Evaluation of fever in the immediate post-operative period following shoulder arthroplasty.

AIMS: To determine the incidence and timing of post-operative fevers following shoulder arthroplasty and the resulting investigations performed. PATIENTS AND METHODS: A retrospective review was conducted of all patients undergoing shoulder arthroplasty over a nine-year period. The charts of all patients with a post-operative fever (≥ 38.6°C) were reviewed and the results of all investigations were analysed. RESULTS: A total of 2167 cases (in 1911 patients) were included of whom 92 (4.2%) had a documented fever. Obese cases had a significantly greater risk for fever (relative risk 1.53; 95% confidence interval 1.02 to 2.32; p = 0.041). Investigations were performed in 43/92 cases (46.7%), with a diagnosis being made in six cases (6.6% of the total, two of whom had their diagnosis made post-discharge). CONCLUSION: Around one in 25 cases develop a fever following shoulder arthroplasty; most have no infective aetiology. These patients may be being over-investigated; investigations should be performed in patients with persistent fever or on those with an identifiable source of infection on clinical examination. Cite this article: Bone Joint J 2017;99-B:1515-19.

Acquired heterotopic ossification of the temporomandibular joint.

Although the risk factors and diagnosis of heterotopic ossification (HO) are discussed in the orthopedics literature, the etiology of HO, as well as its prevention and management, remain theoretical. Furthermore, there is a lack of information in the literature regarding HO in temporomandibular joint replacement (TMJR). This article provides a qualitative review of information relative to the etiology, diagnosis, and management of HO to inform and encourage further investigation in TMJR. The orthopedic HO literature considered for this qualitative review was drawn from a comprehensive examination of the subject published previously by one of the authors. Using the key words "heterotopic ossification" or "heterotopic bone", citations in the PubMed database from both the dental and oral and maxillofacial surgery literature were reviewed. Based on this, it appears that the etiology, diagnosis, imaging, laboratory testing, risk factors, prophylaxis, and non-surgical and surgical options available for the management of TMJR-related HO are similar to those for orthopedic HO, but further elucidation is required for TMJR. There is a lack of published information in the literature on TMJR. Therefore, using the literature from this review as a foundation, studies should be developed and reported so that alloplastic TMJ surgeons have evidence-based protocols that will lead to the early detection and potential prevention of HO.

Biomechanical testing of the reconstructed ulnar collateral ligament: a systematic review of the literature.

PURPOSE: The purpose was to perform a systematic review of the literature investigating biomechanical studies of ulnar collateral ligament reconstruction (UCLR) techniques to summarize the most commonly analyzed methods of fixation (at both the ulna and humerus), the degree of elbow flexion at the time of fixation, graft characteristics, and modes of failure with these techniques. MATERIALS AND METHODS: A systematic review was performed. All cadaveric biomechanical studies that tested a reconstruction method for UCLR were included. Descriptive statistics were calculated for each study and parameter/variable analyzed. RESULTS: Twenty-three studies were included with a total of 397 elbows in 242 cadavers (mean age 54.8 ± 20 years, range 16-96). The majority of studies (65 %) used a palmaris longus graft. The docking technique (37.2 %) was the most commonly tested reconstruction method. Significant heterogeneity between studies precluded assimilation of specific techniques (each of the 23 studies utilized a unique technique). Fixation was performed at 30°-90° of elbow flexion. The most common mode of failure was suture failure (51 %), followed by midsubstance rupture (27.00 %), and bone tunnel fracture (14.00 %). No significant differences were observed amongst techniques for all measures analyzed. CONCLUSION: This study found the docking technique to be the most commonly tested technique, while the mode of reconstruction failure was most commonly at the suture interface. If the graft failed at the bone interface, it was most likely to occur at the ulna. Surgeon preference and comfort level with a specific technique should dictate choice.

Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: a systematic review.

We conducted a systematic review of studies reporting clinical outcomes after proximal row carpectomy or to four-corner arthrodesis for scaphoid non-union advanced collapse or scapholunate advanced collapse arthritis. Seven studies (Levels I-III; 240 patients, 242 wrists) were evaluated. Significantly different post-operative values were as follows for four-corner arthrodesis versus proximal row carpectomy groups: wrist extension, 39 (SD 11º) versus 43 (SD 11º); wrist flexion, 32 (SD 10º) versus 36 (SD 11º); flexion-extension arc, 62 (SD 14º) versus 75 (SD 10º); radial deviation, 14 (SD 5º) versus 10 (SD 5º); hand grip strength as a percentage of contralateral side, 74% (SD 13) versus 67% (SD 16); overall complication rate, 29% versus 14%. The most common post-operative complications were non-union (grouped incidence, 7%) after four-corner arthrodesis and synovitis and clinically significant oedema (3.1%) after proximal row carpectomy. Radial deviation and post-operative hand grip strength (as a percentage of the contralateral side) were significantly better after four-corner arthrodesis. Four-corner arthrodesis gave significantly greater post-operative radial deviation and grip strength as a percentage of the opposite side. Wrist flexion, extension, and the flexion-extension arc were better after proximal row carpectomy, which also had a lower overall complication rate.

