Prevention and Attenuation of Covid-19 with the BNT162b2 and mRNA-1273 Vaccines.

BACKGROUND: Information is limited regarding the effectiveness of the two-dose messenger RNA (mRNA) vaccines BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) in preventing infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and in attenuating coronavirus disease 2019 (Covid-19) when administered in real-world conditions. METHODS: We conducted a prospective cohort study involving 3975 health care personnel, first responders, and other essential and frontline workers. From December 14, 2020, to April 10, 2021, the participants completed weekly SARS-CoV-2 testing by providing mid-turbinate nasal swabs for qualitative and quantitative reverse-transcriptase-polymerase-chain-reaction (RT-PCR) analysis. The formula for calculating vaccine effectiveness was 100% × (1 - hazard ratio for SARS-CoV-2 infection in vaccinated vs. unvaccinated participants), with adjustments for the propensity to be vaccinated, study site, occupation, and local viral circulation. RESULTS: SARS-CoV-2 was detected in 204 participants (5%), of whom 5 were fully vaccinated (≥14 days after dose 2), 11 partially vaccinated (≥14 days after dose 1 and <14 days after dose 2), and 156 unvaccinated; the 32 participants with indeterminate vaccination status (<14 days after dose 1) were excluded. Adjusted vaccine effectiveness was 91% (95% confidence interval [CI], 76 to 97) with full vaccination and 81% (95% CI, 64 to 90) with partial vaccination. Among participants with SARS-CoV-2 infection, the mean viral RNA load was 40% lower (95% CI, 16 to 57) in partially or fully vaccinated participants than in unvaccinated participants. In addition, the risk of febrile symptoms was 58% lower (relative risk, 0.42; 95% CI, 0.18 to 0.98) and the duration of illness was shorter, with 2.3 fewer days spent sick in bed (95% CI, 0.8 to 3.7). CONCLUSIONS: Authorized mRNA vaccines were highly effective among working-age adults in preventing SARS-CoV-2 infection when administered in real-world conditions, and the vaccines attenuated the viral RNA load, risk of febrile symptoms, and duration of illness among those who had breakthrough infection despite vaccination. (Funded by the National Center for Immunization and Respiratory Diseases and the Centers for Disease Control and Prevention.).

Catheter ablation approach and outcome in HIV+ patients with recurrent atrial fibrillation.

INTRODUCTION: Earlier studies have shown a clear association between severity of human immunodeficiency virus (HIV) infection and incident atrial fibrillation (AF). We present the long-term outcome of catheter ablation (CA) and electrophysiological characteristics in HIV+ AF patients. METHODS: This study evaluated 1438 consecutive AF patients [31 (2.15%) with HIV and 1407 (97.8%) without HIV diagnosis] undergoing their first CA at our center. A total of 31 HIV patients and 31 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model. During first procedure, all received isolation of pulmonary vein (PV) + posterior wall and superior vena cava. Non-PV triggers, defined as ectopic triggers originating from sites other than PVs, were identified at the redo ablation with high-dose isoproterenol challenge. RESULTS: Clinical characteristics were not different between the groups. When compared to the control, by the end of 5 years after the first procedure, recurrence was significantly greater in HIV group [100% vs. 54%, p < .001]. Among patients that underwent redo ablation non-PV triggers were higher in HIV group [93.5% vs. 54%, p < .001], and most frequently originated from the coronary sinus [67.7% vs. 45.2%, p < .001] and left atrial appendage [41.9% vs. 25.8%, p < .001]. After focal ablation of non-PV trigger, no difference in arrhythmia recurrence between two groups [80.6% vs. 87.1%, p = .753] at 1-year follow up was found. CONCLUSION: Our findings suggest that non-PV triggers are highly prevalent in HIV+ AF patients resulting in higher rate of the mid- and long-term arrhythmia recurrence.

Best ablation strategy in patients with premature ventricular contractions with multiple morphology: a single-centre experience.

