1
|
González Della Valle A, Sharrock N, Barlow M, Caceres L, Go G, Salvati EA. The modern, hybrid total hip arthroplasty for primary osteoarthritis at the Hospital for Special Surgery. Bone Joint J 2016; 98-B:54-9. [PMID: 26733642 DOI: 10.1302/0301-620x.98b1.36409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe our technique and rationale using hybrid fixation for primary total hip arthroplasty (THA) at the Hospital for Special Surgery. Modern uncemented acetabular components have few screw holes, or no holes, polished inner surfaces, improved locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented sockets can be combined with highly cross-linked polyethylene liners, which have demonstrated very low wear and osteolysis rates after ten to 15 years of implantation. The results of cement fixation with a smooth or polished surface finished stem have been excellent, virtually eliminating complications seen with cementless fixation like peri-operative femoral fractures and thigh pain. Although mid-term results of modern cementless stems are encouraging, the long-term data do not show reduced revision rates for cementless stems compared with cemented smooth stems. In this paper we review the conduct of a hybrid THA, with emphasis on pre-operative planning, surgical technique, hypotensive epidural anaesthesia, and intra-operative physiology.
Collapse
Affiliation(s)
| | - N Sharrock
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - M Barlow
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - L Caceres
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - G Go
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - E A Salvati
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| |
Collapse
|
2
|
Shin D, Choi SH, Go G, Park JH, Narciso-Gaytán C, Morgan CA, Smith SB, Sánchez-Plata MX, Ruiz-Feria CA. Effects of dietary combination of n-3 and n-9 fatty acids on the deposition of linoleic and arachidonic acid in broiler chicken meats. Poult Sci 2012; 91:1009-17. [PMID: 22399741 DOI: 10.3382/ps.2011-01836] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To minimize the amount of n-6 fatty acids in broiler chicken meat, 120 Cobb × Ross male broilers were divided into 6 different groups and fed a basal corn-soybean meal diet containing 5% fat from 5 different lipid sources: 1) a commercial mix of animal and vegetable oil, 2) soybean oil and olive oil (2.5% each), 3) flaxseed oil and olive oil (2.5% each), 4) flaxseed oil, eicosapentaenoic acid (C20:5; EPA; n-3), and olive oil (2.45, 0.05, and 2.5% respectively; FEO), 5) flaxseed oil, docosahexaenoic acid (C22:6; DHA; n-3), and olive oil (2.45, 0.05, and 2.5% respectively; FDO), and 6) fish oil and olive oil (2.5% each; FHO). At 6 and 9 wk, one bird per pen (4 pens per treatment) was processed, and liver, breast, and thigh samples were collected and used for fatty acid profiles or Δ6- and Δ9-desaturase mRNA gene expression levels. The deposition of linoleic acid (C18:2; n-6) or arachidonic acid (C20:4; n-6) was decreased in breast and thigh muscles of chickens fed n-3 fatty acids for 9 wk compared with chickens fed animal and vegetable oil and soybean oil and olive oil diets (P < 0.05). The addition of EPA to the diet (FEO; P > 0.05) did not reduce the deposition of linoleic acid and arachidonic acid as much as DHA (FDO; P < 0.05), and it suppressed the expression of Δ6- and Δ9-desaturase. When EPA and DHA were blended (FHO) and supplied to broiler chickens for 9 wk, EPA and DHA combination effects were observed on the deposition of LA and arachidonic acid in breast and thigh muscles. Thereby, the addition of a mixed EPA and DHA to a broiler chicken diet may be recommendable to reduce arachidonic acid accumulation in both broiler chicken breast and thigh meats, providing a functional broiler chicken meat to consumers.
Collapse
Affiliation(s)
- D Shin
- Department of Poultry Science, 2472 TAMU, Texas A & M University, College Station 77843-2472
| | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Groarke J, O'Brien J, Go G, Susanto M, Owens P, Maree AO. Cost burden of non-specific chest pain admissions. Ir J Med Sci 2012; 182:57-61. [PMID: 22552895 DOI: 10.1007/s11845-012-0826-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 04/16/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-cardiac aetiologies are common among patients presenting with chest pain. AIM To determine the cost of non-specific chest pain admissions to a tertiary referral, teaching hospital. METHODS Thrombolysis in myocardial infarction risk (TIMI) risk score, lengths of stay (LOS), investigations and diagnoses were recorded for patients admitted with chest pain. Non-specific chest pain was defined as chest pain where cardiac, pulmonary and gastroesophageal aetiologies were excluded. Costs of admissions were calculated. RESULTS Of 80 patients, 34 (4%) and 22 (28%) were diagnosed with non-specific chest pain and acute coronary syndrome, respectively. Non-specific chest pain admissions had a mean age of 54 (11; 35-74) years, LOS of 3.8 (2.6; 1-11) days and TIMI risk score of 1.4 (1.5; 0-5). Acute coronary syndrome admissions had a mean age of 67 (14; 43-94) years, LOS of 7.7 (4.3; 2-16) days and TIMI risk score of 3.1 (1.2; 0-5). The mean cost per non-specific chest pain admission was €3,729 (2,378; 1,034-10,468), or 48% of the mean cost per acute coronary syndrome admission of €7,667 (4,279; 1,963-16,071). Bed day costs account for >90% of overall costs. Only 7% of patients were weekend discharges. The mean interval to exercise stress test was 2.7(1.5; 1-7) days. CONCLUSIONS The mean costs of admission and LOS for patients with non-specific chest pain are significant. Extrapolating findings, annual national cost is estimated at approximately €71 million for this cohort, with 73,000 bed days consumed nationally. Delays from admission to tests and low percentage of weekend discharges prolong LOS.
