Revision Total Hip Arthroplasty in Octogenarians Compared with Septuagenarians: Is There a Real Difference?

BACKGROUND: The increasing frequency of total hip arthroplasty (THA) as well as an aging population indicate that the need for revision THA will continue to grow, especially in older and potentially medically complex patients. The purpose of this study was to compare THA revision indications, perioperative complications, and readmissions between octogenarian and septuagenarian patients. We hypothesized that patients aged 80 to 89 years would have similar outcomes to patients aged 70 to 79 years undergoing revision THA. METHODS: Between 2008 and 2019, 572 revision THAs were performed at a single tertiary care hospital. Patients were stratified by age group: 70 to 79 years (n = 407) and 80 to 89 years (n = 165). Indication for revision, perioperative medical complications, and 90-day readmission were identified for each patient. Chi-square tests and t-tests were used to compare the groups. Logistic regression was used to assess medical complications and readmissions. RESULTS: Aseptic loosening was a more common indication for revision in patients aged 70 to 79 years (33.4% versus 26.7%; p < 0.001), while periprosthetic fracture was a more common indication for revision in those aged 80 to 89 years (30.9% versus 13.0%). Perioperative medical complications occurred more often in octogenarians (10.9% versus 3.0%; p = 0.001), with arrythmia being the most common type. Patients aged 80 to 89 years were at increased risk for medical complications (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.5 to 7.3; p = 0.004) and readmission (OR, 3.2; 95% CI, 1.7 to 6.3; p < 0.001) when adjusting for body mass index (BMI) and indication for revision. Octogenarians had a higher rate of reoperation following first-time revision than septuagenarians (10.3% versus 4.2%, p = 0.009). CONCLUSIONS: Octogenarians more commonly underwent revision THA for periprosthetic fracture and had higher rates of perioperative medical complications, 90-day readmissions, and reoperations than septuagenarians. Such findings should be considered when counseling patients on both primary and revision THAs. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

BACKGROUND: Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. QUESTIONS/PURPOSES: (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? METHODS: Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. RESULTS: When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. CONCLUSION: We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Skewness in bee and flower phenological distributions.

Phenological distributions are characterized by their central tendency, breadth, and shape, and all three determine the extent to which interacting species overlap in time. Pollination mutualisms rely on temporal co-occurrence of pollinators and their floral resources, and although much work has been done to characterize the shapes of flower phenological distributions, similar studies that include pollinators are lacking. Here, we provide the first broad assessment of skewness, a component of distribution shape, for a bee community. We compare skewness in bees to that in flowers, relate bee and flower skewness to other properties of their phenology, and quantify the potential consequences of differences in skewness between bees and flowers. Both bee and flower phenologies tend to be right-skewed, with a more exaggerated asymmetry in bees. Early-season species tend to be the most skewed, and this relationship is also stronger in bees than in flowers. Based on a simulation experiment, differences in bee and flower skewness could account for up to 14% of pairwise overlap differences. Given the potential for interaction loss, we argue that difference in skewness of interacting species is an underappreciated property of phenological change.

Mortality and Complications Following Early Conversion Arthroplasty for Failed Hip Fracture Surgery.

BACKGROUND: Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA. METHODS: Patients aged 60 years or more undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversions; 247 comparisons) were analyzed for 6-month, 12-month, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications. RESULTS: Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7% conversion versus 6.1% nonconversion, P = .774), 12 months (11% conversion versus 12% nonconversion, P = .999), and 24 months (14% conversion versus 22% nonconversion, P = .163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14% versus 3.2%, P = .001), and medical complications (17% versus 6.1%, P = .006). Inpatient and 90-day orthopaedic complications were similar. CONCLUSION: Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision-making.

Life-history traits predict responses of wild bees to climate variation.

Life-history traits, which are physical traits or behaviours that affect growth, survivorship and reproduction, could play an important role in how well organisms respond to environmental change. By looking for trait-based responses within groups, we can gain a mechanistic understanding of why environmental change might favour or penalize certain species over others. We monitored the abundance of at least 154 bee species for 8 consecutive years in a subalpine region of the Rocky Mountains to ask whether bees respond differently to changes in abiotic conditions based on their life-history traits. We found that comb-building cavity nesters and larger bodied bees declined in relative abundance with increasing temperatures, while smaller, soil-nesting bees increased. Further, bees with narrower diet breadths increased in relative abundance with decreased rainfall. Finally, reduced snowpack was associated with reduced relative abundance of bees that overwintered as prepupae whereas bees that overwintered as adults increased in relative abundance, suggesting that overwintering conditions might affect body size, lipid content and overwintering survival. Taken together, our results show how climate change may reshape bee pollinator communities, with bees with certain traits increasing in abundance and others declining, potentially leading to novel plant-pollinator interactions and changes in plant reproduction.

