Effect of cementing technique on aseptic stem loosening in cemented primary total hip arthroplasty: a systematic review and meta-analysis.

Aseptic stem loosening after total hip arthroplasty surgery is the commonest complication, whether stem is cemented or uncemented. The aseptic cemented stem loosening has been a challenging problem over the years and a leading cause for revision since the inception of total hip arthroplasty. The objective of systematic review and meta-analysis was to determine the impact of cementing technique on aseptic stem loosening in total hip arthroplasty. Methods: Cochrane, CINAHL, Embase, Google scholar, Medline, PubMed were searched in 13 December 2020. Two independent investigators extracted the data and a third investigator's involvement was reached on consensus. A total of 37 studies of revision rate due to aseptic loosening were reviewed by using fixed/random effects size and were grouped by cementing technique and studies' characteristics. The data were analyzed through Meta-Essentials and RStudio. Results: In revision total hip arthroplasty, retained femoral components revisions rate due to aseptic loosening were recorded in 37 studies involving 6167 cases. Aseptic loosening rate collectively was 5.8% (CI 95%, 0.03-0.08) and mean follow-up of study was 12.5 years. The average follow-up period, mean age at index revision surgery and percentage of aseptic loosening were insignificantly associated with revision rate (P≥0.05), in meta-regression univariant analyses. Conclusion: This investigative analysis showed that there is a minimal difference between results of cementing techniques of total hip arthroplasty in femoral components in long-term follow-ups, and usually have a low risk of failure.

Emphysematous gastritis: a case series and review of the current trend favoring conservative management.

Emphysematous gastritis [EG] is a rare condition associated with a high mortality rate which involves the invasion of gas-forming organisms into the gastric mucosa. Risk factors include mucosal defects such as gastric ulceration as well as systemic illnesses such as diabetes. Clinical presentation includes abdominal pain as well as signs of sepsis. Air in the gastric wall and portal venous system on abdominal imaging are characteristic radiographic findings. The ideal treatment of the condition is unclear, given its rarity. Cases have typically involved either surgical options or conservative management with bowel rest and intravenous antibiotics. We report on two patients treated successfully at our institution with conservative management and a review of the current knowledge in this area. Recent case literature shows a trend towards conservative management for emphysematous gastritis with several successfully managed cases, suggesting that patients can avoid surgery in the majority of cases.

Clinical Outcome of Septic Patients With Heart Failure With Preserved Ejection Fraction Presenting to the Emergency Department of a Tertiary Hospital: A Retrospective Cohort Study.

Background: Patients with heart failure with preserved ejection fraction (HFpEF) may be at a higher risk of mortality from sepsis than patients without heart failure. Objective: The aim of this study is to compare sepsis-related morbidity and mortality between patients with HFpEF and patients without heart failure presenting to the emergency department (ED) of a tertiary medical center. Design: Single-center retrospective cohort study conducted at an academic ED between January 1, 2015 and December 31, 2018. Patients: Patients with a diagnosis of sepsis were included. Main Measures: Bivariate and multivariate analyses were performed to look at differences in demographics, infection, and treatment parameters as well as outcomes of patients with sepsis. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED mortality, lengths of stay, and treatment differences between both groups. Key Results: A total of 1,092 patients presented with sepsis to the ED, of which 305 (27.93%) had HFpEF. There was no significant difference in in-hospital mortality between the two groups (40.7% vs. 37.4%; p = 0.314). However, there was a significant increase in ED mortality for septic HFpEF patients compared to non-heart failure patients (2.4 vs. 0.4%; p = 0.003). Septic HFpEF patients presenting to the ED were older than non-heart failure patients (76.84 vs. 68.44 years old; p < 0.0001). On the other hand, there was no significant increase in the use of vasopressors in the first 24 h between both groups. There was a significantly higher rate of intubation in the first 48 h for septic HFpEF patients (17.5 vs. 8.9%; p < 0.0001). Finally, there was significantly less intravenous fluid requirement at 6 h (1.94 L vs. 2.41L; p < 0.0001) and 24 h (3.11 L vs. 3.54L; p = 0.004) for septic patients with HFpEF compared to non-heart failure patients. Conclusion: Septic HFpEF patients experienced an increase in ED mortality, intubation, and steroid use compared to septic non-heart failure patients.

Lactate/Albumin Ratio as a Predictor of In-Hospital Mortality in Septic Patients Presenting to the Emergency Department.

Background: The aim of this study is to evaluate the prognostic value of the Lactate to Albumin (L/A) ratio compared to that of lactate only in predicting morbidity and mortality in sepsis patients. Methods: This was a single-center retrospective cohort study. All adult patients above the age of 18 with a diagnosis of sepsis who presented between January 1, 2014 and June 30, 2019 were included. The primary outcome was in-hospital mortality. Results: A total of 1,381 patients were included, 44% were female. Overall in-hospital mortality was 58.4% with the mortalities of sepsis and septic shock being 45.8 and 67%, respectively. 55.5% of patients were admitted to the intensive care unit. The area under the curve value for lactate was 0.61 (95% CI 0.57-0.65, p < 0.001) and for the L/A ratio was 0.67 (95% CI 0.63-0.70, p < 0.001). The cutoff generated was 1.22 (sensitivity 59%, specificity 62%) for the L/A ratio in all septic patients and 1.47 (sensitivity 60%, specificity 67%) in patients with septic shock. The L/A ratio was a predictor of in-hospital mortality (OR 1.53, CI 1.32-1.78, p < 0.001). Conclusion: The L/A ratio has better prognostic performance than initial serum lactate for in-hospital mortality in adult septic patients.

The association of cognitive impairment as screened by the Mini-Cog with long term post-hospitalization outcomes.

