Not all hip arthroplasties are created equal: increased complications and re-admissions after total hip arthroplasty for femoral neck fractures compared with osteoarthritis.

AIMS: Total hip arthroplasty (THA) is gaining popularity as a treatment for displaced femoral neck fractures (FNFs), especially in physiologically younger patients. While THA for osteoarthritis (OA) has demonstrated low complication rates and increased quality of life, results of THA for acute FNF are not as clear. Currently, a THA performed for FNF is included in an institutional arthroplasty bundle without adequate risk adjustment, potentially placing centres participating in fracture care at financial disadvantage. The purpose of this study is to report on perioperative complication rates after THA for FNF compared with elective THA performed for OA of the hip. PATIENTS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2008 and 2016 was queried. Patients were identified using the THA Current Procedural Terminology (CPT) code and divided into groups by diagnosis: OA in one and FNF in another. Univariate statistics were performed. Continuous variables were compared between groups using Student's t-test, and the chi-squared test was used to compare categorical variables. Multivariate and propensity-matched logistic regression analyses were performed to control for risk factors of interest. RESULTS: Analyses included 139 635 patients undergoing THA. OA was the indication in 135 013 cases and FNF in 4622 cases. After propensity matching, mortality within 30 days (1.8% vs 0.3%; p < 0.001) and major morbidity (24.2% vs 19%; p < 0.001) were significantly higher among FNF patients. Re-operation (3.7% vs 2.7%; p = 0.014) and re-admission (7.3% vs 5.5%; p = 0.002) were significantly higher among FNF patients. Hip fracture patients had significantly longer operative time and length of stay (LOS), and were significantly less likely to be discharged to their home. Multivariate analyses gave similar results. CONCLUSION: This large database study showed a higher risk of postoperative complications including mortality, major morbidity, re-operation, re-admission, prolonged operative time, increased LOS, and decreased likelihood of discharge home in patients undergoing THA for FNF compared with OA. While THA is a good option for FNF patients, there are increased costs and financial risks to centres with a joint arthroplasty bundle programme participating in fracture care. Cite this article: Bone Joint J 2019;101-B(6 Supple B):84-90.

'Hot Joints' infection protocol reduces unnecessary post-operative re-admissions following total hip and knee arthroplasty.

AIMS: To evaluate the effectiveness of an institutionally developed algorithm for evaluation and diagnosis of prosthetic joint injection and to determine the impact of this protocol on overall hospital re-admissions.p PATIENTS AND METHODS: We retrospectively evaluated 2685 total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients prior to (1263) and following (1422) the introduction of an infection detection protocol. The protocol used conservative thresholds for C-reactive protein to direct the medical attendant to aspirate the joint. The protocol incorporated a clear set of laboratory and clinical criteria that allowed a patient to be discharged home if all were met. Patients were included if they presented to our emergency department within 120 days post-operatively with concerns for swelling, pain or infection and were excluded if they had an unambiguous infection or if their chief complaint was non-orthopaedic in nature. RESULTS: Concern for infection was the single most common (32%) reason for presentation. A total of 296 patients made an emergency visit and were included following THA or TKA. In the pre-protocol cohort, 11 of 27 patients were formally re-admitted to the hospital with concern for infection but only five (45%) patients had actual infections and received additional treatment. In comparison, in the post-protocol cohort, 11 patients were admitted for suspected infection, nine (82%) of whom were truly infected (p = 0.04). Sensitivity increased from 83% to 100% and specificity increased from 71% to 96%. Implementation of this protocol did not miss any infections. CONCLUSION: A standardised protocol for evaluation of THA and TKA infections significantly reduced unnecessary hospital re-admissions. The protocol was both sensitive and specific and did not compromise quality of care. Cite this article: Bone Joint J 2017;99-B:1603-10.

A new approach to managing health in Swine operations.

It is proposed that just as the stethoscope and thermometer are fundamental tools for individual medicine, production and health recording systems are fundamental tools for effective population medicine. Treatment and control of clinical diseases as the primary objective is no longer considered appropriate for livestock population. Disease in populations now describes a deviation between what is happening and what is expected to happen. This redefinition of disease implies that it is of multifactorial origin and thus a different problem solving approach must be implemented. Therefore, a swine enterprise must be considered as a system, a set of interdependent components continuously interacting to produce pork. As a system, it is characterized by certain properties: change, environment, counterintuitive behavior, drift to low performance, interdependency, and organization. A redefinition of diseases implies also that they are not only "treated" but managed. Management consists of planning, monitoring, evaluation, and analysis. For this process to be implemented successfully, a goal-directed recording system providing a farm-based infrastructure for problem solving is essential. Clinical problem solving (diagnosis) is thus based on epidemiological and demographic methods.

Fracture-separation of the distal humeral epiphysis.

