Assessing the Diagnostic Accuracy of Next-Generation Sequencing in Patients With Antibiotic Spacers Before Reimplantation

Use of molecular sequencing modalities in periprosthetic joint infection diagnosis and organism identification has gained popularity recently. To date, there is no diagnostic test that reliably predicts infection eradication in patients with antibiotic spacers. The purpose of this study was to compare the diagnostic accuracy of next-generation sequencing (NGS), culture, the Musculoskeletal Infection Society (MSIS) criteria, and the criteria by Parvizi et al in patients with antibiotic spacers. In this retrospective study, aspirate or tissue samples were collected from 38 knee and 19 hip antibiotic spacers for routine diagnostic workup for the presence of persistent infection and sent to the laboratory for NGS. The kappa statistic along with statistical differences between diagnostic studies were calculated using the chi-square test for categorical data. The kappa coefficient for agreement between NGS and culture was 0.27 (fair agreement). The percentages of positive and negative agreement were 22.8% and 42.1%, respectively, with a total concordance of 64.9%. There were 12 samples that were culture positive and NGS negative. Eight samples were NGS positive but culture negative. The kappa coefficient was 0.42 (moderate agreement) when comparing NGS with MSIS criteria. In our series, NGS did not provide sufficient agreement compared with culture or MSIS criteria in the setting of an antibiotic spacer. A reliable diagnostic indicator for reimplantation has yet to be identified. [Orthopedics. 2024;47(1);46-51.].

Transitioning to Outpatient Shoulder Arthroplasty: Safety, Efficiency, and Cost in a Diverse Payer Mix

Outpatient shoulder arthroplasty presents potential clinical benefits but also risk without perioperative optimization. Length of stay depends largely on surgeon preferences, and a large single-surgeon cohort may provide insight into optimal strategies and costs for outpatient shoulder arthroplasty. A single-surgeon cohort of 472 anatomic and reverse shoulder arthroplasties performed between 2017 and 2020 was retrospectively reviewed. Cases were stratified by those who did or did not undergo same-day discharge. The 90-day readmission, discharge to post-acute care, cost, and 45 patient/case factors were examined. Two hundred fifty (53%) underwent same-day discharge, with the proportion of outpatient cases increasing over time to nearly 80%, with no significant difference in 90-day readmissions. Revision cases often underwent same-day discharge, whereas fractures were typically admitted. The cost was significantly higher for inpatients, with implants accounting for 52%. Surgeons may safely transition a substantial proportion of shoulder arthroplasties to same-day discharge with some reassurance regarding cost savings and 90-day readmissions. (Journal of Surgical Orthopaedic Advances 32(4):263-269, 2023).

The characteristics of opioid use in patients with proximal humerus fractures

BACKGROUND

Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures.

METHODS

A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017.

RESULTS

There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01).

CONCLUSIONS

With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.

Cutibacterium Positive Cultures in Total Hip Arthroplasty: Contaminant or Pathogen?

BACKGROUND

Cutibacterium spp. is an emerging pathogen in total hip arthroplasty (THA) that is not well evaluated in the literature. This study reported on the presentation and management of THA complicated by positive intraoperative Cutibacterium cultures.

METHODS

This is a retrospective review of 27 revision THAs with positive monomicrobial intraoperative Cutibacterium cultures from 2014 to 2020 at one academic center. These patients were divided into two cohorts based on meeting Musculoskeletal Infection Society (MSIS) criteria for prosthetic joint infections (PJI). Patient demographics, preoperative labs, and hip aspirate results were collected. Procedure performed, postoperative antibiotic regimens, and repeat infections were recorded. Data were compared with univariate analysis.

RESULTS

Nine of the 27 patients preoperatively met MSIS criteria for PJI. Patients with positive MSIS criteria had significantly higher median synovial cell count (P = .048) and neutrophil percentage in a preoperative aspirate (P = .050). Eight patients with positive MSIS criteria received six weeks of postoperative antibiotics compared to two patients with negative criteria. Two patients with positive MSIS criteria had a postoperative infection that required further surgical intervention. Four patients with negative criteria who required further surgical intervention did not receive postoperative antibiotics after initial revision.

CONCLUSION

While often categorized as a contaminant, Cutibacterium is an increasingly recognized pathogen in THA. Cutibacterium can often present with normal serology, which may result in misdiagnosis as aseptic THA failure. Without the administration of postoperative antibiotics after positive cultures, there is a risk for persistent infection requiring further surgical intervention.

Quantifying the Economic Impact of Depression for Spine Patients in the United States

STUDY DESIGN

This was a retrospective cross-sectional analysis.

OBJECTIVE

The objective of this study was to estimate the incremental health care costs of depression in patients with spine pathology and offer insight into the drivers behind the increased cost burden.

SUMMARY OF BACKGROUND DATA

Low back pain is estimated to cost over $100 billion per year in the United States. Depression has been shown to negatively impact clinical outcomes in patients with low back pain and those undergoing spine surgery.

MATERIALS AND METHODS

Data was collected from the Medical Expenditure Panel Survey from 2007 to 2015. Spine patients were identified and stratified based on concurrent depression International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Health care utilization and expenditures were analyzed between patients with and without depression using a multivariate 2-part logistic regression with adjustments for sociodemographic characteristics and Charlson Comorbidity Index.

RESULTS

A total of 37,094 patients over 18 years old with a spine condition were included (mean expenditure: $7829±241.67). Of these patients, 7986 had depression (mean expenditure: $11,455.41±651.25) and 29,108 did not have depression (mean expenditure: $6837.89±244.51). The cost of care for spine patients with depression was 1.42 times higher (95% confidence interval, 1.34-1.52; P<0.001) than patients without depression. The incremental expenditure of spine patients with depression was $3388.22 (95% confidence interval, 2906.60-3918.96; P<0.001). Comorbid depression was associated with greater inpatient, outpatient, emergency room, home health, and prescription medication utilization and expenditures compared with the nondepressed cohort.

