Serum was analysed for the presence of antibodies to SARS-CoV-2, and all participants completed; an online survey collecting information on demographics, place of work, role, and exposures; to COVID-19. Seroprevalence was calculated as the proportion participants with SARS-CoV-2; antibodies out of all tested individuals. RESULTS: The crude seroprevalence of SARS-CoV-2 antibodies in this study was 2.17% (16/736). Thirteen of the 16 (81.2%) positive cases had previously been diagnosed with COVID-19 by PCR: the seroprevalence in the group not previously diagnosed with COVID by PCR was 0.42% (3/720). Having direct contact with COVID-19 patients did not increase the likelihood of having positive serology. A prior history of symptoms consistent with COVID-19 was associated with a higher likelihood of having positive serology (OR 17.2, p = 0.006, 95%CI: 2.25-131.55). CONCLUSION: Our calculated seroprevalence of 2.17% is higher than estimated in the general Australian population, but lower than that reported in HCW internationally. The; majority of those with positive serology in our study had previously been diagnosed with COVID-19 by PCR based testing. Seropositivity was not associated with interaction with COVID-19 positive patients, highlighting effective infection prevention and control practices within the workplace.
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Anticuerpos Antivirales/sangre , COVID-19/sangre , Personal de Salud/estadística & datos numéricos , SARS-CoV-2/inmunología , Adulto , Anciano , COVID-19/epidemiología , Estudios de Cohortes , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , SARS-CoV-2/genética , Estudios Seroepidemiológicos , Atención Terciaria de Salud/estadística & datos numéricos , Victoria/epidemiología , Adulto JovenRESUMEN
PURPOSE: To consolidate the evidence from the available literature and undertake a meta-analysis to provide a reference for physicians to make evidence-based recommendations to their patients regarding the return to driving after hip or knee arthroscopic procedures. METHODS: A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The OVID, Embase, and Cochrane databases were searched through June 2020 for articles containing keywords and/or MeSH (Medical Subject Headings) terms "hip arthroscopy" and "knee arthroscopy" in conjunction with "total brake response time" or "reaction time" in the context of automobile driving. A title review and full article review were performed to assess quality and select relevant articles. A meta-analysis of qualifying articles was undertaken. RESULTS: Eight studies met the inclusion criteria for meta-analysis of brake reaction time (BRT). Meta-analysis of all knee BRTs showed times slower than or equal to baseline BRTs through 5 weeks, with a trend of improving BRTs from 6 to 10 weeks (weeks 8 and 10 were significant, P < .05). Among all hip BRTs, week 2 showed times slower than baseline BRTs, but after week 4, a trend toward faster BRTs was observed through week 8 (week 8 was significant, P < .05). CONCLUSIONS: BRTs met baseline or control values and continued to improve after 6 weeks after knee arthroscopy and after 4 weeks after hip arthroscopy. On the basis of these results, it would be safe to recommend a return to driving at 6 weeks after knee arthroscopic procedures and 4 weeks after hip arthroscopic procedures. CLINICAL RELEVANCE: These results can be used by surgeons to base their recommendations on to provide guidance for their patients on the resumption of driving. Although BRT is an important aspect of driving ability, there are additional factors that need to be taken into consideration when making these recommendations, including cessation of opioid analgesics, strength of the surgical limb, and range of motion.