AIMS: This study aimed to examine the clinical benefits of targeted ablation of all Premature ventricular complex (PVC) morphologies vs. predominant PVC only. METHODS AND RESULTS: A total of 171 consecutive patients with reduced left ventricular ejection fraction (LVEF) and ≥2 PVC morphology with high burden (>10%/day) undergoing their first ablation procedure were included in the analysis. At the initial procedure, prevalent PVC alone was ablated in the majority. However, at the redo, all PVC morphologies were targeted for ablation. : At the first procedure, 152 (89%) patients received ablation of the dominant PVC only. In the remaining 19 (11%) patients, all PVC morphologies were ablated. At two years, high PVC burden was detected in 89 (52%) patients. Repeat procedure was performed in 78 of 89, where all PVC morphologies were ablated. At 5 years after the repeat procedure, 71 (91%) had PVC burden of <5% [3.8 ± 1.1% vs. 15.4 ± 4.3% in successful vs. failed subjects (P < 0.001)]. In patients with low PVC burden after the initial procedure, LVEF improved from 37.5% to 41.6% [mean difference (MD): 3.39 ± 2.9%, P < 0.001], whereas a reduction in LVEF from 39.8% to 34.5% (MD: 6.45 ± 4.7%, P < 0.001) was recorded in patients with high PVC burden. One year after the repeat procedure, LVEF improved from 36.2% to 41.7% (MD: 5.5 ± 4.3%, P < 0.001) in patients with successful ablation. CONCLUSION: In this observational series, ablation of all PVC morphologies was associated with significantly lower PVC burden and improvement of LVEF at long-term follow-up, compared with ablation of the dominant morphology only.

Targeting non-pulmonary vein triggers in persistent atrial fibrillation: results from a prospective, multicentre, observational registry.

AIMS: We evaluated the efficacy of an ablation strategy empirically targeting pulmonary veins (PVs) and posterior wall (PW) and the prevalence and clinical impact of extrapulmonary trigger inducibility and ablation in a large cohort of patients with persistent atrial fibrillation (PerAF). METHODS AND RESULTS: A total of 1803 PerAF patients were prospectively enrolled. All patients underwent pulmonary vein antrum isolation (PVAI) extended to the entire PW. A standardized protocol was performed to confirm persistent PVAI and elicit any triggers originating from non-PV sites. All non-PV triggers initiating sustained atrial tachyarrhythmias were ablated. Ablation of non-PV sites triggering non-sustained runs (<30 s) of atrial tachyarrhythmias or promoting frequent premature atrial complexes (≥10/min) was left to operator's discretion. Overall, 1319 (73.2%) patients had documented triggers from non-PV areas. After 17.4 ± 8.5 months of follow-up, the cumulative freedom from atrial tachyarrhythmias among patients without inducible non-PV triggers (n = 484) was 70.2%. Patients with ablation of induced non-PV triggers had a significantly higher arrhythmia control than those whose triggers were not ablated (67.9% vs. 39.4%, respectively; P < 0.001). After adjusting for clinically relevant variables, patients in whom non-PV triggers were documented but not ablated had an increased risk of arrhythmia relapse (hazard ratio: 2.39; 95% confidence interval: 2.01-2.83; P < 0.001). CONCLUSION: Pulmonary vein antrum isolation extended to the entire PW might provide acceptable long-term arrhythmia-free survival in PerAF patients without inducible non-PV triggers. In our population of PerAF patients, non-PV triggers could be elicited in ∼70% of PerAF patients and their elimination significantly improved outcomes.

Association between prolonged P wave duration and left atrial scarring in patients with paroxysmal atrial fibrillation.