Fracture-separation of the distal humeral epiphysis presents problems in diagnosis, radiologic interpretation, and management. All of these problems are affected by the arbitrary division of the affected patients into three age groups. Fortunately, although easily misdiagnosed, this fracture does not bear the inherent disasters of the ununited lateral condylar fracture, the malunited supracondylar fracture, or the untreated elbow dislocation. As with most uncomplicated Type II epiphyseal injuries, healing and childhood remodeling result in satisfactory elbow function. Although rare in incidence, this condition warrants the same critical assessment of, and appropriate attention to detail, as any other elbow problem of childhood.

Presence of interferon in acute- and convalescent-phase sera of humans with influenza or influenza-like illness of undetermined etiology.

Interferon (IFN;titer, greater than 10 units) was present in the acute-phase sera of 30 of 40 subjects with culture and/or serologically documented, naturally acquired influenza A/Brazil/78 (H1N1) and in the acute-phase sera of five of 27 subjects with an influenza-like illness of undetermined etiology. No statistical correlation existed between the quantity of IFN in acute-phase serum and the course of the clinical illness. Antiviral activity in all of nine acute-phase sera and three of four sera obtained on the fifth to seventh days of illness was neutralized to greater than 50% by antibody to virus-induced human leukocyte IFN (HuIFN-alpha). In contrast, none of five sera collected between 21 and 23 days after the onset of illness contained IFN sensitive to neutralization by antibody to HuIFN-alpha. Resistance of IFN in convalescent-phase sera to neutralization by antibody to HuIFN-alpha suggests that multiple IFN species may evolve during viral infections.

Defective oxidative metabolic responses of neutrophils from stressed neonates.

Oxidative metabolic responses of polymorphonuclear leukocytes were assessed in 24 stressed neonates and 22 well, term infants utilizing particulate and soluble stimuli. Stressed neonatal PMNs demonstrated a depressed CL response to zymosan, whereas O2- production for both normal and stressed PMNs of neonates was significantly elevated compared to that in PMNs from adults. These results were not ascribable to phagocytosis since it was comparable in all groups using radiolabeled bacteria. Stressed neonates' PMN responses to soluble stimuli were significantly elevated when compared with those from well neonate and adult controls. Enhanced responses were most prominent in the most severely stressed infants. Treatment of neonates' PMNs with the antioxidants vitamin E and DHB partially corrected the abnormalities, suggesting peroxidative damage to the PMN membrane had occurred. The oxidative metabolic abnormalities of neonates' PMNs are consistent with either a defect in HMPS activity, a defect in functioning of the later portions of the respiratory burst, or a stimulus-specific abnormality in respiratory burst activity.

Lack of effect of oral ribavirin in naturally occurring influenza A virus (H1N1) infection.

A double-blind placebo-controlled trial of ribavirin was conducted in 97 young adult males naturally infected with influenza virus similar to A/Brazil/11/78 (H1N1). Ribavirin was given orally at a dose of 1,000 mg/day for five days beginning within 24 or 48 hr after onset of clinical influenza. The clinical signs and symptoms of influenza and quantitative viral shedding were the same in ribavirin- and placebo-treated groups. Ribavirin treatment was associated with significantly fewer fourfold or greater rises in antibody to influenza A viral antigen by the complement-fixation test, while rises in hemagglutination-inhibiting antibody titers occurred with equal frequency in both groups. The ribavirin-treated group experienced significant increases in bilirubin and in reticulocyte counts after onset of therapy.

A controlled study of a dopa decarboxylase inhibitor (benserazide) in the treatment of schizophrenic patients.

In a double-blind controlled study lasting 6 weeks, 32 schizophrenic patients were randomly assigned to one of two treatments: chlorpromazine or benserazide, a dopa decarboxylase inhibitor. Results on each measure were subject to multifactorial analysis of covariance. Benserazide did not appear to be as effective an antipsychotic medicaiton as chlorpromazine. In fact, chlorpromazine was significantly better on measures of tension, excitement, hallucinatory behavior, thinking disturbance, social interest, and drop-out rate. At the relatively low dosages used in this study, it would seem that benserazide had little effect on the cerebral dopa decarboxylase, and it would be worthwhile trying higher dosages.

Amitriptyline-perphenazine interaction in ambulatory schizophrenic patients. A controled study of drug interaction.

In a double-blind placebo, controlled clinical study, lasting 12 weeks, 48 male and 48 female ambulatory schizophrenic patients were randomly assigned to one of four treatments: placebo; amitriptyline hydrochloride, 125 mg/day; perphenazine, 20 mg/day; or amitriptyline-perphenazine, 20 mg/day. Treatment groups contained an equal number of male and female patients. Perphenazine alone or in combination was substantially more effective in reducing psychopathological disorder than was the placebo, but there was no evidence to indicate the superiority of the amitriptyline-perphenazine combination over perphenazine alone. Amitriptyline alone was not substantially better than placebo and could not be considered an efficacious medication for the maintenance treatment of these patients. Less response to treatment was made by patients with longer-term records of prior hospitalization.