Safe Use of Adapalene 0.1 % Gel in a non-Prescription Environment.

BACKGROUND: Topical retinoids are the mainstay of acne therapy and, until 2016, were only available by prescription. The margin of safety (MOS) of adapalene for potential teratogenic effects, and its use in pregnancy were investigated as part of the OTC switch. OBJECTIVE: To determine MOS using a maximal usage trial (MUsT) and animal embryo-fetal development studies. To conduct a thorough review of safety data with respect to use of Adapalene 0.1% Gel during pregnancy. METHODS: The MUsT was multicenter, open-label pharmacokinetic study which enrolled adolescents and adult subjects with mainly severe acne vulgaris. The no observable adverse event level (NOAEL) for adapalene teratogenicity was established in rat and rabbit embryo-fetal development studies. An exhaustive review of pregnancy data from multiple safety databases was conducted. RESULTS: The calculated MOS for teratogenicity was 70 for Adapalene 0.1% Gel. For the pregnancy safety review, no pregnancy malformations were attributable to topical adapalene use. LIMITATIONS: Animal studies do not always predict effects in human development. Additionally, safety data is voluntarily reported and intrinsically incomplete. CONCLUSION: Adapalene has a large and reassuring MOS making it suitable for OTC use. No teratogenic risk was identified in a MUsT and Pregnancy Safety Review. Adapalene 0.1% Gel is a safe and effective medication for the treatment of acne in a non-prescription environment. Based on available evidence, use of adapalene during pregnancy does not pose harm to the fetus. J Drugs Dermatol. 2021;20(12):1330-1335. doi:10.36849/JDD.6527.

Reporting and Analyzing Demographics in the Journal of Arthroplasty: Are We Making Progress?

BACKGROUND: Demographic factors, including age, sex, body mass index (BMI), race, and ethnicity have great effects on the outcomes of patients undergoing total joint arthroplasty. A portion of this data is included in nearly every study, but the completeness with which it is reported is variable. The purpose of this study is to investigate the frequency at which demographic information is reported and analyzed through formal statistical methods in randomized controlled trials (RCTs) published in the Journal of Arthroplasty (JOA). METHODS: A systematic review was conducted of RCTs published in JOA between 2015 and 2019. For each study, we determined if age, sex, weight, height, BMI, race, and ethnicity were reported and/or analyzed. The overall frequency was assessed, along with the rates of reporting by individual year. Studies were evaluated using Cochrane risk-of-bias tool. RESULTS: Age (96.7%), sex (96.7%), and BMI (80.4%) were reported by the majority of studies. There was very little information provided regarding race (6.2%) and ethnicity (3.8%); although both were reported at the highest frequency in 2019, the final year of articles reviewed. Sex was the most frequently analyzed variable at 11.5%. Only 1 study (0.5%) analyzed ethnicity and no studies analyzed race. CONCLUSION: Although age, sex, and BMI are reported at a high rate, RCTs published in JOA rarely reported information on patient race and ethnicity. Demographics were infrequently included as part of statistical analysis. The importance of this information should be recognized and included in the analysis and interpretation of future studies.

Antibiotic prescribing patterns in patients hospitalized with COVID-19: lessons from the first wave.

BACKGROUND: A high proportion of hospitalized patients with COVID-19 receive antibiotics despite evidence to show low levels of true bacterial coinfection. METHODS: A retrospective cohort study examining antibiotic prescribing patterns of 300 patients sequentially diagnosed with COVID-19. Patients were grouped into 3 sub-cohorts: Group 1 received no antibiotics, Group 2 received antibiotics for microbiologically confirmed infections and Group 3 was empirically treated with antibiotics for pneumonia. The primary aim was to identify factors that influenced prescription and continuation of antibiotics in Group 3. Secondary aims were to examine differences in outcomes between groups. RESULTS: In total, 292 patients were included (63 Group 1, 35 Group 2, 194 Group 3), median age was 60 years (IQR 44-76) and the majority were ethnically Irish (62%). The median duration of antibiotics was 7 days (IQR 5-10). In Group 3, factors associated with prescription IV antibiotics on admission were raised C-reactive protein (CRP) (P = 0.024), increased age (P = 0.023), higher quick SOFA (P = 0.016) score and fever >37.5 °C (P = 0.011). Factors associated with duration of antibiotic course were duration of hypoxia (P < 0.001) and maximum respiratory support requirement (P = 0.013). Twenty-one patients in Group 3 had one or more antibiotic escalation events, most (n = 139) had no escalation or de-escalation of therapy. CONCLUSIONS: Duration of hypoxia and need for respiratory support may have acted as surrogate measures of improvement where usual response measures (CRP, neutrophilia, culture clearance) were absent. Continuous review of antibiotic prescriptions should be at the forefront of clinical management of hospitalized patients with COVID-19.