BACKGROUND: We evaluated the association of P wave duration (PWD) with left atrial scar (LAS) in patients with paroxysmal atrial fibrillation (PAF). METHODS: Consecutive patients with PAF undergoing their first catheter ablation were screened and only those in sinus rhythm at baseline were included in the analysis. A standard 12-lead electrocardiogram (ECG) was performed in all and three-dimensional voltage mapping of the left atrium was generated for identification of low-voltage areas (≤0.2 mV) before the procedure. RESULTS: In total, 411 patients with PAF were included in this study of which 181 had LASs (scar group), while 230 had no scar (nonscar group). In the scar group, patients were older (65.5 ± 8.8 vs 59.7 ± 11.7 years; P < .001), the proportion of female was higher (47.5% vs 37.4%; P = .04) and left atrial (LA) diameter (4.1 ± 0.6 vs 3.9 ± 0.6 cm; P < .001) was larger compared with the nonscar group. There was no significant difference in terms of hypertension, sleep apnea, and diabetes between the two groups. When comparing ECG characteristics between the two groups, PWD was significantly longer in the scar group (122.9 ± 18.5 and 116.9 ± 28.0 ms; P = .01). A multivariate analysis was performed, after adjustment of age, sex, LA diameter, PWD ≥ 120 ms was found to be an independent predictor of LA scarring (OR: 1.69, p-value: 0.02). CONCLUSION: In the current series, prolonged PWD was found to be independently associated with LA scarring in PAF, even after adjustment for age, sex, and LA diameter.

Gender-Based Differences In Mid-Term Clinical Outcomes And Patient Acceptable Symptomatic State Attainment After Arthroscopic Rotator Cuff Repair: Minimum 2-Year Follow Up.

OBJECTIVE: There is paucity of literature on the impact of patients' gender on recovery and treatment success after arthroscopic rotator cuff repair. This study investigates the effect of gender on patient-reported outcomes preoperatively and postoperatively (minimum 2 years), and to determine if gender affects attainment of patient acceptable symptomatic state (PASS) thresholds. METHODS: 266 patients (117 males, 149 female), who underwent primary arthroscopic rotator cuff repair for atraumatic, full-thickness tears, were included. Functional outcomes and pain scores were collected preoperatively and postoperatively. Percentage of attainment of PASS for the various outcome scores was calculated and compared between males and females. RESULTS: Women had statistically significantly poorer functional outcome and pain scores preoperatively and at 1 and 2 years postoperatively (P<0.01). They also experienced less improvement in outcome scores throughout the postoperative period. Women had statistically significantly lower rates of PASS attainment at 2 years postoperatively. CONCLUSION: Women experience greater pain and poorer shoulder function compared with men preoperatively, and up to 2 years postoperatively. Women are less likely to achieve patient acceptable symptom state thresholds postoperatively, compared to their male counterparts. STUDY DESIGN: Retrospective Cohort Study LEVEL OF EVIDENCE: III.

Defining minimal clinically important difference, patient acceptable symptomatic state and substantial clinical benefit for the visual analog scale pain score after arthroscopic rotator cuff repair.

INTRODUCTION: Patient satisfaction after arthroscopic rotator cuff repair (RCR) is commonly assessed with patient-reported outcome measures (PROMs), and there is an increased need to establish clinical relevance within these measures. The purpose of this study was to (1) define minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) for the visual analog scale (VAS) pain score in patients undergoing arthroscopic RCR, and (2) identify preoperative predictors of achieving each of these threshold values. METHODS: Data from consecutive patients who underwent primary arthroscopic rotator cuff repair study between 2010 and 2016 were prospectively collected. Baseline data and VAS pain scores were collected preoperatively and at 1 year and 2 years postoperatively. MCID, PASS and SCB were determined using an anchor-based approach, with anchor questions assessing postoperative satisfaction and expectation fulfillment. Multivariate logistic regression analysis was also used to identify preoperative predictors for achieving MCID, PASS, and SCB. RESULTS: A total of 286 patients were included in the final analysis, with an average age of 60.2 â€‹± â€‹10.4 and the majority being female (61.2%). The values for the VAS pain score identified to represent MCID, PASS, and SCB, respectively, at 1-year postoperatively were: 5, 2, and 1. The rates of achieving clinically significant improvement based on VAS were 60.5%, 63.3%, and 57.2%, respectively. A higher preoperative VAS was predictive for achieving MCID (odds ratio [OR], 1.84; P â€‹< â€‹0.01). CONCLUSION: This study identified threshold VAS pain scores of 5, 2, and 1 for achieving MCID, PASS, and SCB, respectively, at 1-year follow-up after arthroscopic rotator cuff repair. A higher preoperative VAS pain score was also identified as a statistically significant predictor of attaining MCID after arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: II.