Assessment of a novel alternative to conventional formocresol-zinc oxide eugenol pulpotomy for the treatment of pulpally involved human primary teeth: diode laser-mineral trioxide aggregate pulpotomy.

OBJECTIVE: The purpose of this study was to investigate whether a diode laser pulpotomy with mineral trioxide aggregate (MTA) sealing could be an acceptable alternative to the conventional formocresol pulpotomy and zinc oxide eugenol (ZOE) sealing in human primary teeth. METHODS: A randomized, single-blind, split-mouth study was used with a sample of 16 children aged from 3 to 8 years (mean age=5.10 years). A total of 26 pairs of teeth from these 16 patients were selected based on clinical and radiographic criteria. One tooth from each pair was randomly assigned to either the laser-MTA pulpotomy group or the formocresol-ZOE pulpotomy group. All teeth were followed up clinically and radiographically at 2.3, 5.2, 9.5 and 15.7 months. All extracted failures were sectioned and photographed to assess possible reasons for this. RESULTS: A total of seven laser-MTA-treated teeth were deemed to be radiographic failures (mean time until failure=9.1 months) compared to three formocresol-ZOE treated teeth (mean time until failure=12.5 months). These results were not significant using Fisher's exact test (P>0.05). Six of the laser-MTA failures and all three formocresol-ZOE failures exhibited furcal and/or periapical radiolucencies with or without pathologic root resorption. One of the laser-MTA failures displayed premature root resorption and is being observed for exfoliation. Analysis of photographs of teeth available for extraction revealed errors in clinical technique in addition to expected signs of a disease process such as the presence of granulation tissue and areas of pathologic root resorption. CONCLUSIONS: The laser-MTA pulpotomy showed reduced radiographic success rates compared to the formocresol-ZOE pulpotomy at 15.7 months; however, these results were not statistically significant. Improved success rates among a larger patient sample and a longer follow-up period would be required for the laser-MTA pulpotomy to be considered a routine alternative to the conventional formocresol-ZOE procedure. Meticulous restorative techniques must be followed to ensure the success of laser-MTA pulpotomies.

Recent risk rates of occupational fatalities, injuries, and illnesses in U.S. industries and their use in planning environmental controls.

Cost/benefit justifications are now required for new environmental regulations. The benefit is related to the difference between the currently existing health risk rate and the rate corresponding to the proposed permissible exposure limit. The adoption of many permissible exposure limits has been delayed by the lack of supporting human data and the use of animal data instead. This has resulted in difficulties and controversies not likely to be resolved soon. Meanwhile, a review of currently existing occupational risk rates can provide a perspective for best use of available funds. Tables and text are presented summarizing published occupational risk data for 1996. Transportation incidents cause 42 percent of occupational fatalities. Proper selection and training of workers and proper work rules should be cost-effective, also especially in other listed dangerous industries. Annual risk rates per hundred workers for occupational nonfatal injuries and illness were surprisingly high: for manufacturing 10.6, and for the entire private sector, 7.4. Seven worst industries ranged from 25.8 to 30.3. The benefit from controlling such high rates is almost the same whether the final rate is 10(-3) or 10(-6). Thus, specifying a good low-cost procedure that reduces most of the initial risk can provide the lowest cost/benefit ratio, eligible for priority use of available funds.

Lognormal model for determining dose-response curves from epidemiological data and for health risk assessment.

A practical method is proposed for determining human dose-response curves based on reasonable assumptions and simplifications. The epidemiological data needed are the fractions of the population suffering an adverse response from exposures to two or more patterns of fluctuating concentrations of a pollutant, and the statistical parameters of each pattern. The method calculates the two parameters of the threshold type dose-response curve of the pollutant, represented by a cumulative lognormal distribution. This distribution was derived from a reasonable statistical model. The calculation does not require any arbitrary safety factors and yields central values. The dose-response parameters then may be used to calculate the health risk rate of exposure to any other fluctuating concentration pattern. Another method is proposed to select appropriate threshold limit values (TLVs) using calculations involving these parameters. Examples are given to illustrate the calculations. Results with hypothetical data gave apparently reasonable results. They showed the importance not only of the geometric mean concentration but also of the geometric standard deviations of both the concentrations and of the dose-response curve, that greatly influence the results. It is believed that results of useful accuracy should be obtained. Health risk rates are readily understood. They are useful for cost-benefit calculations. Relative rates can be used to compare the hazards of different operations and different plants. The method may make possible the development of standards specifying maximum allowable risk rates.