Bee phenology is predicted by climatic variation and functional traits.

Climate change is shifting the environmental cues that determine the phenology of interacting species. Plant-pollinator systems may be susceptible to temporal mismatch if bees and flowering plants differ in their phenological responses to warming temperatures. While the cues that trigger flowering are well-understood, little is known about what determines bee phenology. Using generalised additive models, we analyzed time-series data representing 67 bee species collected over 9 years in the Colorado Rocky Mountains to perform the first community-wide quantification of the drivers of bee phenology. Bee emergence was sensitive to climatic variation, advancing with earlier snowmelt timing, whereas later phenophases were best explained by functional traits including overwintering stage and nest location. Comparison of these findings to a long-term flower study showed that bee phenology is less sensitive than flower phenology to climatic variation, indicating potential for reduced synchrony of flowers and pollinators under climate change.

Connectivity increases trophic subsidies in fragmented landscapes.

Landscape corridors mitigate the negative effects of habitat fragmentation by increasing dispersal. Corridors also increase biodiversity in connected habitat fragments, suggestive of metacommunity dynamics. What is unknown in this case is the mechanisms through which metacommunity dynamics act. Working in a large-scale fragmentation experiment, we tested the effect of corridors on the movement of prey species and subsequent effects on predator nutrition (which we call trophic subsidies). We enriched plants of central patches with 15 N, then measured δ15 N in green lynx spiders, the most abundant insect predator, in patches that were either connected to or isolated from the enriched patch. We found that corridors increased prey movement, as they increased spider δ15 N by 40% in connected patches. Corridors also improved spider body condition, increasing nitrogen relative to carbon. We suggest a novel mechanism, trophic subsidies, through which corridors may increase the stability or size of populations in connected landscapes.

Interannual bumble bee abundance is driven by indirect climate effects on floral resource phenology.

Climate change can influence consumer populations both directly, by affecting survival and reproduction, and indirectly, by altering resources. However, little is known about the relative importance of direct and indirect effects, particularly for species important to ecosystem functioning, like pollinators. We used structural equation modelling to test the importance of direct and indirect (via floral resources) climate effects on the interannual abundance of three subalpine bumble bee species. In addition, we used long-term data to examine how climate and floral resources have changed over time. Over 8 years, bee abundances were driven primarily by the indirect effects of climate on the temporal distribution of floral resources. Over 43 years, aspects of floral phenology changed in ways that indicate species-specific effects on bees. Our study suggests that climate-driven alterations in floral resource phenology can play a critical role in governing bee population responses to global change.

Detecting sedimentation impacts to coral reefs resulting from dredging the Port of Miami, Florida USA.

The federal channel at Port of Miami, Florida, USA, was dredged between late 2013 and early 2015 to widen and deepen the channel. Due to the limited spatial extent of impact-assessment monitoring associated with the project, the extent of the dredging impacts on surrounding coral reefs has not been well quantified. Previously published remote sensing analyses, as well as agency and anecdotal reports suggest the most severe and largest area of sedimentation occurred on a coral reef feature referred to as the Inner Reef, particularly in the sector north of the channel. A confounding regional warm-water mass bleaching event followed by a coral disease outbreak during this same time frame made the assessment of dredging-related impacts to coral reefs adjacent to the federal channel difficult but still feasible. The current study sought to better understand the sedimentation impacts that occurred in the coral reef environment surrounding Port of Miami, to distinguish those impacts from other regional events or disturbances, and provide supplemental information on impact assessment that will inform discussions on compensatory mitigation requirements. To this end, in-water field assessments conducted after the completion of dredging and a time series analysis of tagged corals photographed pre-, during, and post-dredging, are used to discern dredging-related sedimentation impacts for the Inner Reef north. Results indicate increased sediment accumulation, severe in certain times and places, and an associated biological response (e.g., higher prevalence of partial mortality of corals) extended up to 700 m from the channel, whereas project-associated monitoring was limited to 50 m from the channel. These results can contribute to more realistic prediction of areas of indirect effect from dredging projects needed to accurately evaluate proposed projects and design appropriate compliance monitoring. Dredging projects near valuable and sensitive habitats subject to local and global stressors require monitoring methods capable of discerning non-dredging related impacts and adaptive management to ensure predicted and unpredicted project-related impacts are quantified. Anticipated increasing frequency and intensity of seasonal warming stress also suggests that manageable- but- unavoidable local stressors such as dredging should be partitioned from such seasonal thermal stress events.