BACKGROUND: Prior studies have suggested that patients with cognitive impairment are at increased risk for adverse post-hospitalization outcomes. We aimed to determine if cognitive status assessed by the Mini-Cog, a quick bedside screening test, is associated with long-term outcomes. METHODS: In this secondary analysis of data from a prospective cohort study, 668 patients >65 years of age admitted to a tertiary care academic hospital over a two-year period were screened for cognitive impairment with the Mini-Cog within 24 h of admission. We performed multivariable regression adjusting for demographics, comorbidities, principal diagnoses and functional status to determine association between cognitive impairment and discharge to post-acute care, 90-day readmission and one-year mortality. RESULTS: Overall 35% screened positive for cognitive impairment. Those with impairment were older (median age 83 versus 78), less likely to be admitted from home and had lower functional independence and self-reported performance scores (p < 0.001 for all). Patients with cognitive impairment were more likely to be discharged to post-acute care facilities (54% versus 39%, p < 0.001). 90-day readmission rate of patients with and without cognitive impairment was 35% versus 27%; one-year survival 77% versus 84% and median length-of-stay was 4 days for both groups. Differences in readmission and mortality were not statistically significant after adjusting for covariates. CONCLUSION: Cognitive impairment as screened for by the Mini-Cog was not associated with readmission, length-of-stay, or 1-year mortality but was associated with discharge to post-acute care. Other tools such as frailty assessment may be more useful in predicting these outcomes in hospitalized older adults.

Serum lactate is an independent predictor of hospital mortality in critically ill patients in the emergency department: a retrospective study.

BACKGROUND: Elevated lactate has been found to be associated with a higher mortality in a diverse patient population. The aim of the study is to investigate if initial serum lactate level is independently associated with hospital mortality for critically ill patients presenting to the Emergency Department. METHODS: Single-center, retrospective study at a tertiary care hospital looking at patients who presented to the Emergency Department (ED) between 2014 and 2016. A total of 450 patients were included in the study. Patients were stratified to lactate levels: <2 mmol/L, 2-4 mmol/L and >4 mmol/L. The primary outcome was in-hospital mortality. Secondary outcomes included 72-h hospital mortality, ED and hospital lengths of stay. RESULTS: The mean age was 64.87 ± 18.08 years in the <2 mmol/L group, 68.51 ± 18.01 years in the 2-4 mmol/L group, and 67.46 ± 17.67 years in the >4 mmol/L group. All 3 groups were comparable in terms of age, gender and comorbidities except for diabetes, with the 2-4 mmol/L and >4 mmol/L groups having a higher proportion of diabetic patients. The mean lactate level was 1.42 ± 0.38 (<2 mmol/L), 2.72 ± 0.55 (2-4 mmol/L) and 7.18 ± 3.42 (>4 mmol/L). In-hospital mortality was found to be 4 (2.7%), 18(12%) and 61(40.7%) patients in the low, intermediate and high lactate groups respectively. ED and hospital length of stay were longer for the >4 mmol/L group as compared to the other groups. While adjusting for all variables, patients with intermediate and high lactate had 7.13 (CI 95% 2.22-22.87 p = 0.001) and 29.48 (CI 95% 9.75-89.07 p = <0.001) greater odds of in-hospital mortality respectively. DISCUSSION: Our results showed that for all patients presenting to the ED, a rising lactate value is associated with a higher mortality. This pattern was similar regardless of patients' age, presence of infection or blood pressure at presentation. CONCLUSION: Higher lactate values are associated with higher hospital mortalities and longer ED and hospital lengths of stays. Initial ED lactate is a useful test to risk-stratify critically ill patients presenting to the ED.

Molecular signatures for the Crenarchaeota and the Thaumarchaeota.

Crenarchaeotes found in mesophilic marine environments were recently placed into a new phylum of Archaea called the Thaumarchaeota. However, very few molecular characteristics of this new phylum are currently known which can be used to distinguish them from the Crenarchaeota. In addition, their relationships to deep-branching archaeal lineages are unclear. We report here detailed analyses of protein sequences from Crenarchaeota and Thaumarchaeota that have identified many conserved signature indels (CSIs) and signature proteins (SPs) (i.e., proteins for which all significant blast hits are from these groups) that are specific for these archaeal groups. Of the identified signatures 6 CSIs and 13 SPs are specific for the Crenarchaeota phylum; 6 CSIs and >250 SPs are uniquely found in various Thaumarchaeota (viz. Cenarchaeum symbiosum, Nitrosopumilus maritimus and a number of uncultured marine crenarchaeotes) and 3 CSIs and ~10 SPs are found in both Thaumarchaeota and Crenarchaeota species. Some of the molecular signatures are also present in Korarchaeum cryptofilum, which forms the independent phylum Korarchaeota. Although some of these molecular signatures suggest a distant shared ancestry between Thaumarchaeota and Crenarchaeota, our identification of large numbers of Thaumarchaeota-specific proteins and their deep branching between the Crenarchaeota and Euryarchaeota phyla in phylogenetic trees shows that they are distinct from both Crenarchaeota and Euryarchaeota in both genetic and phylogenetic terms. These observations support the placement of marine mesophilic archaea into the separate phylum Thaumarchaeota. Additionally, many CSIs and SPs have been found that are specific for different orders within Crenarchaeota (viz. Sulfolobales-3 CSIs and 169 SPs, Thermoproteales-5 CSIs and 25 SPs, Desulfurococcales-4 SPs, and Sulfolobales and Desulfurococcales-2 CSIs and 18 SPs). The signatures described here provide novel means for distinguishing the Crenarchaeota and the Thaumarchaeota and for the classification of related and novel species in different environments. Functional studies on these signature proteins could lead to discovery of novel biochemical properties that are unique to these groups of archaea.