Collapse
Affiliation(s)
- J Groarke
- Department of Cardiology, Waterford Regional Hospital, Waterford, Ireland.
| | | | | | | | | | | |
Collapse
|
4
|
Go G, Kim K, Seo S, Bak B, Shin S, Ko K. [P2.25]: The role of GSK3β in NSC proliferation and neural differentiation in the brain of rats prenatally exposured to valproic acid. Int J Dev Neurosci 2010. [DOI: 10.1016/j.ijdevneu.2010.07.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- G. Go
- Seoul National UniversityRepublic of Korea
| | - K. Kim
- Seoul National UniversityRepublic of Korea
| | - S. Seo
- Seoul National UniversityRepublic of Korea
| | - B. Bak
- Seoul National UniversityRepublic of Korea
| | - S. Shin
- Konkuk UniversityRepublic of Korea
| | - K. Ko
- Seoul National UniversityRepublic of Korea
| |
Collapse
|
5
|
Sharrock NE, Beksac B, Flynn E, Go G, Della Valle AG. Hypotensive epidural anaesthesia in patients with preoperative renal dysfunction undergoing total hip replacement. Br J Anaesth 2006; 96:207-12. [PMID: 16377652 DOI: 10.1093/bja/aei308] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hypotensive anaesthesia does not impair renal function after surgery in normal patients but there are no reports of hypotensive anaesthesia in patients with chronic renal dysfunction (CRD). METHODS From a database of 1893 consecutive patients undergoing total hip replacement (THR) under hypotensive epidural anaesthesia (HEA) from 1999 to 2004, 54 patients were identified with CRD (preoperative serum creatinine > or =124 micromol litre(-1)). Fifty matched pairs were identified for patients with normal renal function who have hypertension (n=50) or no hypertension (n=50). Changes in serum creatinine and blood urea nitrogen (BUN) were recorded daily for 3 days. Acute renal failure was defined as an increase in serum creatinine of 44 micromol litre(-1). RESULTS The mean duration of hypotension (MAP<55 mm Hg) was 94 min (range 35-305 min). The mean age was 71 yr. All patients with a creatinine level of 124 micromol litre(-1) had a creatinine clearance of <40 ml min(-1) 1.73 m(-2) (range: 13-56). Patients with CRD received more crystalloid during surgery (1755 ml) than the other two groups (1435 ml) (P<0.001). Otherwise, all three groups were similar. No patients developed evidence of acute renal dysfunction immediately after or by 24 h after surgery. Three patients with CRD had an increase in creatinine of >44 micromol litre(-1) at 48 and 72 h after surgery in the setting of volume depletion (acute blood loss in two patients and early ileus in one). Renal function subsequently improved. CONCLUSION HEA, per se, when carefully managed does not appear to predispose patients with CRD to acute renal failure after THR.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology and Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA.
| | | | | | | | | |
Collapse
|
6
|
Abstract
The toxicity and pharmacokinetic properties of a drug determine whether hemodialysis and/or hemoperfusion are indicated in acute intoxications. Valproic acid is considered unremovable by hemodialysis because of the high protein binding of 90%-95%. A 27-year-old male with a history of seizures was admitted to the emergency room because of coma, hypernatriemia, and respiratory failure caused by an intoxication with a large dose of valproic acid. At admission, the plasma valproic acid level was 1414 mg/L (9.9 mmol/L) (therapeutic range: 50-100 mg/L (350-700 micromol/ L). The anion gap was 26 mmol/L (normal <12-14 mmol/L) and corresponded fairly well with this valproic acid level. Because of the potential toxicity of this high valproic acid level serial hemodialysis and hemoperfusion was performed. The first session was done with a charcoal column and the second session with a resin column. The patient recovered during the course of treatment. The valproic acid plasma clearances during treatment were: 80 mL/min (hemodialysis); 40 mL/min (hemoperfusion by charcoal) and 80 mL/min (hemoperfusion by resin, only in the first hour). The protein binding of valproic acid in plasma was only 32% at the start and was 54% at the end of the two sessions. In this specific case of a severe valproic acid intoxication, saturated protein binding resulted in an increased fraction of unbound valproic acid. This made hemodialysis an effective treatment, while hemoperfusion was relatively less effective because of saturation of the column. In conclusion, the toxicokinetics of valproate are quite different from the pharmacokinetics at therapeutic levels. The anion gap and protein binding are important parameters in toxicokinetics.