Short- to medium-term outcomes and future direction of reverse shoulder arthroplasty: Current concepts.

Reverse shoulder arthroplasty is typically indicated for patients with severe shoulder osteoarthritis, rotator cuff tear arthropathy, or proximal humerus fractures that have failed to heal properly. The primary goal of reverse shoulder arthroplasty is to improve shoulder function and reduce pain, while also restoring the ability to perform daily activities. There is a growing body of evidence supporting the effectiveness of reverse shoulder arthroplasty in improving shoulder function and reducing pain in patients with severe shoulder osteoarthritis or rotator cuff tear arthropathy. Reverse shoulder arthroplasty is associated with significant improvements in shoulder function and pain reduction compared to non-surgical treatments. This paper aims to summarize current knowledge, practices and present a summary of the long-term effects of reverse shoulder arthroplasty (RSA) on patient outcomes, including how these outcomes are defined and what measures are typically used to assess them. It will also cover newer definitions of outcomes for RSA that have been developed in recent years in order to better understand the long-term effects of the procedure on patient-reported outcomes and functional ability, as well as information on revision surgery and implant survivorship, and the future of RSA (3D-navigation, patient-specific instrumentation, robotics and artificial intelligence) and its effects on outcomes.

Current advances in pain regimens for percutaneous nephrolithotomy A comprehensive review.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) causes pain and discomfort after surgery. The primary causes of immediate postoperative pain after PCNL are visceral pain from the ureters and kidneys, and body surface discomfort from incisions. Acute, untreated pain has the potential to develop into chronic pain, which remains a considerable burden for the rehabilitation of patients. The goal of this review was to describe the current options for treating pain post-PCNL. METHODS: We conducted a literature review of all published manuscripts on pain protocols for patients undergoing PCNL and related topics; 50 published manuscripts were identified and reviewed. RESULTS: PCNL morbidity must be reduced by an appropriate management of postoperative pain. Opioids, multimodal therapy, tubeless PCNL, reduced size of nephrostomy tube, and regional anesthesia are currently available for reducing postoperative pain. CONCLUSIONS: Implementing successful treatment strategies for postoperative pain after PCNL is key in reducing the morbidity and mortality of PCNL.

Treatment of Chronic Dislocated Patella in a Skeletally Mature Down Syndrome Patient: A Case Report.

CASE: A 55-year-old man with Down syndrome (DS) suffered from chronic irreducible right patellar dislocation. Imaging studies showed an attenuated appearance of the medial patellar retinaculum, and the tibial tubercle to trochlear groove distance measured 1.6 cm. Right medial patellofemoral ligament reconstruction (MPFLR) and lateral lengthening (LL) with proximalization of the tibial tubercle (PTT) were performed with good surgical outcomes. CONCLUSION: The combination of MPFLR, LL, and PTT is a viable option for treating a skeletally mature DS patient with patellofemoral instability causing recurrent patellar dislocation.

Home-based portable fNIRS-derived cortical laterality correlates with impairment and function in chronic stroke.