The Role of Elevated Lactate as a Risk Factor for Pulmonary Morbidity After Early Fixation of Femoral Shaft Fractures.

OBJECTIVES: To evaluate lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation. DESIGN: Retrospective study. SETTING: Three academic, tertiary care trauma centers. PATIENTS: Age ≥18 years, injury severity score ≥17, admission lactate ≥ 2.5 mmol/L, elevated preoperative lactate = preoperative lactate ≥ 2.5 mmol/L. INTERVENTION: Reamed IMN of femur fracture within 24 hours. MAIN OUTCOME MEASURE: Total duration of mechanical ventilation, pulmonary complications (PC) = duration of mechanical ventilation ≥5 days. RESULTS: Four hundred and fourteen patients identified; 294/414 (71.0%) with admission lactate ≥ 2.5 mmol/L. No difference in PC among the groups (86/294, 29.3% vs. 28/120, 23.3%; P = 0.22). Median admission lactate: 3.7 (interquartile range: 3.0-4.6); median preoperative lactate: 2.8 (interquartile range: 1.9-3.5). 184/294 (62.6%) demonstrated an elevated preoperative lactate (≥ 2.5 mmol/L) before fracture fixation. No difference in elevated preoperative lactate and vent days (4.8 ± 9.9 vs. 3.9 ± 6.0, P = 0.41) or PC (50/86, 58.1% vs. 134/208, 64.4%; P = 0.31). There was no difference in PC when preoperative lactate was considered separately for a lactate ≥3.0 (34/123, 27.6% vs. 52/171, 30.4%; P = 0.61), ≥3.5 (21/79, 26.6% vs. 65/215, 30.2%; P = 0.54), or ≥4.0 (14/50, 28.0% vs. 72/244, 29.5%; P = 0.83). Multivariable linear regression modeling demonstrated that admission lactate [coefficient of variation: 0.84, standard error: 0.33, 95% confidence interval (CI): 0.20-1.49] was correlated with duration of mechanical ventilation, after adjusting for emergency department Glasgow Coma Scale, age, chest Abbreviated Injury Scale (AIS) score, abdominal AIS, and admission glucose. Logistic regression demonstrated admission lactate was also significantly associated with PC (odds ratio: 1.26, 95% CI: 1.03-1.53) after controlling for age, admission Glasgow Coma Scale, chest AIS, abdominal AIS, admission pulse and admission glucose; preoperative lactate was not a risk factor (odds ratio: 0.84, 95% CI: 0.65-1.09) for PC. CONCLUSION: Median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥5 days, whereas median preoperative lactate of 2.8 mmol/L was not, when multisystem trauma patients with a femoral shaft fracture were treated with reamed IMN within 24 hours after admission. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Non-bee insects are important contributors to global crop pollination.

Wild and managed bees are well documented as effective pollinators of global crops of economic importance. However, the contributions by pollinators other than bees have been little explored despite their potential to contribute to crop production and stability in the face of environmental change. Non-bee pollinators include flies, beetles, moths, butterflies, wasps, ants, birds, and bats, among others. Here we focus on non-bee insects and synthesize 39 field studies from five continents that directly measured the crop pollination services provided by non-bees, honey bees, and other bees to compare the relative contributions of these taxa. Non-bees performed 25-50% of the total number of flower visits. Although non-bees were less effective pollinators than bees per flower visit, they made more visits; thus these two factors compensated for each other, resulting in pollination services rendered by non-bees that were similar to those provided by bees. In the subset of studies that measured fruit set, fruit set increased with non-bee insect visits independently of bee visitation rates, indicating that non-bee insects provide a unique benefit that is not provided by bees. We also show that non-bee insects are not as reliant as bees on the presence of remnant natural or seminatural habitat in the surrounding landscape. These results strongly suggest that non-bee insect pollinators play a significant role in global crop production and respond differently than bees to landscape structure, probably making their crop pollination services more robust to changes in land use. Non-bee insects provide a valuable service and provide potential insurance against bee population declines.