Collapse
Affiliation(s)
- E J Franssen
- Department of Pharmacy, Groningen University Hospital, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
7
|
Sharrock NE, Go G, Sculco TP, Salvati EA, Westrich GH, Harpel PC. Dose response of intravenous heparin on markers of thrombosis during primary total hip replacement. Anesthesiology 1999; 90:981-7. [PMID: 10201667 DOI: 10.1097/00000542-199904000-00009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thrombogenesis in total hip replacement (THR) begins during surgery on the femur. This study assesses the effect of two doses of unfractionated intravenous heparin administered before femoral preparation during THR on circulating markers of thrombosis. METHODS Seventy-five patients undergoing hybrid primary THR were randomly assigned to receive blinded intravenous injection of either saline or 10 or 20 U/kg of unfractionated heparin after insertion of the acetabular component. Central venous blood samples were assayed for prothrombin F1+2 (F1+2), thrombin-antithrombin complexes (TAT), fibrinopeptide A (FPA), and D-dimer. RESULTS No changes in the markers of thrombosis were noted after insertion of the acetabular component. During surgery on the femur, significant increases in all markers were noted in the saline group (P < 0.0001). Heparin did not affect D-dimer or TAT. Twenty units per kilogram of heparin significantly reduced the increase of F1+2 after relocation of the hip joint (P < 0.001). Administration of both 10 and 20 U/kg significantly reduced the increase in FPA during implantation of the femoral component (P < 0.0001). A fourfold increase in FPA was noted in 6 of 25 patients receiving 10 U/kg of heparin but in none receiving 20 U/kg (P = 0.03). Intraoperative heparin did not affect intra- or postoperative blood loss, postoperative hematocrit, or surgeon's subjective assessments of bleeding. No bleeding complications were noted. CONCLUSIONS This study demonstrates that 20 U/kg of heparin administered before surgery on the femur suppresses fibrin formation during primary THR. This finding provides the pathophysiologic basis for the clinical use of intraoperative heparin during THR.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, The Hospital for Special Surgery, Cornell University Medical College, New York, New York 10021, USA.
| | | | | | | | | | | |
Collapse
|
8
|
Sharrock NE, Mather LE, Go G, Sculco TP. Arterial and pulmonary arterial concentrations of the enantiomers of bupivacaine after epidural injection in elderly patients. Anesth Analg 1998; 86:812-7. [PMID: 9539607 DOI: 10.1097/00000539-199804000-00025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED Bupivacaine HCl is a 50:50 racemic mixture of the levo [S(-)] and dex [R(+)] enantiomers. The R(+) enantiomer exhibits greater cardiac tissue binding and toxicity. To determine whether the lung exhibits selective uptake of one of the enantiomers of bupivacaine, we measured pulmonary artery and radial artery blood concentrations of the two enantiomers after a lumbar epidural injection of 20 mL of 0.75% bupivacaine in 10 elderly patients undergoing one-stage bilateral total knee arthroplasty. Significantly lower concentrations of R(+) than S(-) were noted in both pulmonary artery and arterial blood. Both enantiomers were absorbed by the lung to a similar extent within the first 5 min after epidural injection (extraction ratio approximately equal to 0.1 or 10%). Mean time of maximal concentration (Tmax) was 6 min. In 3 of the 10 patients, Tmax occurred in 1-3 min. We conclude that the lung absorbs both the R(+) and S(-) enantiomers of bupivacaine to a similar extent after epidural injection and that this is of doubtful clinical significance. This study also suggests that peak concentrations of bupivacaine may occur earlier after epidural injection in certain elderly patients than previously believed. IMPLICATIONS In the first 5 min after epidural injection, approximately 10% of the local anesthetic bupivacaine was absorbed by the lung. Absorption of the two enantiomers (mirror images) of bupivacaine were similar. Lung absorption of bupivacaine is unlikely to influence local anesthetic toxicity.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, The Hospital for Special Surgery, New York, New York 10021, USA.