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Importance: Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with mortality of more than 20%. Combining standard therapy with a ß-lactam antibiotic has been associated with reduced mortality, although adequately powered randomized clinical trials of this intervention have not been conducted. Objective: To determine whether combining an antistaphylococcal ß-lactam with standard therapy is more effective than standard therapy alone in patients with MRSA bacteremia. Design, Setting, and Participants: Open-label, randomized clinical trial conducted at 27 hospital sites in 4 countries from August 2015 to July 2018 among 352 hospitalized adults with MRSA bacteremia. Follow-up was complete on October 23, 2018. Interventions: Participants were randomized to standard therapy (intravenous vancomycin or daptomycin) plus an antistaphylococcal ß-lactam (intravenous flucloxacillin, cloxacillin, or cefazolin) (n = 174) or standard therapy alone (n = 178). Total duration of therapy was determined by treating clinicians and the ß-lactam was administered for 7 days. Main Outcomes and Measures: The primary end point was a 90-day composite of mortality, persistent bacteremia at day 5, microbiological relapse, and microbiological treatment failure. Secondary outcomes included mortality at days 14, 42, and 90; persistent bacteremia at days 2 and 5; acute kidney injury (AKI); microbiological relapse; microbiological treatment failure; and duration of intravenous antibiotics. Results: The data and safety monitoring board recommended early termination of the study prior to enrollment of 440 patients because of safety. Among 352 patients randomized (mean age, 62.2 [SD, 17.7] years; 121 women [34.4%]), 345 (98%) completed the trial. The primary end point was met by 59 (35%) with combination therapy and 68 (39%) with standard therapy (absolute difference, -4.2%; 95% CI, -14.3% to 6.0%). Seven of 9 prespecified secondary end points showed no significant difference. For the combination therapy vs standard therapy groups, all-cause 90-day mortality occurred in 35 (21%) vs 28 (16%) (difference, 4.5%; 95% CI, -3.7% to 12.7%); persistent bacteremia at day 5 was observed in 19 of 166 (11%) vs 35 of 172 (20%) (difference, -8.9%; 95% CI, -16.6% to -1.2%); and, excluding patients receiving dialysis at baseline, AKI occurred in 34 of 145 (23%) vs 9 of 145 (6%) (difference, 17.2%; 95% CI, 9.3%-25.2%). Conclusions and Relevance: Among patients with MRSA bacteremia, addition of an antistaphylococcal ß-lactam to standard antibiotic therapy with vancomycin or daptomycin did not result in significant improvement in the primary composite end point of mortality, persistent bacteremia, relapse, or treatment failure. Early trial termination for safety concerns and the possibility that the study was underpowered to detect clinically important differences in favor of the intervention should be considered when interpreting the findings. Trial Registration: ClinicalTrials.gov Identifier: NCT02365493.
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Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Daptomicina/uso terapéutico , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas/tratamiento farmacológico , Vancomicina/uso terapéutico , beta-Lactamas/uso terapéutico , Adulto , Anciano , Antibacterianos/efectos adversos , Bacteriemia/microbiología , Bacteriemia/mortalidad , Cefazolina/uso terapéutico , Cloxacilina/uso terapéutico , Quimioterapia Combinada , Endocarditis Bacteriana/tratamiento farmacológico , Femenino , Floxacilina/uso terapéutico , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/mortalidad , Insuficiencia del Tratamiento , beta-Lactamas/efectos adversosRESUMEN
OBJECTIVES: This study investigated the biomechanical performance of decellularized porcine superflexor tendon (pSFT) grafts of varying diameters when utilized in conjunction with contemporary ACL graft fixation systems. This aimed to produce a range of 'off-the-shelf' products with predictable mechanical performance, depending on the individual requirements of the patient. METHODS: Decellularized pSFTs were prepared to create double-bundle grafts of 7 mm, 8 mm, and 9 mm diameter. Femoral and tibial fixation systems were simulated utilizing Arthrex suspension devices and interference screws in bovine bone, respectively. Dynamic stiffness and creep were measured, followed by ramp to failure from which linear stiffness and load at failure were measured. The mechanisms of failure were also recorded. RESULTS: Dynamic stiffness was found to increase with greater graft diameter, with significant differences between all groups. Conversely, dynamic creep reduced with increasing graft diameter with significant differences between the 7 mm and 9 mm groups and the 8 mm and 9 mm groups. Significant differences were also found between the 7 mm, 8 mm, and 9 mm groups for linear stiffness, but no significant differences were found between groups for load at failure. The distribution of failure mechanisms was found to change with graft diameter. CONCLUSION: This study showed that decellularized pSFTs demonstrate comparable biomechanical properties to other ACL graft options and are a potentially viable option for ACL reconstruction. Although grafts can be stratified by their diameter to provide varying biomechanical properties, it may be more appropriate to alter the fixation technique to stratify for a greater diversity of biomechanical requirements.Cite this article: Bone Joint Res 2019;8:518-525.