CONCLUSIONS

Spine patients with depression had significantly increased incremental economic cost of nearly $3500 more annually than those without depression. When extrapolated nationally, this translates to an additional $27.5 billion annually in incremental expenditures that can be attributed directly to depression among spine patients, which equates to roughly 10% of the total estimated spending on depression nationally. Strategies focused on optimizing the treatment of depression have the potential for dramatically reducing health care costs in spine surgery patients.

Efficacy of Common Antiseptic Solutions Against Clinically Relevant Planktonic Microorganisms

Prosthetic joint infections (PJIs) are among the most devastating complications after joint replacement. There is limited evidence regarding the efficacy of different antiseptic solutions in reducing planktonic microorganism burden. The purpose of this study was to test the efficacy of different antiseptic solutions against clinically relevant planktonic microorganisms. We designed an experiment examining the efficacy of several antiseptic solutions against clinically relevant planktonic microorganisms in vitro. Regarding planktonic microorganisms, povidone-iodine had 99.9% or greater reduction for all microorganisms tested except for methicillin-resistant Staphylococcus aureus, which was reduced by 60.44%. Irrisept (Irrimax Corp) had 99.9% or greater reduction for all microorganisms except Staphylococcus epidermidis (98.31%) and Enterococcus faecalis (48.61%). Bactisure (Zimmer Surgical Inc) had 99.9% or greater reduction for all microorganisms tested. Various measures exist for PJI prevention, one of which is intraoperative irrigation. We tested irrigants against clinically relevant planktonic microorganisms in vitro and found significant differences in efficacy among them. Further clinical outcome data are necessary to determine whether these solutions can impact PJI in vivo. [Orthopedics. 2022;45(2):122-127.].

Fracture Severity Based on Neer Classification Does Not Predict Short-term Complications Following Reverse Shoulder Arthroplasty

Proximal humerus fractures (PHF) are common in elderly and osteoporotic patients, and these fractures are often described using the Neer classification. As reverse shoulder arthroplasty (RSA) for PHF becomes more common, it is helpful to identify the utility of Neer classification in predicting postoperative outcomes for patients undergoing RSA. The medical records of patients undergoing primary RSA for PHF at a single academic institution from 2013-2019 were identified using medical billing codes. A multivariable logistic regression analysis identified independent factors associated with all cause 90-day readmissions, reoperation, and length of stay (LOS) greater than three days. Fifty-five patients (average age of 72.3 ± 8.6 years) were included. No statistically significant differences among two-, three-, and four-part fractures with regard to LOS, discharge location, 90-day readmission, revision surgery, postoperative dislocation, or deep infection were detected. These findings suggest that Neer classification for PHF is not predictive of short-term complications after RSA. (Journal of Surgical Orthopaedic Advances 31(2):104-108, 2022).

Efficacy of common antiseptic solutions against clinically relevant microorganisms in biofilm

AIMS

Periprosthetic joint infections (PJIs) are among the most devastating complications after joint arthroplasty. There is limited evidence on the efficacy of different antiseptic solutions on reducing biofilm burden. The purpose of the present study was to test the efficacy of different antiseptic solutions against clinically relevant microorganisms in biofilm.

METHODS

We conducted an in vitro study examining the efficacy of several antiseptic solutions against clinically relevant microorganisms. We tested antiseptic irrigants against nascent (four-hour) and mature (three-day) single-species biofilm created in vitro using a drip-flow reactor model.

RESULTS

With regard to irrigant efficacy against biofilms, Povidone-iodine treatment resulted in greater reductions in nascent MRSA biofilms (logarithmic reduction (LR) = 3.12; p < 0.001) compared to other solutions. Bactisure treatment had the greatest reduction of mature Pseudomonas aeruginosa biofilms (LR = 1.94; p = 0.032) and a larger reduction than Vashe or Irrisept for mature Staphylococcus epidermidis biofilms (LR = 2.12; p = 0.025). Pooled data for all biofilms tested resulted in Bactisure and Povidone-iodine with significantly greater reductions compared to Vashe, Prontosan, and Irrisept solutions (p < 0.001).

CONCLUSION

Treatment failure in PJI is often due to failure to clear the biofilm; antiseptics are often used as an adjunct to biofilm clearance. We tested irrigants against clinically relevant microorganisms in biofilm in vitro and showed significant differences in efficacy among the different solutions. Further clinical outcome data is necessary to determine whether these solutions can impact PJI outcome in vivo. Cite this article: Bone Joint J 2021;103-B(5):908-915.

Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis

Purpose

To assess the current national rate of medial ulnar collateral ligament (MUCL) repair of the elbow and delineate the patient demographics of those undergoing repair.

Methods

A retrospective review and analysis of a national private insurance database was conducted covering 2007-2017 using Pearl Diver technologies. All patients diagnosed with a MUCL injury and those who underwent repair were included using Clinical Modification and Current Procedural Terminology code 24345, referencing repair of the ulnar collateral ligament of the elbow with local tissue. The extracted data included patient age at time of procedure, sex, race, region, year of surgery, insurance type, hospital setting, and any associated diagnoses with 90 days of the repair procedure. Standard descriptive methods characterized our study sample to calculate frequency counts and percentages. Means with respective standard deviations and/or standard errors, and 95% confidence intervals were calculated and reported for continuous variables, whereas frequencies and percentages were reported for categorical variables. Pearson χ² tests were used to determine differences between group proportion categorical variables. Significance was considered at a P ≤ .05.