| | | | | | | |
Collapse
|
9
|
Sharrock NE, Go G, Williams-Russo P, Haas SB, Harpel PC. Comparison of extradural and general anaesthesia on the fibrinolytic response to total knee arthroplasty. Br J Anaesth 1997; 79:29-34. [PMID: 9301385 DOI: 10.1093/bja/79.1.29] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Extradural anaesthesia is associated with lower incidences of deep vein thrombosis after total knee arthroplasty. It is not known if the type of anaesthesia influences thrombogenesis or fibrinolysis during knee surgery performed under tourniquet. We studied 31 patients allocated randomly to receive either extradural or general anaesthesia for primary unilateral total knee arthroplasty performed under tourniquet. Radial artery blood samples were obtained before surgery, during surgery with the tourniquet inflated and on deflation of the tourniquet. Plasma samples were assayed for markers of thrombin generation and fibrinolysis. Two of the circulating indices of thrombin generation, fibrinopeptide A and thrombin-antithrombin complexes, increased to a similar degree in the perioperative period in both groups. Fibrinolytic activity was similar in both groups, as measured by tissue plasminogen activator (t-PA) antigen, t-PA activity, t-PA-plasminogen activator inhibitor complexes, alpha 2-plasmin inhibitor-plasmin complexes and D-dimer. Extradural and general anaesthesia did not result in significant differences in either thrombin generation or fibrinolytic activity during total knee arthroplasty performed under tourniquet.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anaesthesiology, Hospital for Special Surgery, Cornell University Medical College, New York, USA
| | | | | | | | | |
Collapse
|
10
|
Williams-Russo P, Sharrock NE, Haas SB, Insall J, Windsor RE, Laskin RS, Ranawat CS, Go G, Ganz SB. Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement. Clin Orthop Relat Res 1996:199-208. [PMID: 8895639 DOI: 10.1097/00003086-199610000-00028] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To compare the effects of epidural anesthesia and general anesthesia on early postoperative outcomes after unilateral primary total knee replacement, 262 patients were randomly assigned to receive either epidural or general anesthesia. All patients received a common rehabilitation protocol including a standardized assessment of progress. One hundred eighty-eight patients received a common thromboembolic prophylaxis protocol with postoperative aspirin, and had a standardized surveillance protocol to detect thromboembolic complications. Deep vein thrombosis was determined by venography on the operative limb, and pulmonary embolism was determined by comparison of preoperative and postoperative lung perfusion scans. The epidural anesthesia group reached all rehabilitative milestones earlier postoperatively than did the general anesthesia group, with a statistically significant earlier attainment of stair climbing. The incidence of deep vein thrombosis was 40% with epidural anesthesia, and 48% with general anesthesia. There were no clots proximal to the popliteal veins. The incidence of pulmonary embolism on lung scan was 12% with epidural anesthesia and 9% with general anesthesia. Epidural anesthesia is associated with more rapid achievement of postoperative in hospital rehabilitation goals after total knee replacement. A minor reduction in postoperative deep vein thrombosis rate was observed with epidural anesthesia, but this did not reach statistical significance. No difference in early postoperative pulmonary embolism was observed between the 2 types of anesthesia.
Collapse
Affiliation(s)
- P Williams-Russo
- Department of Medicine, The Hospital for Special Surgery, Cornell University Medical College, New York, NY, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Fujioka H, Nakabayashi Y, Hirata S, Go G, Nishi S, Mizuno K. Analysis of tardy ulnar nerve palsy associated with cubitus varus deformity after a supracondylar fracture of the humerus: a report of four cases. J Orthop Trauma 1995; 9:435-40. [PMID: 8537849 DOI: 10.1097/00005131-199505000-00013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Four cases of tardy ulnar nerve palsy associated with a cubitus varus deformity of the elbow secondary to a supracondylar fracture of the humerus are presented. All patients had surgical management of their ulnar nerve palsy. In two patients, the ulnar nerve was entrapped by scar tissue at the abnormal position and the nerve developed a sharp V-shaped kink when the elbow was flexed. In one patient, the ulnar nerve displaced anteriorly with elbow flexion and spontaneously reduced into the ulnar nerve groove with elbow extension. In one patient, the ulnar nerve remained in the ulnar nerve groove; however, it was entrapped by fibrous bands arising from the flexor carpi ulnaris. It is speculated that malunion resulting in cubitus varus deformity will alter the anatomy at the elbow and that this can have a direct effect on the position and instability of the ulnar nerve. Incongruity of the elbow joint due to cubitus varus deformity also may cause osteoarthritis changes. As a result, ulnar neuropathy may develop from irritation to the ulnar nerve from the posttraumatic osteoarthritic changes at the elbow joint.