A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation.

BACKGROUND: Post-liver-transplant biliary anastomotic strictures (ASs) are currently managed with repeated endoscopic retrograde cholangiopancreatographies (ERCPs) inserting multiple plastic stents. Fully covered self-expanding metal stents (FCSEMSs) are being increasingly reported in the management of this condition, however no prospective randomized trials have been performed to date. AIM: The aim of this study was to determine whether FCSEMSs decrease overall numbers of ERCPs needed to achieve stricture resolution and to establish the safety, efficacy and cost-effectiveness in this setting. METHODS: Two tertiary referral centres performed this open-label prospective randomized trial. A total of 32 patients consented and subsequently 20 were randomized with 10 in the FCSEMS arm and 10 in the plastic arm. The FCSEMS arm had the stent in situ for 12 weeks with the plastic stent arm undergoing 3-monthly multiple plastic stenting with or without dilatation over a year. RESULTS: The median number of ERCPs performed per patient in the FCSEMS was 2 versus 4.5 (p = 0.0001) in the plastic stenting arm. Stricture resolution was achieved in all 10 patients with FCSEMSs compared with 8/10 in the plastic arm [p = not significant (NS)]. Complications occurred in 1/10 patients in the FCSEMS arm versus 5/10 in the plastic arm (p = 0.051). Days in hospital for complications was 6 in the FCSEMS versus 56 in the plastic arm (p = 0.11). Cost analysis shows that the FCSEMS arm was more cost effective. No cases of FCSEMS migration were seen. CONCLUSIONS: FCSEMSs reduced the number of ERCPs needed to achieve stricture resolution with similar recurrence rates between arms. The FCSEMSs may do so with fewer complications making it cost effective.

Heterotopic ossification rates after acetabular fracture surgery are unchanged without indomethacin prophylaxis.

BACKGROUND: We previously found no reduction in heterotopic ossification (HO) rates after acetabular surgery with indomethacin compared with a placebo. We subsequently abandoned routine indomethacin therapy after acetabular surgery but questioned whether the incidence had changed using a posterior approach. QUESTIONS/PURPOSES: We therefore determined (1) the incidence of HO after acetabular fracture surgery through a posterior approach; (2) the incidence of symptoms attributable to HO; and (3) the rate of reoperation for HO. METHODS: We retrospectively reviewed the records of all 423 patients with acetabular fractures following our clinical protocol change; of these, 120 were treated with a Kocher-Langenbeck approach and included. The presence of radiographic HO was documented a minimum of 10 weeks postoperatively using the classification of Brooker et al. Symptoms and reoperations were recorded. RESULTS: The overall incidence of radiographic HO was 47% (56 of 120 patients): 26% Class I-II 13% Class III, and 8% Class IV. Overall, 15% of patients developed symptoms; 3.3% underwent reoperations for excision of HO. There were no major differences between the incidence of moderate and severe HO in this study when compared with the indomethacin and placebo groups from the prior study. CONCLUSIONS: Our incidence of moderate and severe HO has not changed since discontinuing indomethacin. These findings support our institutional decision to abandon routine indomethacin prophylaxis after acetabular surgery. We recommend improved surgical techniques to limit damage to the abductors and improved risk stratification of patients when considering treatment options for HO prophylaxis.

Navigating the orthopaedic trauma fellowship match from a candidate's perspective.

The Orthopaedic Trauma Fellowship Match is now in its fourth year as the principal match service for prospective orthopaedic traumatology fellowship candidates. The match is facilitated by SF Match. There are now more than 50 participating programs in the United States and Canada, and the number of applicants has expanded in recent years. For many applicants, the match process can be very time consuming and expensive and there are a multitude of factors to consider. Here, we share our experiences in the trauma match and offer our best advice for success.

Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy.