Results

From 2007 to 2014, MUCL injuries showed an upward trend in incidence per 100,000 from 4.59 to 7.19 (56% increase) within the database population. Accordingly, the incidence of MUCL repair rose from 0.016 to 0.49 (2962%). However, from 2015-2017 there was a drop in both categories, as injury incidence fell from 7.19 to 1.48 whereas repair rates dropped from 0.49 to 0.012. The ages undergoing repair show a significant peak in 15-24-year-olds. The incidence of MUCL repair was greatest in the West and South (P < .01). Male patients had a greater incidence of MUCL injury, and a greater incidence of MUCL repair per 100,000 persons compared to females (P < .01).

Conclusions

MUCL repair has emerged as a viable alternative to reconstruction in select indications. The impetus for this change may be to provide a quicker return to sport and fewer complications, largely due to recent improvements in surgical technique for MUCL repair. As anticipated, the incidence of MUCL repair had steadily increased in the United States from 2007 to 2014, with a subsequent relatively inexplicable decrease primarily in 2017, according to the database utilized in this study. The 15-24 year-old age group encompassing young athletes has the greatest incidence of repair by a significant margin.

Level of Evidence

IV, Therapeutic Case Series.

Risk of suprascapular nerve injury during glenoid baseplate fixation for reverse total shoulder arthroplasty: a cadaveric study

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) is an effective treatment for patients with advanced rotator cuff arthropathy. During implantation of the glenoid baseplate, screws are inserted through the glenoid face into the scapular body to achieve adequate fixation. Placement of peripheral baseplate screws in the superior and posterior glenoid may increase the risk of injury to the suprascapular nerve (SSN). The purpose of this cadaveric study was to evaluate the risk of SSN injury with placement of baseplate screws in the superior and posterior direction.

METHODS

Twelve cadaveric shoulders were implanted with glenoid baseplates. A bicortical 44-mm screw was placed in both the superior and posterior glenoid baseplate screw holes. Following implantation, the SSN was dissected and visualized through a posterior shoulder approach. The distance from the tip of the screws to the SSN and the distance from the screw's scapular exiting hole to the SSN was recorded. Average distances were calculated for each measurement.

RESULTS

The superior screw contacted the SSN in 8 of the 12 specimens (66%). For the superior screw, the average distance from the exiting point in the scapula to the SSN was 9.2 ± 6.3 mm, with the shortest distance being 3.9 mm. The posterior screw contacted the SSN in 6 of 12 specimens (50%). For the posterior screw, the average distance from the exiting point to the SSN was 8.9 ± 3.8 mm, with the shortest distance to the nerve being 2.2 mm.

CONCLUSION

Placement of the superior and posterior screws in the glenoid baseplate during rTSA risks injury to the SSN. The safe zone for superior- and posterior-directed baseplate screw is <2 mm from its exiting point on the scapula. Therefore, precise measurements of screw lengths in this area is important in avoiding injury to the SSN.

Time to Surgery Affects Return to Work Rates for Workers' Compensation Patients With Single-Level Lumbar Disk Herniation

The optimal timing of lumbar diskectomy in patients with lumbar disk herniation and radiculopathy has not been studied in the workers' compensation (WC) population. A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disk herniation between 2005 and 2012. The primary outcome was whether subjects return to work (RTW). To determine the impact time to surgery had on RTW status, the authors performed a multivariate logistic regression analysis. They compared other secondary outcomes using chi-square and t tests. The authors identified 1287 WC patients with single-level disk herniation and radiculopathy. Average time from injury to surgery was 364 days (range, 2-2710 days). The WC patients with shorter duration of radiculopathy before diskectomy had higher RTW rates; fewer physical therapy, chiropractic, and psychotherapy sessions; and fewer postoperative diagnoses of psychological illnesses (P<.05). A multivariate logistic regression model showed that time to surgery was an independent, negative predictor of RTW (odds ratio [OR], 0.97 per month; P<.01). Legal representation (OR, 0.56; P<.01), psychological comorbidity (OR, 0.32; P=.01), and mean household income (OR, 1.01 per $1000; P<.01) also significantly affected RTW status. These results confirm that the duration of radiculopathy due to single-level lumbar disk herniation has a predictive value for the WC population undergoing diskectomy. Within 12 weeks of injury, post-diskectomy patients do reasonably well, with 70.0% of subjects returning to work. [Orthopedics. 2021;44(1):e43-e49.].

The Impact of Smoking in Workers' Compensation Patients Receiving Spinal Cord Stimulation

The objective of this study was to determine the impact of smoking on clinical outcomes in workers' compensation (WC) patients receiving spinal cord stimulation (SCS). One hundred and ninety-six patients from the Ohio Bureau of Workers' Compensation were identified who received SCS with implantation occurring between 2007-2012. Patients were divided into smokers (n = 120) and nonsmokers (n = 76). Population characteristics before and after implantation were analyzed between the two groups. A multivariate logistic regression was run to determine predictors of return to work (RTW) status. Our regression determined smoking (p = 0.006; odds ratio [OR] = 0.260) and body mass index (p = 0.036; OR = 0.905) to be negative predictors of RTW status. After implantation, smokers were less likely to RTW after 6 months and had higher pain scores after 6 and 12 months. Both smokers and nonsmokers had significance reductions in opioid use after SCS implantation. (Journal of Surgical Orthopaedic Advances 30(3):185-189, 2021).