Collapse
Affiliation(s)
- H Fujioka
- Department of Orthopedic Surgery, Kobe University School of Medicine, Japan
| | | | | | | | | | | |
Collapse
|
12
|
Sharrock NE, Go G, Harpel PC, Ranawat CS, Sculco TP, Salvati EA. The John Charnley Award. Thrombogenesis during total hip arthroplasty. Clin Orthop Relat Res 1995:16-27. [PMID: 7554626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The activation of the clotting cascade leading to deep venous thrombosis begins during total hip arthroplasty, but few studies have assessed changes in coagulation during surgery. A better understanding of thrombogenesis during total hip arthroplasty may provide a more rational basis for treatment. In 3 separate studies, the following observations were made. Circulating indices of thrombosis and fibrinolysis: prothrombin F1.2, thrombin-antithrombin complexes, fibrinopeptide A, and D-dimer, did not increase during osteotomy of the neck of the femur or during insertion of the acetabular component, but rose significantly during insertion of the femoral component. Thrombin-antithrombin complexes, fibrinopeptide A, and D-dimer were higher after insertion of a cemented component than insertion of a noncemented femoral component. A significant decline in central venous oxygen tension was observed after relocation of the hip joint and after insertions of cemented and noncemented femoral components, providing evidence of femoral venous occlusion during insertion of the femoral component. In patients receiving a cemented femoral component, mean pulmonary artery pressure increased after relocation of the hip joint, indicating intraoperative pulmonary embolism. No changes in mean pulmonary artery pressure were noted with noncemented total hip arthroplasty. Administration of 1000 units of unfractionated heparin before insertion of a cemented femoral component blunted the rise of fibrinopeptide A. The results of these studies suggest that (1) the greatest risk of activation of the clotting cascade during total hip arthroplasty occurs during insertion of the femoral component; (2) femoral venous occlusion and use of cemented components are factors in thrombogenesis during total hip arthroplasty; and (3) measures to prevent deep venous thrombosis during total hip arthroplasty (such as intraoperative anticoagulation) should begin during surgery rather than during the postoperative period and be applied during insertion of the femoral component.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA
| | | | | | | | | | | |
Collapse
|
13
|
Sharrock NE, Go G, Sculco TP, Ranawat CS, Maynard MJ, Harpel PC. Changes in circulatory indices of thrombosis and fibrinolysis during total knee arthroplasty performed under tourniquet. J Arthroplasty 1995; 10:523-8. [PMID: 8523013 DOI: 10.1016/s0883-5403(05)80155-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Deep vein thrombosis may begin during surgery with the tourniquet inflated. Arterial levels of fibrinopeptide A, thrombin-antithrombin complexes, D-dimer, tissue plasminogen activator (t-PA) activity, and t-PA antigen were measured before surgery, during surgery with the tourniquet inflated, and following deflation of the tourniquet in 12 patients undergoing total knee arthroplasty. Minimal increases in fibrinopeptide A, thrombin-antithrombin complexes, and D-dimer were noted during surgery with the tourniquet inflated, but significant increases occurred immediately following deflation of the tourniquet. In 10 patients, intravenous heparin administration significantly suppressed the rise in fibrinopeptide A, but did not significantly alter the increases in either thrombin-antithrombin complexes, D-dimer, t-PA antigen, or t-PA activity. This study provides further evidence that deep vein thrombosis begins during surgery.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA
| | | | | | | | | | | |
Collapse
|
14
|
Sharrock NE, Go G, Mineo R, Urmey WF, Arthur GR. Relationship between body surface area and arterial concentrations of bupivacaine following lumbar epidural anesthesia. Reg Anesth 1995; 20:139-44. [PMID: 7605761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND OBJECTIVES Most prior studies have shown no relationship between body mass or body surface area (BSA) and maximum plasma concentration of local anesthetic agent (Cmax) following neural block. METHODS Forty-nine patients, aged 55 or older, undergoing elective total hip arthroplasty, had arterial plasma bupivacaine concentrations measured (gas chromatography) at 10-minute intervals for the first 60 minutes following lumbar epidural injection of 25 mL 0.75% bupivacaine plain. Hemodynamic stability was maintained with either low-dose epinephrine (EPI) or phenylephrine (PHE) intravenous infusions. RESULTS A significant relationship between arterial bupivacaine concentration and BSA was noted for both EPI and PHE groups at each observation point (P < .05). In addition, Cmax for each group was correlated to both BSA and body mass (P < .05). Arterial plasma bupivacaine concentrations were significantly higher in patients at 10, 20, 30, and 40 minutes following epidural injection in patients receiving PHE than EPI (P < .05). CONCLUSIONS Between 20% and 40% of the variability in the arterial concentrations of bupivacaine following lumbar epidural injection in elderly patients can be accounted for by differences in BSA.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York 10021, USA
| | | | | | | | | |
Collapse
|
15
|
Sharrock NE, Mineo R, Go G. The effect of cardiac output on intraoperative blood loss during total hip arthroplasty. Reg Anesth 1993; 18:24-9. [PMID: 8448094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES It is not clear whether cardiac output affects intraoperative blood loss under epidural hypotensive anesthesia. METHODS Thirty patients undergoing primary total hip arthroplasty were randomly assigned to receive intravenous infusions of either low-dose epinephrine or phenylephrine to maintain mean arterial pressure at 50 to 60 mm Hg throughout surgery under lumbar epidural anesthesia. Patients were monitored with radial artery and thermodilution pulmonary artery catheters. Hemodynamic parameters were measured every 10 minutes during surgery, and blood loss was estimated by a blinded observer weighing sponges. RESULTS Mean arterial pressure was similar between groups. Cardiac output remained unchanged in patients receiving low-dose epinephrine but declined significantly in patients receiving phenylephrine (p = 0.0001). Blood loss was 228 and 236 mL in patients receiving low-dose epinephrine and phenylephrine, respectively (p = 0.86). No correlation was observed between cardiac output and blood loss at any point during surgery. CONCLUSIONS Cardiac output is not a factor influencing blood loss during hypotensive epidural anesthesia in elderly patients undergoing primary total hip arthroplasty.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York 10021