Feasibility of collecting buccal cell DNA by mail in a cohort study.

This study assessed the feasibility of obtaining buccal cell DNA by mail from participants in a large, community-based cohort study in Hawaii. Mouthwash collection kits were sent to a total of 355 randomly selected Japanese, Caucasian, and Hawaiian cohort members. Subjects were requested to swish 10 ml of mouthwash in their mouth for 60 s and expel it into a collection cup, which they mailed back to our laboratory. Half of the subjects were requested to collect a second sample. After up to two mailings and two reminder phone calls, two-thirds of the subjects returned a sample. The participation rate was lower for Hawaiians (59.0%) than for Caucasians (68.1%) and Japanese (76.3%). Participation was not affected by requesting two specimens. Participants did not differ from the total sample in terms of education and smoking status. The mean DNA yield was lower in females (41.7 microg) than males (53.4 microg) and in Japanese (37.8 microg) as compared with Hawaiians (51.9 microg) and Caucasians (54.5 microg). For subjects who returned two samples, the DNA yields were similar when both specimens were extracted in the same batch. All samples were successfully genotyped for polymorphisms in the CYP1A1, CYP2E1, GSTM1, GSTT1, and NQO1 genes by PCR-RFLP. From these and previous data, we conclude that, in situations where blood samples cannot be obtained, mail collection of mouthwash samples should be considered because it yields substantial amounts of high-quality genomic DNA for large numbers of study subjects.

Comparison of the efficacy and safety of finasteride in older versus younger men with benign prostatic hyperplasia.

OBJECTIVES: To compare the efficacy and safety of finasteride 5 mg in older (65 years old or older) versus younger (45 to younger than 65 years old) men with benign prostatic hyperplasia (BPH). METHODS: The Proscar Long-Term Efficacy and Safety Study (PLESS) was a 4-year, randomized, double-blind, placebo-controlled trial assessing the efficacy and safety of finasteride 5 mg in 3040 men 45 to 78 years old with symptomatic BPH, enlarged prostates, and no evidence of prostate cancer. The endpoints included urinary symptoms, prostate volume, occurrence of acute urinary retention and/or BPH-related surgery, and safety. RESULTS: In both age cohorts, finasteride treatment led to a 51% reduction (P <0.001) in the relative risk for acute urinary retention and/or BPH-related surgery, a significant (P <0.001) and durable improvement in symptom score, and a significant (P <0.001) and sustained reduction in prostate volume. Within each age cohort, no significant differences were found between the placebo and finasteride-treated patients in the incidence of cardiovascular adverse events. Significant differences were evident between the placebo and finasteride groups in the incidence of the typical, known, drug-related adverse events, but no specific differences were associated with age. No drug interactions of clinical importance were observed in the finasteride-treated patients. CONCLUSIONS: The present analysis from PLESS demonstrates that in both older (65 years old or older) and younger men with symptomatic BPH and enlarged prostates, finasteride is highly effective in improving symptoms and reducing prostate volume in many men and in reducing the risk of acute urinary retention and BPH-related surgery. In addition, the safety profile of finasteride in both older and younger men is similar and no drug interactions of clinical importance were observed.

Magnetic resonance imaging in endourology.

Historically, the utilization of magnetic resonance imaging (MRI) in endourology has been limited. The availability of faster and stronger gradient systems has given rise to a number of data acquisition strategies that have significantly broadened the scope of MRI applications. These methods have led to the evaluation of anatomy and function using a single modality, and we describe our experience with MRI for comprehensive evaluation of the obstructed ureteropelvic junction. We also utilize these new imaging sequences in the investigation of alterated renal hemodynamics after extracorporeal shockwave lithotripsy and present our preliminary data on the application of MR perfusion imaging as a noninvasive technique for the evaluation of renal blood flow.

Intraoperative treatment planning for radioactive seed implant therapy for prostate cancer.

We describe a procedure for intraoperative treatment planning for seed implantation. One hundred seven treatment plans have been analyzed at the Beth Israel Deaconess Medical Center and affiliated hospitals. The average time for the intraoperative procedure was 1. 74 hours. No significant difference in dose coverage to the prostate or normal tissues was evident.