Rotator cuff to deltoid and pectoralis tendon to anatomic neck distances: methods for anatomic restoration of humeral height and tuberosity position in proximal humerus fractures for operative fixation and arthroplasty

Introduction

Proper anatomic tuberosity reduction and restoration of humeral height during surgical treatment of proximal humerus fractures leads to fewer complications and better outcomes. In the presence of significant displacement and comminution in proximal humerus fractures, the assessment of the correct tuberosity position and humeral height can be challenging. The goal of this cadaveric study was to provide new and useful measurements for intraoperative guidance of proper tuberosity position and humeral height when treating proximal humerus fractures with open reduction internal fixation, anatomic hemiarthroplasty, or reverse total shoulder arthroplasty.

Methods

A total of 28 cadaveric shoulders were dissected with a deltopectoral approach. The distance between the insertion of the supraspinatus tendon and the superior aspect of the deltoid tendon was measured (cuff to deltoid distance [CDD]). Secondly, the distance between the superior aspects of the pectoralis major tendon to the medial aspect of the anatomic neck (PND) was measured. Further, we sought to determine if these measurements would correlate to patient height and differ between gender.

Results

The average age of the donors was 65.3 years (64% male). The CDD and PND were 87.6 ± 10.6 and 16.6 ± 6.9 mm, respectively (mean ± standard deviation). There were no differences between females and males for the CDD (86.9 ± 9.4 vs. 87.2 ± 15.2 mm, P = .96) and PND (16.3 ± 9.1 vs. 17.1 ± 5.9 mm, P = .76). There was no correlation between the cadaver height and CDD (R2 = 0.1) and PND (R2 = 0.3).

Discussion

In this study, we describe 2 new measurement tools that can readily be applied intraoperatively during surgical treatment of proximal humerus fractures to aid in tuberosity reduction and humeral height assessment. These measurements were found to be independent of patient height and gender and can be used as a reference tool for most patients.

Shorter Time to Surgery Is Associated With Better Outcomes for Spondylolisthesis in the Workers' Compensation Population

This study sought to determine the impact of time to surgery on clinical outcomes in patients with spondylolisthesis in the workers' compensation (WC) population. There is conflicting evidence regarding the effect of time to surgery on patients with spondylolisthesis. Patients receiving WC are known to have worse outcomes following spine surgery compared with the general population. A total of 791 patients from the Ohio Bureau of Workers' Compensation were identified who underwent lumbar fusion for spondylolisthesis between 1993 and 2013. The patients were divided into those who had surgery within 2 years of injury date and after 2 years. Confounding factors were corrected for in a multivariate logistic regression to determine predictors of return to work (RTW) status. Multivariate logistic regression determined that longer time to surgery (P=.003; odds ratio, 0.89 per year), age at index fusion (P=.003; odds ratio, 0.98 per year), and use of physical therapy before fusion (P=.008; odds ratio, 0.54) were negative predictors of RTW status. Patients who had surgery within 2 years were more likely to RTW and have fewer days absent from work, lower medical costs, and fewer sessions of psychotherapy, physical therapy, and chiropractor care. The authors demonstrated that for WC patients with spondylolisthesis, longer time to surgery was a negative predictor of RTW status. Patients who had surgery within 2 years of injury date were significantly more likely to RTW compared with after 2 years. [Orthopedics. 2020;43(3):154-160.].

Modern Dual-Mobility Cups in Revision Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this systematic review is to analyze the outcomes of dual-mobility (DM) cups in revision total hip arthroplasty (THA). Specifically, we evaluated the following: (1) all-cause and aseptic survivorship rates; (2) dislocation rates; (3) complications; and (4) clinical outcomes reported using validated health status measures.

METHODS

A comprehensive literature search included studies that reported the following: (1) re-revision rates, (2) complications, and (3) clinical outcomes following DM use in revision THA. The following exclusion criteria were used: (1) studies that did not stratify their analysis between primary and revision THA, (2) studies that utilized off-label techniques, (3) review articles, (4) case studies, (5) basic science articles, (6) non-English language reports, and (6) reports on patients who underwent surgery before 2010, in order to reflect modern DM implants use and technology. A total of 9 studies were included in our final analysis.

RESULTS

Aseptic and all-cause survivorship rates were 97.7% and 94.5%. Prevalence of dislocation was 2.2%, and 0.3% for intraprosthetic dislocation. Meta-analysis comparing DM to fixed-bearing prostheses demonstrated a significantly lower odds of dislocation in the DM cohort (odds ratio 0.24, P = .002). Complications occurred in 7.4% of revision THAs with DM cups, while infection rates totaled to 3.3% of cases. Studies comparing outcomes using Harris Hip Scores did not demonstrate a statistically significant difference in improved postoperative scores (P > .05).

CONCLUSION

DM cups have demonstrated excellent survivorship, low dislocation, and overall complication rates. Therefore, it can be considered a safe and effective option, particularly in the high-risk patients who undergo revision THA.

Outcomes of tibia shaft fractures caused by low energy gunshot wounds

BACKGROUND

The purpose of this project was to compare the rates of infections, nonunions, malunions, and secondary operations in tibia fractures resultant from low energy GSWs versus those seen in open and closed tibia fractures resultant from blunt trauma. A secondary objective was to assess the utility of using the traditional Gustilo-Anderson classification system for open fractures to describe fractures secondary to low energy GSW.

METHODS

A retrospective review of 327 patients with tibia shaft fractures was conducted at our level I trauma center. Patients underwent a variety of interventions depending on their injury. Standard fixation techniques were utilized. Outcome measures include: mechanism of injury, rates of superficial and deep infection, nonunion, malunion, and secondary operations.