| | | | | |
Collapse
|
16
|
Sharrock NE, Go G, Mineo R, Harpel PC. The hemodynamic and fibrinolytic response to low dose epinephrine and phenylephrine infusions during total hip replacement under epidural anesthesia. Thromb Haemost 1992; 68:436-41. [PMID: 1448777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lower rates of deep vein thrombosis have been noted following total hip replacement under epidural anesthesia in patients receiving exogenous epinephrine throughout surgery. To determine whether this is due to enhanced fibrinolysis or to circulatory effects of epinephrine, 30 patients scheduled for primary total hip replacement under epidural anesthesia were randomly assigned to receive intravenous infusions of either low dose epinephrine or phenylephrine intraoperatively. All patients received lumbar epidural anesthesia with induced hypotension and were monitored with radial artery and pulmonary artery catheters. Patients receiving low dose epinephrine infusion had maintenance of heart rate and cardiac index whereas both heart rate and cardiac index declined significantly throughout surgery in patients receiving phenylephrine (p = 0.0001 and p = 0.0001, respectively). Tissue plasminogen activator (t-PA) activity increased significantly during surgery (p < 0.005) and declined below baseline postoperatively (p < 0.005) in both groups. Low dose epinephrine was not associated with any additional augmentation of fibrinolytic activity perioperatively. There were no significant differences in changes in D-Dimer, t-PA antigen, alpha 2-plasmin inhibitor-plasmin complexes or thrombin-antithrombin III complexes perioperatively between groups receiving low dose epinephrine or phenylephrine. The reduction in deep vein thrombosis rate with low dose epinephrine is more likely mediated by a circulatory mechanism than by augmentation of fibrinolysis.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021
| | | | | | | |
Collapse
|
17
|
Stefanacci L, Farb CR, Pitkänen A, Go G, LeDoux JE, Amaral DG. Projections from the lateral nucleus to the basal nucleus of the amygdala: a light and electron microscopic PHA-L study in the rat. J Comp Neurol 1992; 323:586-601. [PMID: 1430325 DOI: 10.1002/cne.903230411] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A recent study, carried out in the monkey brain demonstrated a hitherto undescribed projection from the lateral to the basal nucleus of the amygdaloid complex. In the present study, we used light and electron microscopic techniques to determine whether a similar connection exists in the rat brain and to define what type(s) of synaptic contacts are produced by fibers of this projection. Injections of the lectin tracer Phaseolus vulgaris leucoagglutinin (PHA-L) were placed into several levels of the lateral nucleus and the distribution of fibers in the basal (basolateral) nucleus was evaluated. All lateral nucleus injections resulted in labeled fibers in the basal nucleus, though the density and distribution of labeled fibers depended on the position of the injection site within the lateral nucleus. In general, the heaviest labeling of the basal nucleus was observed after injections at midrostrocaudal levels of the lateral nucleus, especially when the injection was located ventrally. Fibers originating from cells labeled by these injections were observed throughout much of the rostrocaudal extent of the basal nucleus. Rostrally situated injections resulted in substantially lower levels of labeled fibers in the basal nucleus. Injections placed caudally in the lateral nucleus resulted in light to medium levels of labeled fibers in the basal nucleus; the terminal field in these cases did not extend as far rostrally as after the rostral and midlevel injections. Electron microscopic analysis of PHA-L labeled fibers revealed that they contributed synapses to the basal nucleus. The majority of PHA-L labeled terminals formed asymmetric contacts on dendritic spines or shafts; a smaller number of PHA-L labeled terminals formed symmetrical synapses.
Collapse
Affiliation(s)
- L Stefanacci
- Group in Neurosciences, University of California San Diego 92093
| | | | | | | | | | | |
Collapse
|
18
|
Huo MH, Salvati EA, Sharrock NE, Pellicci PM, Sculco TP, Go G, Mineo R, Brien WW. Intraoperative adjusted-dose heparin thromboembolic prophylaxis in primary total hip arthroplasty. Clin Orthop Relat Res 1992:188-96. [PMID: 1555341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intraoperative, fixed, intermittent, low-dose intravenous heparin prophylaxis has been reported to significantly reduce the incidence of thromboembolic disease from 24.3% to 8.3% after primary total hip arthroplasty (THA). This study examined the potential efficacy of adjusted-dose intraoperative heparin administration, keeping the activated clotting time at 30%-50% greater than normal. It was hypothesized that prolongation of clotting parameters in a uniform manner would further decrease the incidence of thromboembolic disease postoperatively. Sixty-one patients completed the protocol. The overall incidence of thromboembolic disease was 9.8%. Five patients had a positive postoperative venogram: four in the calf and one in the proximal deep thigh vein. One patient had a symptomatic nonfatal pulmonary embolus diagnosed by ventilation-perfusion scan. There were no complications related to heparin administration. This approach was therefore equally as effective as the fixed-dose regimen, and it further confirmed the efficacy and safety of an intraoperative heparin prophylaxis regimen. The extra efforts required to maintain a constant intraoperative level of anticoagulation did not prove advantageous over the simpler, fixed-dose regimen in reducing the incidence of thromboembolic disease after primary THA.