Role of brachytherapy in patients with stage T1c, T2a adenocarcinoma of the prostate.

The precise role of brachytherapy in treating patients with adenocarcinoma of the prostate remains unclear. Recent literature suggests that the long-term disease-free survival of patients with well-differentiated and localized tumors who receive brachytherapy is comparable to that of patients with similar tumors who are treated with radical prostatectomy or external-beam radiation. Advances in imaging technology, treatment planning software, and delivery apparatus have resulted in a technique that is accurate and reproducible. We explore the development of contemporary brachytherapy and examine the current published data relating to its emergence as a medically successful, cost-effective, and low-morbidity therapeutic modality for patients with stage T(1c), T(2a) prostate cancer.

Protective effect of aminophylline on renal perfusion changes induced by high-energy shockwaves identified by Gd-DTPA-enhanced first-pass perfusion MRI.

PURPOSE: The purpose of this study was to evaluate regional renal hemodynamics in a noninvasive manner using gadolinium-DPTA magnetic resonance imaging (MRI) before and after extracorporeal shockwave lithotripsy (SWL). In addition, the renoprotective effect of intravenous aminophylline was evaluated on the perfusion on kidneys undergoing SWL. PATIENTS AND METHODS: Ten randomly selected patients were evaluated for regional renal blood flow in the cortex and medulla with Gd-DTPA MRI studies within 2 weeks before and 4 hours after SWL. Five of these patients were treated with 500 mg of intravenous aminophylline 45 minutes prior to SWL. Renal hemodynamics were assessed utilizing relative perfusion indices (PI) calculated from signal intensity-v-time curves obtained from regions of interest (ROI). The ROI choice was based on the contrast-enhanced MRI images. Relative PIs of pre-SWL and post-SWL studies were compared in the first group of patients. Relative PIs of the treated kidney were compared with those of the contralateral kidney in the second group of patients, who received aminophylline. RESULTS: In the group not treated with aminophylline, there was no significant difference in cortical perfusion before SWL (average PI -7+/-3%). However, after lithotripsy, there was a reduction of cortical flow (average PI 31+/-12%) in the treated kidney. In the group treated with aminophylline, renal hemodynamics study after SWL revealed no significant difference in relative perfusion (average PI -8+/-6%). Relative PIs of the medulla were small for all patients, but standard errors were large, indicating a wide range of values. CONCLUSIONS: This study helps to establish reduced cortical flow after SWL and demonstrates that aminophylline attenuated this response in the kidneys subjected to lithotripsy. It appears that aminophylline administration causes no alteration in medullary blood flow.

Urolithiasis associated with protease inhibitors.

OBJECTIVE: We evaluated the radiographic characteristics as well as the clinical management of urolithiasis induced by systemic therapy with indinavir sulfate, a protease inhibitor utilized in the treatment of HIV infection. PATIENTS AND METHODS: Fifteen consecutive HIV-positive male patients (average age 41.3 years) who presented with urolithiasis while being treated with indinavir sulfate (average time 11.1 months) were studied. RESULTS: All patients presented with flank pain, and eight had gross hematuria. All but one patient had microscopic hematuria. The location of the stones was the kidney in three, the proximal ureter in four, and the distal ureter in nine. One patient had both a renal and a proximal ureteral stone. The stones were radiolucent on CT imaging in five patients and could not be seen in five. In the five cases in which a stone was not definitely identified, a diagnosis of urolithiasis was established on the basis of ureteral obstruction and periureteral/renal streaking noted on CT. Treatment included observation with hydration in eight patients, ureteral stent placement in two patients, ureteroscopy in three patients, and extracorporeal shockwave lithotripsy in two patients. Stones were analyzed in five patients and proved to be 100% indinavir in three and a mixture of indinavir, calcium oxalate monohydrate, and calcium oxalate dihydrate in two. CONCLUSIONS: Urolithiasis is a recognized complication of treatment with indinavir sulfate. Pure indinavir stones cannot be seen on CT unless intravenous contrast medium is utilized. Mixed calcium and indinavir stones can occur and may be radiopaque. The majority of HIV-positive patients with symptomatic urolithiasis can be treated conservatively with hydration. Metabolic evaluation of these patients with identification and correction of factors predisposing to stone formation may minimize future recurrences. Administration of this effective medication thus can continue uninterrupted.

Serum prostate-specific antigen concentration is a powerful predictor of acute urinary retention and need for surgery in men with clinical benign prostatic hyperplasia. PLESS Study Group.