RESULTS

Deep infection after low energy GSW tibia fractures was uncommon and seen in only 2.3% of patients. Rates of infection after low energy GSWs were similar to low and high energy closed tibia fractures resultant from blunt trauma, but significantly less than that seen in open type II (25%, p < 0.05), type IIIA (19.5%, p < 0.05), and type IIIB fractures (47%, p < 0.01). There were no nonunions following GSW fractures, versus 3.7% after closed tibia fractures from blunt trauma (p = 0.2). Nonunions were more common after open fractures from blunt trauma (11%, p < 0.05) versus GSWs. Differences in infection and nonunion were associated with more secondary operations (18%, p < 0.01) in the open tibia fracture group compared with GSWs (2.3%) and closed fractures (7.9% p = 0.19).

CONCLUSIONS

While GSWs are traditionally thought of as open injuries, low energy GSW tibia fractures had a low rate of infection and no nonunions, and resulted in a reoperation rate similar to closed blunt tibia shaft fractures and significantly lower than open tibia fractures.

Lumbar Discography Is Associated With Poor Return to Work Status Following Lumbar Fusion Surgery in a Workers' Compensation Setting

Lumbar discography (LD) is used to guide surgical decision making in patients with degenerative disc disease (DDD). Its safety and diagnostic accuracy are under contention. This study evaluates LD's efficacy within the workers' compensation (WC) population. Multivariate logistic regression analysis was used to determine the impact that undergoing LD before lumbar fusion for DDD had on return to work (RTW) rates among 1407 WC subjects. Discography was negatively associated with RTW status (p = .042; OR 0.76); 22.2% (142/641) of LD subjects met the RTW criteria, compared with 29.6% (227/766) of controls. Additional preoperative risk factors included psychological comorbidity (p < .001; OR 0.34), age greater than 50 (p < .005; OR 0.64), male gender (p < .037; OR 0.75), chronic opioid use (p < .001; OR 0.53), legal representation (p < .034; OR 0.72), and fusion technique (p < .043). LD subjects used postoperative narcotics for an average of 123 additional days (p < .001). This raises concerns regarding the utility of discography in the WC population. (Journal of Surgical Orthopaedic Advances 27(1):25-32, 2018).

Early prediction of cardiac allograft vasculopathy and heart transplant failure

Early risk-prediction is essential to prevent cardiac allograft vasculopathy (CAV) and graft failure in heart transplant patients. We developed multivariate models to identify patients likely to experience CAV, severe CAV, and failure due to CAV, at 1, 5 and 10 years. A cohort of 172 patients was followed prospectively for 6.7 ± 3.9 years. Logistic regression models were developed and cross-validated using bootstrap resampling. Predictive markers of atherothrombosis (myocardial fibrin deposition, and loss of vascular antithrombin and tissue plasminogen activator) and arterial endothelial activation (intercellular adhesion molecule-1 expression) were measured in serial biopsies obtained within 3 months posttransplant. Most markers were univariately associated with outcome. Multivariate models showed that loss of tissue plasminogen activator was the dominant and, in most cases, only predictor of long-term CAV (p < 0.001), severe CAV (p < 0.001), and graft failure due to CAV (p < 0.001). The models discriminated patients having adverse outcomes, had particularly high negative predictive values (graft failure due to CAV: 99%, 99% and 95% at 1, 5 and 10 years) and predicted event incidence and time to event. Early absence of atherothrombotic risk identifies a patient subgroup that rarely develops CAV or graft failure, implying that this low-risk subgroup could possibly be followed with fewer invasive procedures.

Lysine requirement of kittens given purified diets for maximal growth

Three experiments were conducted using a total of 15 male and 15 female weaned specific pathogen-free kittens given amino acid-based purified diets containing varying concentrations of lysine (from 4.0 to 11.3 g/kg diet) in a Latin square design of 10 day periods. In experiment 1, the predicted lysine requirement was 7.7 g/kg diet, and in experiments 2 and 3, maximal weight gain occurred at 8.0 g lysine/kg diet. In experiment 3, nitrogen balance was not different for kittens given diets containing 8.0 and 9.0 g lysine/kg. These experiments support a requirement of 8.0 g lysine (free base)/kg diet, in a diet with a calculated metabolizable energy value of 4.7 kcal/g.

Skin and soft tissues. Management of four common infections in the nursing home patient

Common skin and soft tissue infections in nursing home patients include herpes zoster, cellulitis, pressure ulcer infections, and scables. Treatment of shingles with an oral antiviral should be started within 24 hours of symptom onset. Dissemination and bacterial superinfection require antibiotic therapy. Use of corticosteroids to prevent post-herpetic neuralgia remains controversial. Cellulitis is most often caused by Staphylococcus aureus and beta-hemolytic streptococci (groups A and B). Therapy for cellulitis is empiric; gram-negative bacilli should be covered in diabetic patients. Most pressure ulcers never become infected; for those that do, empiric therapy should cover S aureus, gram-negative bacilli, and anaerobes. Topical treatment of scables with 5% permethrin cream or 1% lindane lotion is recommended.

Treatment of vascular thrombosis with enoxaparin in orthotopic heart transplant patients during the early postoperative period

Management of anti-coagulation in the early period after orthotopic heart transplantation, when the frequency of invasive procedures to assess for graft rejection is high, presents a difficult clinical problem in which the need for effective therapy must be weighed against the desire for outpatient treatment. In this report, we summarize the clinical course and long-term outcome of 6 patients from our center in whom vascular thrombosis was treated on an outpatient basis with enoxaparin. We conclude that the use of enoxaparin may provide a safe and reasonable alternative to conventional anti-coagulation therapy during this period.

A prospective comparison of pedal ergometry with conventional treadmill testing in the investigation of lower extremity pain

BACKGROUND

Investigation of lower extremity pain is compromised by comorbid disorders that may interfere with conventional testing.