Collapse
Affiliation(s)
- M H Huo
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, D.C
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Huo MH, Salvati EA, Sharrock NE, Brien WW, Sculco TP, Pellicci PM, Mineo R, Go G. Intraoperative heparin thromboembolic prophylaxis in primary total hip arthroplasty. A prospective, randomized, controlled, clinical trial. Clin Orthop Relat Res 1992:35-46. [PMID: 1729021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Venous thromboembolic disease remains the most common and potentially fatal complication after total hip arthroplasty (THA). Proximal femoral deep vein thrombosis (DVT) is especially prone to propagate and embolize. The authors' hypothesis was that intraoperative intravenous heparin administration could reduce proximal DVT in THA. There were 286 patients who entered into a prospective, double-blind, randomized clinical trial at the authors' institution between June 1988 and May 1990. All patients had unilateral primary THA under hypotensive epidural anesthesia. The epidural catheter was placed at least 60 minutes before heparin administration. Intravenous heparin was given during surgery only. All patients received aspirin twice daily (650 mg/day) after surgery. Detection of DVT was by contrast venography on Postoperative Day 6 or 7. The study was divided into three phases. There was four groups: control (intraoperative saline), 30 minutes (1000 U heparin at beginning of surgery followed by 500 U every 30 minutes), continuous adjusted (1000 U or 1500 U initial bolus followed by continuous heparin infusion maintaining anticoagulation at 30%-50% elevation from baseline), and fixed dose (1000 U bolus before hip dislocation, and 500 U bolus before femoral canal preparation). Proximal femoral DVT was effectively reduced from 9.1% in the control group to 1.7% in the heparin groups (1.7% in 30 minute, 1.6% in continuous adjusted, 1.7% in fixed dose) (p less than 0.02). The overall DVT rate was also significantly reduced from 24.3% to 10% (p less than 0.01). No adverse effects from heparin administration were noted. Postoperative drainage, hematocrit levels on Postoperative Day 2 and at discharge, and transfusion requirements were not significantly different among the groups. The current recommended protocol is 1000 U bolus five minutes before hip dislocation, followed by 500 U bolus five minutes before femoral preparation. This, in conjunction with hypotensive epidural anesthesia and postoperative aspirin, is effective in reducing proximal DVT to less than 2% in primary THA.
Collapse
Affiliation(s)
- M H Huo
- Hospital for Special Surgery, New York, New York 10021
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Sharrock NE, Go G, Mineo R. Effect of i.v. low-dose adrenaline and phenylephrine infusions on plasma concentrations of bupivacaine after lumbar extradural anaesthesia in elderly patients. Br J Anaesth 1991; 67:694-8. [PMID: 1768539 DOI: 10.1093/bja/67.6.694] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Thirty patients undergoing primary total hip replacement under lumbar extradural anaesthesia with 0.75% bupivacaine 25 ml were allocated randomly to receive either low-dose adrenaline or phenylephrine infusions i.v. throughout surgery. Haemodynamic measurements and arterial blood samples were obtained before the extradural injection and at 10, 20, 30, 40, 50, 60 and 90 min thereafter. Peak arterial plasma concentrations of bupivacaine were observed 10 min after extradural anaesthesia and were significantly lower in patients receiving adrenaline infusions. Cardiac output was significantly greater in patients receiving adrenaline infusions (P less than 0.01). It is postulated that the smaller circulating concentrations of bupivacaine observed in patients receiving adrenaline were caused by increased cardiac output and a greater volume of distribution than in patients receiving phenylephrine.
Collapse
Affiliation(s)
- N E Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021
| | | | | |
Collapse
|
21
|
Abstract
A case of massive osteolysis of the skull and its histology is described. Removal of the bone defect with a margin of normal bone and covering of the defect by cranioplasty is advised and may arrest the disease.
