Ten-day culture incubation time can accurately detect bacterial infection in periprosthetic infection in shoulder arthroplasty.

BACKGROUND: Cutibacterium acnes is the most commonly isolated organism involved in periprosthetic shoulder infections. C acnes has traditionally been difficult to isolate, and much debate exists over appropriate culture methods. Recently, our institution initiated a 10-day culture method using a Brucella blood agar medium to enhance anaerobic growth specifically for C acnes in shoulder specimens. METHODS: A retrospective review of shoulder cultures from 2014-2017 of patients undergoing workup for possible infected shoulder arthroplasty was performed. Cultures were obtained in patients either preoperatively or intraoperatively at the time of revision. Presence of infection was determined based on at least 1 positive culture and treatment with either prolonged antibiotics, placement of an antibiotic spacer at the time of revision, or repeat surgical débridement. RESULTS: The records of 85 patients with 136 cultures were reviewed. Eighty-two patients had full records with at least 1-year clinical follow-up. Fifty-eight cultures were positive, with C acnes as the most commonly recovered organism (57% of positive cultures). Clinical follow-up of patients with negative cultures found no incidence of missed periprosthetic infection. CONCLUSIONS: Use of a 10-day culture incubation method to enhance anaerobic bacterial growth is able to accurately detect periprosthetic infection in the shoulder including those related to C acnes. Our results suggest that by adopting more uniform culture methods, a shorter culture incubation time may be adequate. Ultimately, prospective studies with rigorous microbiologic methods are needed to best understand the clinical significance of unexpected positive bacterial cultures in shoulder arthroplasty.

A blinded, randomized, controlled trial of three doses of high-dose insulin in poison-induced cardiogenic shock.

BACKGROUND: High dose insulin (HDI) has proven superior to glucagon and catecholamines in the treatment of poison-induced cardiogenic shock (PICS) in previous animal studies. Standard recommendations for dosing of insulin vary and the optimal dose of HDI in PICS has not been established. Our hypothesis was a dose of 10 U/kg/hr of HDI would be superior to 1 U/kg/hr with cardiac output (CO) as our primary outcome measure in pigs with propranolol-induced PICS. METHODS: This was a blinded, prospective, randomized trial with 4 arms consisting of 4 pigs in each arm. The arms were as follows: placebo (P), 1 U/kg/hr (HDI-1), 5 U/kg/hr (HDI-5), and 10 U/kg/hr (HDI-10). Cardiogenic shock was induced with a bolus of 0.5 mg/kg of propranolol followed by an infusion of 0.25 mg/kg/min until the point of toxicity, defined as 0.75 x (HR x MAP) was reached. At this point the propranolol infusion was decreased to 0.125 mg/kg/min and a 20 mL/kg bolus of normal saline (NS) was administered. The protocol was continued for 6 hours or until the animals died. RESULTS: 2 pigs died in the P arm, 1 pig died each in the HDI-1 and HDI-5 arms, and all pigs lived in the HDI-10 arm. There was a statistically significant difference in dose by time interaction on CO of 1.13 L/min over the 6 hr study period (p = < 0.001). There was also a statistically significant difference in dose by time interaction on MAP, HR, and systemic vascular resistance (SVR). No statistically significant difference was found between any of the arms regarding glucose utilization. CONCLUSION: HDI was statistically and clinically significantly superior to placebo in this propranolol model of PICS. Furthermore a dose response over time was found where CO increased corresponding to increases in doses of HDI.

Evaluation of a new triphasic oral contraceptive in private practice.

We evaluated the clinical and metabolic effects of a new triphasic regimen developed in the continuing attempt to reduce the dose of estrogen and progestogen in oral contraceptives. A combination of ethinyl estradiol (EE) and levonorgestrel (LNg) was used (six tablets with 30 micrograms EE + 50 micrograms LNg, five tablets with 40 micrograms EE + 75 micrograms LNg, and 10 tablets with 30 micrograms EE + 125 micrograms LNg), also known as Triphasil (Wyeth). In a private practice, 409 subjects participated in 7,286 treatment cycles. Three pregnancies occurred, all due to subject failure. Menstrual regulation was excellent and the incidence of side effects extremely low. Withdrawals from the study for possibly drug-related medical reasons totaled 9.0% through 56 cycles of treatment. Metabolic changes also were evaluated in 14 of these women over a 6-month period. The only statistically significant increase in carbohydrate values occurred at 6 months. The mean glucose level at 30 minutes of the oral glucose tolerance test was above the baseline mean value, but serum insulin levels showed no statistically significant deviation. Lipid values presented are total lipids, total cholesterol, triglycerides, alpha-, beta-, and pre-beta-lipoproteins, and high density and low density lipoprotein cholesterol. There was no statistically significant difference between the mean values at baseline and those during treatment for any lipid variable. These results indicate that this triphasic oral contraceptive has a high degree of efficacy, a low incidence of side effects, excellent cycle control, and high subject compliance, and would seem to indicate a minimal influence on the metabolism of lipids and carbohydrates in the small number of subjects studied.