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INTRODUCTION: The initiation of a kidney transplant program, in a low- and middle-income country, while striving to maintain excellent outcomes and adhere to high ethical, legal standards, is a formidable task. Herein, we review the outcomes and challenges of a living donor kidney transplant program from its inception to sustainability, in Guyana, South America. METHODS: This is a retrospective review of a living donor kidney transplant program instituted in Guyana in 2008. Data included recipient and donor demographics, cause of renal failure, donor-recipient matching and relationship, perioperative complications, timing and cause of death, graft failure, surgical technique, and laterality of organ procured. Patient and donor data were compared by phases and additionally compared to United States Renal Data Base System. Survival outcomes were compared by phases and by Kaplan-Meier curves. RESULTS: To date, 45 kidney transplants have been completed. Phase I (2007-2008) was the initiation of the program, which was comprised of upgrading hospital and operating rooms, obtaining antirejection medications, educating local providers, fostering a relationship with the government, and screening patients and living donors. We also began vascular access and peritoneal dialysis in the country, as well as introduced the companion public health service initiative: the SEVAK program. Phase II (2008-2014) involved completion of 25 living donor kidney transplants, of which there have been 11 confirmed deaths and 10 lost to follow-up. In Phase III (2015-present), 20 transplants have been completed to date, of whom only 1 died and none were lost to follow-up. In the third phase, we also introduced corneal transplantation to Guyana and have performed over 100 transplants. CONCLUSION: Kidney transplantation can be safely and ethically performed in a low- and middle-income country. We applied lessons learnt from the first two phases to improve follow-up by appointing a local coordinator who goes to patient's homes in remote villages. Currently, there is a stable local team that is performing transplants and following the patients. We believe that our model of public-private partnership can sustain kidney, as well as corneal, transplantation and could be replicated in other countries.
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Trasplante de Riñón , Adulto , Países en Desarrollo , Femenino , Humanos , Trasplante de Riñón/métodos , Donadores Vivos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
RATIONALE & OBJECTIVE: There is debate on whether weight loss, a hallmark of frailty, signals higher risk for adverse outcomes among recipients of deceased donor kidney transplantation (DDKT). STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Using national Organ Procurement and Transplantation Network data, we included all DDKT recipients in the United States between December 4, 2004, and December 3, 2014, who were adults (aged ≥ 18 years) when listed for DDKT. EXPOSURES: Relative pre-DDKT weight change as a continuous predictor and categorized as <5% weight change from listing to DDKT, ≥5% to <10% weight loss, ≥10% weight loss, ≥5% to <10% weight gain, and ≥10% weight gain. OUTCOMES: We examined 3 post-DDKT outcomes: (1) transplant hospitalization length of stay (LOS) in days, (2) all-cause graft failure, and (3) mortality. ANALYTIC APPROACH: Unadjusted fractional polynomial methods, multivariable log-gamma models, and multivariable Cox proportional hazards models. RESULTS: Among 94,465 recipients of DDKT, median pre-DDKT weight change was 0 (interquartile range, -3.5 to +3.9) kg. There were nonlinear unadjusted associations between relative pre-DDKT weight loss and longer transplant hospitalization LOS, higher all-cause graft loss, and higher mortality. Compared with recipients with <5% pre-DDKT weight change (n = 49,366; 52%), recipients who lost ≥10% of their listing weight (n = 10,614; 11%) had 0.66 (95% CI, 0.23-1.09) days longer average transplant hospitalization LOS (P = 0.003), 1.11-fold higher graft loss (adjusted HR [aHR], 1.11; 95% CI, 1.06-1.17; P < 0.001), and 1.18-fold higher mortality (aHR, 1.18; 95% CI, 1.11-1.25; P < 0.001) independent of recipient, donor, and transplant factors. Pre-DDKT dialysis exposure, listing body mass index category, and waiting time modified the association of pre-DDKT weight change with hospital LOS (interaction P < 0.10), but not with all-cause graft loss and mortality. LIMITATIONS: Unmeasured confounders and inability to identify volitional weight change. Also, the higher significance level set to increase the power of detecting interactions with the fixed sample size may have resulted in increased risk for type 1 error. CONCLUSIONS: DDKT recipients with ≥10% pre-DDKT weight loss are at increased risk for adverse outcomes and may benefit from augmented support post-DDKT.