AIMS

To compare pedal ergometry with conventional treadmill testing.

METHODS

A prospective study was performed where patients presenting with a diagnosis of intermittent claudication were assessed by both methods of testing.

RESULTS

Of 78 patients studied with both tests, no exercise-induced ankle pressure changes occurred in 26, two were unable to complete either test despite normal pressure measurements, while 24 had exercise-induced pressure drop detected by both tests. Of patients who completed pedal ergometry, 21 were unable to complete the treadmill test, 14 of whom had negative ergometry, while seven had a pressure drop detected by pedal ergometry. Three had pressure changes with pedal ergometry, but not with treadmill testing and two had pressure changes on the treadmill not reproduced by pedal ergometry.

CONCLUSIONS

Pedal ergometer is more sensitive than treadmill testing in detecting arterial insufficiency, as indicated by a 20% or greater fall in ankle pressure, and more suitable in a subgroup of patients unable to tolerate conventional treadmill testing.

Clinical manifestations of early syphilis by HIV status and gender: results of the syphilis and HIV study

BACKGROUND

Despite reports of unusual clinical presentations and therapeutic responses among HIV-infected patients with syphilis, syphilis has not been regarded as a serious opportunistic infection that predictably progresses among most HIV-coinfected patients.

GOAL

To define and describe differences in the presentation and response to treatment of early syphilis among HIV-infected and HIV-uninfected patients, to describe any differences by gender, and to determine if clinical presentation of central nervous system involvement predicted serologic failure.

DESIGN

A prospective, multicenter, randomized, controlled trial of enhanced versus standard therapy to compare the benefit of enhanced therapy, the clinical importance of central nervous system involvement, and the clinical manifestations of early syphilis infection among HIV-infected and HIV-uninfected patients.

RESULTS

The median number of ulcers was significantly greater among HIV-infected and HIV-uninfected patients, as was the percent of HIV-infected patients with multiple ulcers. Among patients diagnosed with secondary syphilis, a higher percentage of HIV-infected patients presented with genital ulcers [13/53 (25%)] than did HIV-uninfected patients [27/200 (14%)]. No differences between HIV-infected and HIV-uninfected patients were detected for other secondary syphilis manifestations. Although women presented more frequently with secondary syphilis than did men, no other gender differences in clinical manifestations were noted. Neurologic complaints were reported most frequently among patients with secondary syphilis [103/248 patients (42%)] compared with patients with primary syphilis [32/136 (24%)] and early latent syphilis [48/ 142, (34%)] (P < 0.05), but no differences in neurologic complaints were apparent by HIV status or CSF abnormalities. No neurologic complaints were significantly associated with serologic treatment failures at 6 months.

CONCLUSIONS

Overall, HIV infection had a small effect on the clinical manifestations of primary and secondary syphilis. Compared with HIV-uninfected patients, HIV-infected patients with primary syphilis tended to present more frequently with multiple ulcers, and HIV-infected patients with secondary syphilis presented with concomitant genitals ulcers more frequently.

Fluoroquinolones

The fluoroquinolone class of antimicrobial agents has expanded dramatically in the last 5 years and will continue to grow over the next decade. This article discusses the newer fluoroquinolones in detail, including pharmacokinetics, pharmacodynamics, safety, and drug interactions, and the spectrum of in vitro activity. Newer agents are compared and contrasted with the older ones, particularly ciprofloxacin and ofloxacin, and problems with liver toxicity and trovafloxacin are described. Finally, appropriate use of the fluoroquinolones is discussed, including their role in the treatment of urinary tract infections, sexually transmitted diseases, gastrointestinal infections, osteomyelitis, and respiratory tract infections.

Bacteroides fragilis bacteremia and infected aortic aneurysm presenting as fever of unknown origin: diagnostic delay without routine anaerobic blood cultures

We report the case of a 71-year-old male with Bacteroides fragilis bactermia and infected aortic aneurysm that went undiagnosed, in part, because routine anaerobic blood cultures were not obtained. Bacteremia caused by anaerobes has been reported to be declining, and recommendations to discontinue routine anaerobic blood cultures have been implemented in some hospitals. To our knowledge, this is the first report of an anaerobic bacteremia and infection that had a delay in diagnosis due to this change in blood-culturing protocol. The potential impact of deleting anaerobic blood cultures from routine protocols is discussed.

Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease Surveillance Group

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.

Long term results of polytetrafluoroethylene in above knee femoropopliteal bypass for critical ischaemia

Ninety-six consecutive above-knee femoropopliteal bypasses, using polytetrafluoroethylene (PTFE) preferentially, were performed for limb-threatening ischaemia. Cumulative primary graft patency was 68 per cent, 49 per cent and 36 per cent and limb salvage 93 per cent, 85 per cent and 75 per cent at 1, 3 and 5 yr respectively. As a result of poor long term survival (51 per cent at 5 yr), and the healing of remedial lesions before graft occlusion, 68 patients (72 per cent) required no further intervention. Eighteen secondary bypasses were undertaken, 12 using ipsilateral saphenous vein. In this group of elderly patients with poor life expectancy, where a limited operation is desirable, the use of PTFE provided excellent limb salvage with low morbidity. Although we can no longer justify our continued use of PTFE in every case of critical ischaemia because of its inferior patency to autogenous vein, we continue to use it preferentially in patients whose lifespan is likely to be short and in cases where a remedial lesion is present.