OBJECTIVES: Prostate-specific antigen (PSA) is produced exclusively in the prostate gland and is currently the most useful clinical marker for the detection of prostate cancer. In this report, we examine whether serum PSA is also a predictor of important benign prostatic hyperplasia (BPH)-related outcomes, acute urinary retention (AUR), and the need for BPH-related surgery. METHODS: Three thousand forty men were treated with either placebo or finasteride in a double-blind, randomized study of 4-year duration. Serum PSA was measured at baseline, and baseline prostate volume was measured in a 10% subset of 312 men. Probabilities and cumulative incidences of AUR and BPH-related surgery, as well as reduction in risk of events with finasteride, were calculated for the entire patient population, stratified by treatment assignment, baseline serum PSA, and prostate volume. RESULTS: The risk of either needing BPH-related surgery or developing AUR ranged from 8.9% to 22.0% during the 4 years in placebo-treated patients stratified by increasing prostate volume and from 7.8% to 19.9% when stratified by increasing serum PSA. In comparison with symptom scores, flow rates, and residual urine volume, receiver operating characteristic curve analyses showed that serum PSA and prostate volume were the most powerful predictors of spontaneous AUR in placebo-treated patients (area under the curve 0.70 and 0.81, respectively). Finasteride treatment reduced the relative risk of needing surgery or developing AUR by 50% to 74% and by 43% to 60% when stratified by increasing prostate volume and serum PSA, respectively. CONCLUSIONS: Serum PSA and prostate volume are powerful predictors of the risk of AUR and the need for BPH-related surgery in men with BPH. Knowledge of baseline serum PSA and/or prostate volume are useful tools to aid physicians and decision makers in predicting the risk of BPH-related outcomes and choosing therapy for BPH.

Characteristics of bladder leiomyoma as noted on magnetic resonance imaging.

Leiomyoma of the bladder is a rare benign mesenchymal tumor that can be evaluated preoperatively with magnetic resonance imaging. Small tumors that appear to be leiomyomas on magnetic resonance imaging can be treated conservatively with transurethral resection.

An effective technique to facilitate radiographic stone visualization with an internal stent during shock wave lithotripsy.

PURPOSE: We describe a simple method to assist stone localization during shock wave lithotripsy in the presence of a Double J stent. MATERIALS AND METHODS: A 4F whistle tip ureteral catheter is passed alongside a previously inserted 6F Double J stent. The tip of the ureteral stent is positioned in the lower or mid third of the ureter. Contrast material is injected through the ureteral catheter during lithotripsy to assist stone localization. RESULTS: This technique has been successful in localization of poorly opacified renal stones during lithotripsy. CONCLUSIONS: Radiolucent and poorly calcified renal stones can be easily localized during shock wave lithotripsy, despite the presence of a Double J stent. No special catheters or stents are required for this technique.

Extracorporeal shock wave lithotripsy: a comprehensive review.

Extracorporeal shock wave lithotripsy (ESWL) has revolutionized treatment of urolithiasis since its introduction in the 1980s. The great majority of renal and ureteral stones can be successfully treated with ESWL. Complications can be minimized with maximal efficacy if patient selection is optimum.

Redistribution of renal blood flow after SWL evaluated by Gd-DTPA-enhanced magnetic resonance imaging.

Extracorporeal shockwave lithotripsy (SWL) is currently accepted as an effective noninvasive treatment for a wide variety of urinary tract calculi. However, the bioeffects of high-energy shockwaves on renal parenchyma have yet to be fully elucidated. The objective of this study was to measure the acute changes in regional renal hemodynamics associated with SWL utilizing dynamic gadolinium-DTPA-enhanced magnetic resonance imaging (MRI). Seven patients who underwent SWL for renal calculi had an MRI study within 4 hours after the treatment. To assess renal hemodynamics, a bolus of Gd DTPA (0.03 mmol/kg) was administered, and dynamic contrast enhanced images was obtained. Regions of interest (ROI) were defined over the cortex and medulla to obtain signal intensity-v-time curves. The contralateral kidney in each patient was used as the control. The initial slope of the contrast-enhanced signal intensity-v-time curve was used as a measure of the perfusion index (PI). In six patients, perfusion imaging showed a consistent trend of decreased cortical flow (29+/-8%) and a concomitant increase in medullary flow (34+/-14%) in the region of the kidney that was targeted with SWL in six patients (86%). This study shows that renal hemodynamics are modified by SWL. We hypothesize that this change represents a shunting of flow from cortex to medulla in an attempt to prevent ischemia of the medulla.