PIP: We evaluated the clinical and metabolic effects of a new triphasic regimen developed in the continuing attempt to reduce the dose of estrogen and progestogen in oral contraceptives. A combination of ethinyl estradiol (EE) and levonorgestrel (LNg) was used (6 tablets with 30 microgram EE + 50 microgram LNg, 5 tablets with 40 microgram EE + 75 microgram LNg, and 10 tablets with 30 microgram EE + 125 microgram LNg), also known as Triphasil (Weyth). In a private practice, 409 subjects participated in 7,286 treatment cycles. 3 pregnancies occurred, all due to subject failure. Menstrual regulation was excellent and the incidence of side effects extremely low. Withdrawals from the study for possibly drug-related medical reasons totaled 9.0% through 56 cycles of treatment. Metabolic changes also were evaluated in 14 of these women over a 6-month period. The only statistically significant increase in carbohydrate values occurred at 6 months. The mean glucose level at 30 minutes of the oral glucose tolerance test was above the baseline value, but serum insulin levels showed on statistically significant deviation. Lipid values presented are total lipids, total cholesterol, triglycerides, alpha-,beta, and pre-beta-lipoproteins, and high density and low density lipoprotein cholesterol. There was no statistically significant difference between the mean values at baseline and those during treatment for any lipid variable. These results indicate that this triphasic oral contraceptive has a high degree of efficacy, a low incidence of side effects, excellent cycle control, and high subject compliance, and would seem to indicate a minimal influence on the metabolism of lipids and carbohydrates in the small number of subjects studied.

Oral contraception, 1986. Focus on Triphasil.

Clinical studies of 8,349 cycles of a triphasic oral contraceptive have shown it to be safe, effective and well tolerated.

Further studies on horn aberrations in Dall's sheep (Ovis dalli dalli) from Yukon Territory, Canada.

The prevalence of horn aberrations in Dall's sheep from the Kluane Lake area of Yukon Territory observed during July 1982 represented 1% of the total population and 7% of rams 6 yr or older. Ewes were not considered in these percentages because they were too difficult to inspect by aerial survey. When these data were combined with other data collected from 1977 through 1981, the prevalence equalled 2.4% of the total population and slightly exceeded 16% in mature rams (greater than or equal to 6 yr). The anomaly followed necrosis of the terminal region of the horn core and the sequestering of portions of the core within the sheath as the sheath continued to grow. Sheath that was produced after the core was anatomically altered resulted in abnormal growth patterns of the horn. Rams with aberrant horns could not maintain homeostatic temperatures within horn cores when horns were experimentally exposed to -80 C for 30 min. Histologic examination of superficial and cornual vascular systems did not reveal any structural alterations that would restrict blood flow within cores of affected horns. Examination of museum specimens consisting of 130 skulls from rams and 81 from ewes collected from Alaska, USA, Yukon Territory, Canada, and Northwest Territories, Canada, established only one ewe and no rams with the horn aberration. The skull was from a ewe and had both horns affected and was collected from the Joe River Drainage, Yukon Territory in 1912.

Horn aberrations in Dall's sheep (Ovis dalli) from Yukon Territory, Canada.

Horn aberrations in Dall's sheep from the Kluane Lake area of Yukon Territory were of two basic types. In the more prevalent type, the horn was severed at an annual growth check and the terminal segment of the remaining portion formed a short conical protuberance. The second type had characteristics of the first, but in addition, underwent extreme twisting or torquing during subsequent growth. Sheep with aberrant horns represented 2% of the Kluane Lake population or 14% of harvestable rams (greater than or equal to 6 yr old). Deformed horns, occurring in ewes and rams, were generally observed in animals 6 yr or older. Aberrations followed necrosis of the terminal segment of the horn core: cavitation of the sheath between successive periods of growth or the sequestering of portions of necrotic core within the sheath resulted. All sheep examined (eight) had a normal complement of 54 chromosomes.

Evaluation of d-norgestrel 1.0 mg in cyclic regimen.

PIP: 111 women took a total of 584 cycles of 1.0 mg norgestrel for 21 days out of a 28 day cycle, in a trial of a low-dose progestin-only oral contraceptive, intended to avoid the side effects of estrogen and the menstrual irregularity of mini-pills. This study followed an 18 month blind trial of norgestrel, .5, 1.0 and 1.5 mg in 100 patients, which found the 1.0 mg dose most suitable. 33.6% of these subjects had used pills within the last 90 days, and all were private patients of the Western Gynecological and Obstetrical Clinic, Inc. 97.7% of menstrual cycles before, and 81% during the trial were 21-35 days in length; the mean cycle length was 28.8 days before, and 29.0 days during treatment. Menses lasted a mean of 4.8 days before and 5.6 days during norgestrel. Menstrual flow became lighter in most, but breakthrough bleeding increased from 1.8% to 10%, spotting from 6.3% to 30.7%, and amenorrhea from 4.5% to 11.1%. Dropouts included 10 for bleeding, 5 for weight gain, 3 for acne, and 1 each for edema, generalized somatic complaints, irritability, depression and decreased libido. One pregnancy resulted from patient failure. The authors concluded that, except for the "fastidious," most women should not object to this degree of irregular bleeding, once it becomes "individualized."^ieng