Exercise echocardiography, angiography, and intracoronary ultrasound after cardiac transplantation

Fifty-one consecutive patients underwent exercise echocardiography, angiography, and intracoronary ultrasound (ICUS) 2.5 years (range from 1 to 6) after cardiac transplantation. The average age of the donor was 29 years (range 13 to 50), and the average age of the recipient was 49 +/- 12 years. In total, 78 studies were performed, as 25 patients had >1 annual evaluation and 2 patients had 3 consecutive annual evaluations. Of the 78 angiographic studies, 40 (26 patients) had evidence of coronary artery disease, defined as a focal stenosis (>20%, n=4) or luminal irregularities (n=36). However, by ICUS all 51 patients had intimal thickening at some point, with 34 patients possessing diffuse disease and 17 focal intimal thickening only. Of the 25 serial studies, 12 progressed by at least 1 Stanford class. The sensitivity of angiography for determination of class III to IV intimal thickening was 64% and the specificity was 76%. On exercise echocardiography, 6 examinations revealed resting wall motions abnormalities, whereas 6 had inducible wall motion abnormalities with exercise. The sensitivity of exercise echocardiography to determine class III to IV intimal thickening was 15%, and the specificity was 85%. In conclusion, exercise echocardiography is an insensitive method for predicting transplant-mediated coronary artery disease, whereas luminal irregularities on angiography may predict the presence of Stanford grade III to IV intimal thickening.

Spinal claudication versus arterial claudication

Ninety-three consecutive treadmill exercise stress test were performed for the assessment of peripheral vascular function. Thirty-one were for atypical claudication-like symptoms including pain on standing, relief on sitting and back pain. Pedal pulses were palpable in 24 patients. Twenty-five patients (81%) had a negative stress test, suggesting a non-vascular aetiology and this finding was subsequently confirmed in 24 of the 25. The final diagnoses were spinal stenosis 13, [CT = 3, myelogram = 5, neurosurgeon opinion = 4, MRI = 1], myositis 2, restless leg syndrome 2 and osteoarthritis 7. Four patients had symptoms due to a combination of peripheral occlusive arterial disease and spinal stenosis; the latter was considered the predominant disorder in all four. Of the original 31 patients with atypical symptoms, spinal stenosis was present in 13 (42%). Atypia- in the common syndrome of intermittent claudication should alert the surgeon to the possibility of spinal canal disorders. Further investigation may identify significant pathology spinal stenosis in particular.

Infantile hypertrophic pyloric stenosis: long-term audit from a general surgical unit

This article describes a 22 year experience of a general surgical unit in the treatment of infantile hypertrophic pyloric stenosis (IHPS). The hospital course of 229 IHPS patients is reviewed. The male:female ratio was 3.6:1, median age 6 weeks (range 2-26 weeks) with a positive family history in 8.3%. The diagnosis of IHPS was established clinically by palpation of a "pyloric tumour" during a pre operative test meal/clinical examination in 92.6%; in the remainder, the diagnosis was made radiologically. Ramstedt's pyloromyotomy was performed within 5 days of admission in 74% of patients and within 10 days of admission in 89%. The median post-operative hospital stay was 10 days (range 3-60 days). Wound morbidity occurred in 10.0% wound infection (7.3%) and wound dehiscence (2.6%). However, wound morbidity was reduced in the second half of the series, partly by greater utililisation of non-absorbable suture in place of chromic catgut for wound closure. Mucosal penetration was suspected in 14.8% of cases. Repeat pyloromyotomy was necessary in 1.3%. One baby died (0.4%)- this was in the early part of the series and was directly attributable to fluid and electrolyte disorder. We conclude that Ramstedt's pyloromyotomy for infantile hypertrophic pyloric stenosis can be performed with acceptable morbidity and minimal mortality in a general surgical unit.

Institutional variation in hemotherapy for solid organ transplantation

BACKGROUND

Solid organ allograft recipients may require large amounts of blood components. The modification of components to make them safer for iatrogenically immunosuppressed transplant patients increases workload demands on blood banks and transfusion services.

STUDY DESIGN AND METHODS

Institutions within the United States and Canada providing hemotherapy as support for transplant recipients were surveyed for their transfusion practices.

RESULTS

Responses from 25 institutions provide the data for this report. In 1991, the mean intraoperative red cell requirements ranged from <1 unit for renal allograft recipients to 17.3 units for liver transplant recipients. The latter group also required the greatest amounts of platelets, fresh-frozen plasma, and cryoprecipitate. More than 75 percent of responding institutions provided either cytomegalovirus-seronegative or white cell-reduced cellular components to pediatric recipients of liver allografts and to both adult and pediatric recipients of heart, lung, and heart-lung allografts. The use of irradiated cellular blood components, although uncommon, was greatest in heart transplant recipients. The use of pretransplantation transfusions for immunomodulation was generally limited to patients awaiting a living-donor renal transplant.

CONCLUSION

Transfusion practices varied among the institutions, but the majority provide cytomegalovirus-safe cellular blood components to heart and lung allograft recipients and to pediatric transplant patients. Gamma-radiated cellular components are not routinely provided to patients undergoing solid organ transplantation. Liver allograft recipients require the greatest amount of hemotherapeutic support.

An exploratory study of the pattern of consent for autopsy in a regional hospital setting

A prospective study of the pattern of responses to requests for autopsy in a general surgical unit was performed. Information on the characteristics of the deceased, of the requestee and of the requester was documented in the case of 66 patients who died while in hospital. Permission to perform autopsy was not requested in 39 out of 66 cases and this was the most frequent contributory factor to the low rate of autopsy. Once a decision to grant or refuse autopsy is made by relatives of the deceased, the decision is unlikely to be reversed. Permission to perform autopsy was more likely to be sought when the deceased was male than when deceased was female. The relatives of patients who had recently undergone surgery were more likely to refuse permission for autopsy than were those of patients who had not had recent surgery.