Introduction: Improved understanding of the relationship between post-stroke rehabilitation interventions and functional motor outcomes could result in improvements in the efficacy of post-stroke physical rehabilitation. The laterality of motor cortex activity (M1-LAT) during paretic upper-extremity movement has been documented as a useful biomarker of post-stroke motor recovery. However, the expensive, labor intensive, and laboratory-based equipment required to take measurements of M1-LAT limit its potential clinical utility in improving post-stroke physical rehabilitation. The present study tested the ability of a mobile functional near-infrared spectroscopy (fNIRS) system (designed to enable independent measurement by stroke survivors) to measure cerebral hemodynamics at the motor cortex in the homes of chronic stroke survivors. Methods: Eleven chronic stroke survivors, ranging widely in their level of upper-extremity motor deficit, used their stroke-affected upper-extremity to perform a simple unilateral movement protocol in their homes while a wireless prototype fNIRS headband took measurements at the motor cortex. Measures of participants' upper-extremity impairment and function were taken. Results: Participants demonstrated either a typically lateralized response, with an increase in contralateral relative oxyhemoglobin (ΔHbO), or response showing a bilateral pattern of increase in ΔHbO during the motor task. During the simple unilateral task, M1-LAT correlated significantly with measures of both upper-extremity impairment and function, indicating that participants with more severe motor deficits had more a more atypical (i.e., bilateral) pattern of lateralization. Discussion: These results indicate it is feasible to gain M1-LAT measures from stroke survivors in their homes using fNIRS. These findings represent a preliminary step toward the goals of using ergonomic functional neuroimaging to improve post-stroke rehabilitative care, via the capture of neural biomarkers of post-stroke motor recovery, and/or via use as part of an accessible rehabilitation brain-computer-interface.

Determining the Minimal Clinically Important Difference on the Oxford Shoulder Instability Score in Patients Undergoing Arthroscopic Bankart Repair for Shoulder Instability.

BACKGROUND: The literature on minimal clinically important differences (MCIDs) for patient-reported outcome measures assessing shoulder instability is limited, with none addressing the Oxford Shoulder Instability Score (OSIS). The OSIS was developed to provide a standardized method for assessing shoulder function after surgery for shoulder instability, and previous studies have demonstrated its high reliability, low interrater variability, and ease of administration. PURPOSE: To identify the MCID for the OSIS after arthroscopic Bankart repair for recurrent shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A longitudinally maintained institutional registry was queried for patients who underwent arthroscopic Bankart repair from 2010 to 2016 for recurrent shoulder instability secondary to a Bankart lesion without significant glenoid bone loss. The OSIS was completed preoperatively and at 1 year postoperatively. Patients were categorized into "expectations met" and "expectations unmet" groups using a questionnaire evaluating expectation fulfilment. The MCID of the OSIS at 1 year was calculated using 3 anchor-based approaches and a distribution-based approach. The 3 anchor-based approaches comprised (1) simple linear regression analysis, (2) receiver operating characteristic curve analysis, and (3) calculation of mean differences in change for the OSIS between the "expectations met" and "expectations unmet" groups. RESULTS: The study cohort comprised 68 men and 11 women aged 29.9 ± 12.7 years (mean ± SD). Duration of follow-up for all patients exceeded 1 year. The MCIDs for the OSIS based on the 4 calculation approaches yielded a narrow range of values, ranging from 7.7 to 8.5 for the anchor-based methods and 8.6 for the distribution-based method. CONCLUSION: Study results indicated that patients with recurrent shoulder instability without significant bone loss who undergo primary arthroscopic Bankart repair and have at least 8.6 points of improvement on their OSIS experience a clinically significant change at 1 year postoperatively.

Rare Mental Health Disorders Affecting Urologic Care: A Comprehensive Review.