AIM: To study the significance of cap-fitted colonoscopy in improving cecal intubation time and polyp detection rate. METHODS: This study was a prospective randomized controlled trial conducted from March 2008 to February 2009 in a tertiary referral hospital at Sydney. The primary end point was cecal intubation time and the secondary endpoint was polyp detection rate. Consecutive cases of total colonoscopy over a 1-year period were recruited. Randomization into either standard colonoscopy (SC) or cap-assisted colonoscopy (CAC) was performed after consent was obtained. For cases randomized to CAC, one of the three sizes of cap was used: D-201-15004 (with a diameter of 15.3 mm), D-201-14304 (14.6 mm) and D-201-12704 (13.0 mm). All of these caps were produced by Olympus Medical Systems, Japan. Independent predictors for faster cecal time and better polyp detection rate were also determined from this study. RESULTS: There were 200 cases in each group. There was no significant difference in terms of demographic characteristics between the two groups. CAC, when compared to the SC group, had no significant difference in terms of cecal intubation rate (96.0% vs 97.0%, P = 0.40) and time (9.94 +/- 7.05 min vs 10.34 +/- 6.82 min, P = 0.21), or polyp detection rate (32.8% vs 31.3%, P = 0.75). On the subgroup analysis, there was no significant difference in terms of cecal intubation time by trainees (88.1% vs 84.8%, P = 0.40), ileal intubation rate (82.5% vs 79.0%, P = 0.38) or total colonoscopy time (23.24 +/- 13.95 min vs 22.56 +/- 9.94 min, P = 0.88). On multivariate analysis, the independent determinants of faster cecal time were consultant-performed procedures (P < 0.001), male patients (P < 0.001), non-usage of hyoscine (P < 0.001) and better bowel preparation (P = 0.01). The determinants of better polyp detection rate were older age (P < 0.001), no history of previous abdominal surgery (P = 0.04), patients not having esophagogastroduodenoscopy in the same setting (P = 0.003), trainee-performed procedures (P = 0.01), usage of hyoscine (P = 0.01) and procedures performed for polyp follow-up (P = 0.01). The limitations of the study were that it was a single-center experience, no blinding was possible, and there were a large number of endoscopists. CONCLUSION: CAC did not significantly different from SC in term of cecal intubation time and polyp detection rate.

Diesel fumes do kill: a case of fatal carbon monoxide poisoning directly attributed to diesel fuel exhaust with a 10-year retrospective case and literature review*.

While it is known that diesel fuel combustion engines produce much lower concentrations of carbon monoxide (CO) than gasoline engines, these emissions could certainly generate lethal ambient concentrations given a sufficient amount of time in an enclosed space and under suitable environmental conditions. The authors report a case of CO poisoning which was initially referred for autopsy as a presumed natural death of a truck driver found in the secure cab of a running diesel tractor trailer truck. Completion of the preliminary investigation ascribed death to complications of ischemic heart disease (IHD), pending toxicological analysis that included quantification of CO. When the toxicology results showed lethal blood COHbg, the cause of death was re-certified as CO intoxication secondary to inhalation of (diesel) vehicular exhaust fumes. Because of the unique source of fatal CO intoxication in this case, the contributory IHD and the possible contaminants in the putrefied blood, a 10-year retrospective review was conducted on all nonfire related CO deaths autopsied (n = 94) at the Office of the Chief Medical Examiner in Louisville, KY from 1994 to 2003. For validation of the COHbg detection method used by the Kentucky Office of Forensic Toxicology (KYOFT), blood samples from these cases along with controls were submitted to three laboratories using various analytical methods yielding no statistically significant differences. Lastly, an extensive literature review produced no scientifically reported cases of fatal CO poisoning attributed to diesel fuel exhaust.

Evaluation of thermal acclimation capacity in corals with different thermal histories based on catalase concentrations and antioxidant potentials.

Colonies of Pocillopora damicornis from Kaneohe Bay and colonies of Pocillopora meandrina from a thermal outfall site and a control site at Kahe were exposed to three different temperatures (29, 32 and 33 degrees C) in outdoor aquaria on running water tables for five days. Samples (n=3) were taken from each treatment at 0800, 1200 and 1600 h. ELISAs using catalase antibodies and ferric reducing/antioxidant potential (FRAP) assays were run on the samples to determine how antioxidant levels changed throughout the experiment. Light levels during the experiment were highest in the morning ( approximately 1000-1500 micromol quanta m(-2) s(-1)) and decreased to 25-60 micromol quanta m(-2) s(-1) by 1100 h and remained low until sunset. Antioxidant concentrations were highest in the morning for P. damicornis from Kaneohe and P. meandrina outfall samples. There was no significant change through the day for P. meandrina samples from the control site. The difference in response between the outfall samples and the control samples suggests that P. meandrina has acclimated to elevated temperatures found at the outfall site.