Collapse
Affiliation(s)
- C Bouwsma
- Department of Neurology, University Hospital, Groningen, The Netherlands
| | | | | | | | | |
Collapse
|
22
|
Melechen NE, Go G. Induction of lambdoid prophages by amino acid deprivation: differential inducibility; role of recA. Mol Gen Genet 1980; 180:147-55. [PMID: 6449654 DOI: 10.1007/bf00267364] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Lambda prophage in auxotrophic lysogens can be induced by omission of one or combinations of the required amino acids from the culture medium. Such amino acid deprivation can result in nearly as effective induction of lambda as thymine deprivation. Prophage 424 is also induced equally effectively under both conditions although to a lesser extent than lambda. By contrast prophage 21 and lambda i21 are differentially induced effectively by thymine deprivation and virtually not at all during amino acid deprivation. The same differential induction of 21 and equivalent induction of lambda and 424 occur when all three prophages are present in the same lysogen. Increasing the levels of lambda repressor with a cI carrying-plasmid prevented amino acidless induction of lambda as did the lambda ind- mutation. A recA, but not a recB, mutation in the host prevented induction by amino acid deprivation. A recC mutant host showed increased spontaneous induction of lambda and 21 prophages. The findings reported are used as an argument that the recA protease probably is not itself acting as the inducing protease and that a likely source of the observed specificity is an effector molecule. Different effector molecules may be produced in response to different exigent situations, to which the phage repressors may have evolved sensitivity. lambda i80 was inducible both by amino acid and thymine deprivation.
Collapse
|
23
|
Melechen NE, Go G, Lozeron HA. Effect of cI repressor level on thymineless and spontaneous induction; specificity of lambda RNA transcription. Mol Gen Genet 1978; 163:213-21. [PMID: 355850 DOI: 10.1007/bf00267412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To determine the role of the cI repressor in induction provoked by thymine deprivation, we have analyzed lambda messenger RNA made during and the effect of cI repressor levels on thymineless induction. During thymineless induction, the l- and r-strand transcription of lambda is restricted to the "early" and "delayed early" RNA. This transcriptional pattern is similar to that reported for lambda mutants defective in DNA synthesis. "Late" r-strand transcription requires the addition of thymine. A decrease (to less than 10% of 0 time) in the amount of exogenous label (3H-uridine) incorporated into total RNA by the time of maximum thymineless induction was observed. Since subsequent burst sizes are not diminished by the thymine deprivation and competition experiments show that the amount of lambda message RNA present is at least as great as that in heat induced lambda cI857 lysogens, this decrease must involve either enlarged uridine pool sizes or decreased entry of label. The introduction into the lambda lysogen of a plasmid (pKB252) carrying the lambda cI gene prevents (1) the thymineless induction of lambda (curing the plasmid restores thymineless induction) and, (2) the appearance of both spontaneously induced cells and free phage. Thus, thymineless induction is dependent on the level of cI repressor and spontaneous induction also appears to be the consequence of lowered repressor levels in lambda lysogens.
Collapse
|
24
|
Westergaard E, Go G, Klatzo I, Spatz M. Increased permeability of cerebral vessels to horseradish peroxidase induced by ischemia in Mongolian Gerbils. Acta Neuropathol 1976; 35:307-25. [PMID: 961382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cerebral ischemia was induced by occlusion of the left common carotic artery in adult Mongolian gerbils. The period of occlusion was 3, 6, or 18 h. Horseradish peroxidase (HRP) was intravenously injected in animals with clear neurological signs 1 h release of the clip. The HRP was allowed to circulate for 5 min. Fixation was carried out by perfusion with aldehydes. Tissue, incubated for peroxidatic activity, from the left side of the brain was treated for electron microscopy. During the postischemic period enhanced permeability was demonstrated in the brains of all animals. The amount of HRP transferred into the neuropil depended on the duration of ischemia. Thus the gerbils with 18 h occlusion showed the greatest content. The cells comprising the neuropil adjacent to vessels were studied and the degree of the pathological changes described below was increased proportionally to the time period of occlusion. The intercellular spaces, often filled with peroxidase, were expanded and the astrocytes swollen, especially the endfeet. Sometimes the astrocytes were pervious to HRP. The neurons were also swollen, but to a lesser degree than the astrocytes. No endothelial cell damage was observed. Even 18 h of occlusion did not change the plasma membranes. The intercellular spaces were free of HRP from the first luminal to the first abluminal tight junction. The cytoplasm exhibited HRP-containing vesicles of various types and shapes. Some were freely situated; others were connected to the plasma membrane and then open to the vessel lumen or to the basement membrane. Since no cell damage was demonstrated, and since no HRP was diffusely dispersed in the cytoplasm it is assumed that vesicles are responsible for the enhancement of the vesicular transport that normally occurs after intravenous injection of HRP.
Collapse
|
25
|
Westergaard E, Go G, Klatzo I, Spate M. THE EFFECT OF CEREBRAL ISCHEMIA ON THE BLOOD-BRAIN BARRIER TO HORSERADISH PEROXIDASE IN MONGOLIAN GERBILS. J Neuropathol Exp Neurol 1976. [DOI: 10.1097/00005072-197605000-00170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
26
|
Go G, Nakamura FH, Rhoads GG, Dickinson LE. Long-term health effects of dietary monosodium glutamate. Hawaii Med J 1973; 32:13-7. [PMID: 4689313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|