Management of mental health illnesses and needs are important in fostering psychosocial support, interprofessional coordination, and greater adherence to treatment protocols in the field of urology. This can be especially true for mental health conditions that may greatly impact the presentation of a patient in the healthcare setting with urologic symptoms. This review describes the history, epidemiology, pathophysiology, clinical presentation, and treatment of somatic symptom disorder, illness anxiety disorder, compulsive sexual behavior/hypersexuality, factitious disorder, malingering symptoms, and conversion disorder in the realm of urology. Given the newly updated psychiatric diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, there has been a lack of studies reviewing how these illnesses may present in a urology patient encounter. Additionally, as these mental health illnesses may carry a rare incidence compared to other well-known mental health illness such as generalized depression or generalized anxiety disorder, we have found that the lack of provisions and recognition of the diseases can prolong the timeline for diagnosis and lead to an increased cost in both healthcare and quality of life of patients with these mental health illnesses. This review provides awareness on these mental health conditions which may greatly impact patient history and presentation within the field of urology. Additionally, urologic care providers may have an improved understanding of interdisciplinary management of such illnesses and the common symptoms patients may present with such diseases.

Knee subchondroplasty for management of subchondral bone cysts: a novel treatment method.

Knee subchondroplasty (SCP) is one of the most novel minimally invasive methods for treating bone marrow lesions. The literature suggests that it is safe, with few complications and good outcomes. However, no studies have documented its usage for managing large subchondral bone cysts. This article outlines a case report and details the pearls and pitfalls of SCP in treating large subchondral bone cysts. Our patient underwent arthroscopic debridement with medial femoral condyle SCP. Mild posterior extravasation of synthetic bone substitute was observed on Postoperative Day 1, which was immediately rectified on revision arthroscopy. Gradual escalation of weight bearing and good pain relief were subsequently achieved, and the patient has remained complication-free after two years. No further extravasation were observed on repeat radiography. SCP is a feasible temporising measure that may help to delay the need for bone allograft or immediate knee arthroplasty in younger patients while retaining function and delaying loss of productivity.

Arthroscopic Management of Scapulothoracic Bursitis: Clinical Outcomes and Assessment of Novel Bony Parameters on Magnetic Resonance Imaging.

BACKGROUND: Scapulothoracic bursitis is a significant clinical condition that limits day-to-day function. Arthroscopic scapular debridement and resection have provided satisfactory outcomes; however, techniques, approaches, and recommendations remain varied. Novel bony parameters have also gained increasing interest owing to their value in preoperative planning. PURPOSE: To assess midterm clinical outcomes after the arthroscopic management of scapulothoracic bursitis and to identify and measure novel bony parameters on preoperative magnetic resonance imaging. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 8 patients underwent arthroscopic scapular debridement and bursectomy; 5 of the 8 patients underwent additional medial scapulectomy. There were 5 male (62.5%) and 3 female (37.5%) patients with a mean age of 30.1 ± 12.3 years (range, 19-58 years). Inclusion criteria for surgery were patients with symptomatic scapulothoracic bursitis for whom extensive nonoperative modalities had been utilized for at least 6 months but failed. Outcome measures included the Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) shoulder rating scale, Constant Shoulder Score (CSS), and visual analog scale (VAS) for pain. The bony parameters included scapular shape, anterior offset, costomedial angle, and medial scapular corpus angle (MSCA). RESULTS: The follow-up duration was at least 2 years for all patients (mean follow-up, 25.0 ± 4.1 months [range, 24-35 months]). The majority of patients had a concave-shaped scapula (62.5%). The mean anterior offset was 24.3 ± 3.4 mm, and the mean costomedial angle was 132.3° ± 9.6°. Half the patients had a positive MSCA, while the other half had a negative MSCA. A statistically significant improvement was observed in the OSS, UCLA, CSS, and VAS scores from preoperatively to 2-year follow-up (P < .001 for all). No complications were observed. CONCLUSION: Arthroscopic scapular debridement and resection provided satisfactory midterm clinical outcomes for the treatment of scapulothoracic bursitis.

No difference in long-term outcomes between men and women undergoing medial fixed-bearing cemented unicompartmental knee arthroplasty: A retrospective cohort study with minimum 10-year follow up.

BACKGROUND: Some studies have suggested that women have poorer short-term outcomes after unicompartmental knee arthroplasty (UKA) due to a higher incidence of implant overhang. This study aimed to compare patient-reported outcome measures (PROMs) between men and women after UKA at a minimum follow-up of 10 years. METHODS: Patients who underwent medial fixed-bearing UKA by two arthroplasty surgeons were identified from an institutional joint registry. Men and women were matched for age, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists class, range-of-motion and baseline PROMs using propensity scores. PROMs were compared at 2 and 10 years. Patients also completed a satisfaction questionnaire during these visits. Radiographic outliers were defined as > 2 mm of overhang. RESULTS: A total of 128 patients were included. There was no difference in complications, length of stay or readmissions. Women had poorer Knee Society functional scores, Short-Form 36 physical and mental component scores (SF-36 MCS) at 2 years. No difference in PROMs was found at 10 years, except for poorer SF-36 MCS in women (P = 0.041). At 10 years, 96% of women and 92% of men were satisfied (P = 0.243). Fifteen-year survivorship free from any revision was 96% in each group. There were more medial-tibial outliers in women (9%) compared with men (5%) (P = 0.018). However, no association between outliers and outcomes or survivorship was found on multivariate analyses. CONCLUSION: There was nodifference in clinical outcomes between men and women undergoing UKA at a minimum follow-up of 10 years. While women had a higher incidence of medial tibial overhang, this was not associated with long-term outcomes or survivorship.

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of NMDA Antagonists, Neostigmine, Epinephrine, and Sodium Bicarbonate.

The potential for misuse, overdose, and chronic use has led researchers to look for other methods to decrease opioid consumption in patients with acute and chronic pain states. The use of peripheral nerve blocks for surgery has gained increasing popularity as it minimizes peripheral pain signals from the nociceptors of local tissue sustaining trauma and inflammation from surgery. The individualization of peripheral nerve blocks using adjuvant drugs has the potential to improve patient outcomes and reduce chronic pain. The major limitations of peripheral nerve blocks are their limited duration of action and dose-dependent adverse effects. Adjuvant drugs for peripheral nerve blocks show increasing potential as a solution for postoperative and chronic pain with their synergistic effects to increase the duration of action and decrease the required dosage of local anesthetic. N-methyl-d-aspartate (NMDA) receptor antagonists are a viable option for patients with opioid resistance and neuropathic pain due to their affinity to the neurotransmitter glutamate, which is released when patients experience a noxious stimulus. Neostigmine is a cholinesterase inhibitor that exerts its effect by competitively binding at the active site of acetylcholinesterase, which prevents the hydrolysis of acetylcholine and subsequently retaining acetylcholine at the nerve terminal. Epinephrine, also known as adrenaline, can potentially be used as an adjuvant to accelerate and prolong analgesic effects in digital nerve blocks. The theorized role of sodium bicarbonate in local anesthetic preparations is to increase the pH of the anesthetic. The resulting alkaline solution enables the anesthetic to more readily exist in its un-ionized form, which more efficiently crosses lipid membranes of peripheral nerves. However, more research is needed to show the efficacy of these adjuvants for nerve block prolongation as studies have been either mixed or have small sample sizes.

Incidence of deep vein thrombosis and pulmonary embolism in Asian patients after direct anterior total hip arthroplasty.

OBJECTIVE: Venous thromboembolism (VTE), comprising either deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most significant complications after Total Hip Arthroplasty (THA). The incidence of VTE after Direct Anterior Approach (DAA) hip arthroplasty is not known. Preceding studies have shown that internal femoral rotation used in the posterior approach leads to "scissoring" of the femoral vein and complete occlusion of flow. In contrast, external femoral rotation, utilized in an anterior approach, does not lead to any limitation in venous flow. We hypothesize that the rate of VTE post-operatively after DAA THA is comparable, if not lower, to other conventional approaches. METHODS: Retrospective analysis of medical records was examined to identify the incidence of symptomatic DVT within 6 months post-surgery, yielding 196 cases of elective primary DAA after THAs between 2015 and 2019. Aspirin was administered post-operatively. Corresponding imaging was performed for cases with high clinical suspicion of either DVT or PE based on Well's criteria. RESULTS: There were no cases of symptomatic DVT or fatal PE within 1 year of THA. There was 1 case of non-fatal subsegmental pulmonary embolism, treated with warfarin, which made an uneventful recovery. The overall incidence of symptomatic DVT and PE after DAA THA was 0% and 0.5% respectively in our study population. CONCLUSION: Cumulative rate of symptomatic DVT and PE was less than 1%, demonstrating that incidence of VTE after DAA THA is low. DAA is a viable approach in Asian patients undergoing THA, in view of lower incidence of post-operative VTE compared values cited in other conventional surgical approaches. Further large scale studies involving use of routine post-operative venography for assessment will further validate our results.

Induced Membrane Bone Grafting Technique for Treatment of Large Postinfectious Acetabular Bone Defects.

Management of large acetabular bone defects is challenging. The Masquelet technique has successfully reconstructed segmental defects in long bones arising from trauma, tumors, or infection but not been described for large acetabular defects. We present 3 cases of large acetabular bone defects arising from chronic prosthetic joint infection, treated via a novel induced membrane bone grafting technique, drawn from the Masquelet technique. All cases showed satisfactory clinical and radiological outcomes at midterm follow-up. This technique holds promise and can be an alternative means when treating large acetabular bone defects.

Dyslipidemia With Perioperative Statin Usage Is Not Associated With Poorer 24-Month Functional Outcomes After Arthroscopic Rotator Cuff Surgery.

BACKGROUND: Current literature suggests a higher rate of rotator cuff disease development in patients with dyslipidemia (DL). Moderate to high levels of DL are associated with higher rates of retear and revision surgery after arthroscopic rotator cuff repair. Statins protect against development of rotator cuff disease and mitigate the need for rotator cuff repair. PURPOSE: We aimed to investigate the influence of DL and statin use on postoperative functional outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between 2010 and 2016, 266 patients underwent arthroscopic double-row rotator cuff repair for atraumatic full-thickness tears. Evaluation was conducted preoperatively and at 3, 6, 12, and 24 months postoperatively. Three functional outcome measures were used (Constant Shoulder Score [CSS], Oxford Shoulder Score [OXF], and University of California, Los Angeles, Shoulder Rating Scale [UCLASS]), as well as a visual analog scale (VAS) for pain. DL and non-DL were classified through screening of health and assessment of lipid levels within 6 months of surgery (triglycerides, total cholesterol, low-density lipoprotein, and high-density lipoprotein). Patients with DL were divided into statin users and nonusers. Types and dosages of statins were recorded, and intensity and equivalency charts were employed for standardization. Mann-Whitney U test and Pearson chi-square test were used for analysis. Generalized estimating equations and linear mixed models were used to examine the influence of DL and statin dosage, respectively on percentage change of postoperative outcome scores. RESULTS: Increased age was associated with a higher incidence of DL (P < .001), and 86% of the DL group was taking statins. The DL group also exhibited poorer scores preoperatively (CSS, P = .001; OXF, P = .032). No significant difference in scores was elicited between the DL and non-DL groups at 24 months. However, patients with DL experienced greater percentage improvement of CSS and OXF from preoperative baseline than did patients without DL (P = .008 and P = .034, respectively) at 24 months. There was no significant difference in 24-month functional outcomes between statin users and nonusers. No statistically significant change of CSS; OXF; UCLASS; or VAS was noted with increasing statin doses at 24 months. CONCLUSION: Patients with DL with perioperative statin usage did not have poorer 24-month functional outcomes after arthroscopic rotator cuff surgery compared with those in patients without DL.