"How safe is splenectomy?"

The increased risk of sepsis in patients following splenectomy has been well documented. Fear of overwhelming post-splenectomy sepsis (OPSI) has resulted in a generalized trend towards splenic salvage among surgeons. However, splenorrhaphy and attempts at splenic salvage may of themselves predispose to significant morbidity, sometimes more serious than increased susceptibility to infection associated with splenectomy. This study aims to assess the risk of splenectomy and subsequent asplenia. We reviewed 246 patients who underwent splenectomy over a 16 year period. Indications for splenectomy were considered under the following headings: haematological (N = 116), trauma (N = 69), visceral carcinoma (N = 28), incidental (N = 13) and miscellaneous (N = 20). There were 28 deaths in the series, primarily among those in the intra-abdominal carcinoma (13) and multiple trauma (13) groups. Two deaths were recorded among patients undergoing elective splenectomy for benign disease. Thrombo-embolic complications were recorded in nine patients; respiratory tract infection in 36 patients and intra-abdominal abscess in two patients. Two cases of post-splenectomy pneumococcal septicaemia were documented, neither of which was fatal. While not an entirely benign procedure, splenectomy can be performed relatively safely, especially when performed for benign disease in an adult population.

The use of granulocyte colony-stimulating factor in the treatment of fever and neutropenia in a heart transplant patient

We had the opportunity to study the clinical effects of granulocyte colony-stimulating factor in a heart transplant patient with a classic febrile neutropenic episode that was thought to be caused by immunosuppressive therapy. Administration of granulocyte colony-stimulating factor resulted in rapid recovery of his absolute neutrophil count, with resolution of fevers. Endomyocardial biopsy showed no pathologic evidence of worsened rejection. The use of hematopoietic cytokines after the organ allograft requires further study before it can be routinely advocated in this patient population.

Detection of coronary artery disease with upright bicycle exercise echocardiography

This study examined the advantages and limitations of upright bicycle exercise echocardiography in the evaluation of a large series of patients with known or suspected coronary artery disease. The study population consisted of 309 patients (231 men, mean age 57 +/- 11 years) who underwent exercise echocardiography within 8.5 +/- 16.1 days of coronary angiography. All stress electrocardiographic, echocardiographic, and angiographic data were reinterpreted in a blinded manner by the investigators. No patient was excluded because of poor echocardiographic image quality. Wall motion was analyzed at baseline, peak exercise, and immediately after exercise with a 16-segment model, and a regional wall motion score index was calculated at each stage. Abnormalities were ascribed to the distribution of the three coronary arteries and correlated with qualitative angiography. There were 126 patients with wall motion abnormalities at rest and 211 (75%) with coronary artery disease. The stress electrocardiogram (ECG) was negative in 61, positive in 144, and nondiagnostic in 104, yielding a sensitivity of 40% and a specificity of 89%. Echocardiography was normal in 76 of 98 patients without coronary disease (78% specificity) and abnormal in 193 of 211 patients with disease (91% sensitivity). Sensitivity was higher among patients with multivessel disease compared with those with single vessel disease (95% versus 86%, respectively, p = 0.03). Among patients with normal wall motion at rest (n = 183), sensitivity was 83% and specificity was 84%. Of the 104 patients with a nondiagnostic stress ECG, echocardiography correctly identified 95% of those with coronary disease and 75% of those without disease. Among 82 patients with a wall motion abnormality at rest, an additional exercise-induced wall motion abnormality developed in 32 of 46 patients (70%) with multivessel disease and seven of 32 (22%) with single-vessel disease. Overall, echocardiography detected 258 of 392 (66%) individual coronary lesions. Accuracy was higher for lesions in the left anterior descending and right coronary arteries (both 79%) compared with the left circumflex artery (36%, p < 0.001). In conclusion, upright bicycle exercise echocardiography is an accurate technique for the evaluation of patients with known or suspected coronary artery disease and is especially valuable in patients with a nondiagnostic stress ECG. The test provides supplemental information on the extent and location of coronary lesions and is useful in patients with and without prior myocardial infarction.

Polytetrafluoroethylene in above-knee arterial bypass surgery for critical ischemia

Seventy-one consecutive above-knee polytetrafluoroethylene (PTFE) femoropopliteal arterial bypasses performed between 1981 and 1989 for critical ischemia were followed prospectively to determine graft patency and limb salvage. Cumulative graft patency and limb salvage rates were calculated by life table analysis. Graft patency was 80%, 68%, 55%, 39%, and 39%, and limb salvage 97%, 87%, 84%, 77%, and 77% at 1, 2, 3, 4, and 5 years, respectively. Twenty-nine grafts have occluded with re-emergence of critical ischemia in 14, treated by 5 amputations and 9 reconstructions using autogenous saphenous vein (ASV) in 6 and PTFE in 3. These favorable results are not as good in terms of primary patency as those reported with ASV, but good limb salvage, good early patency, ease of use, and preservation of the saphenous vein for use later have encouraged us toward primary use of PTFE in selected patients. This experience strongly questions the wisdom of an "all autogenous" policy for reconstruction at this level.

Duplex imaging of lower limb arterial bypass grafts

A non-invasive programme of post-operative surveillance and intervention where necessary is essential to optimise results with arterial reconstruction. We report our experience with duplex ultrasonography in the follow-up lower limb arterial bypass grafts. One hundred and three duplex studies were performed in 58 patients with 59 lower limb arterial bypass grafts. Grafts were visualised throughout their length and haemodynamic characteristics including peak systolic velocity (PSV) were measured. Angiography was performed on the basis of any significant anatomical or haemodynamic abnormality on duplex. All grafts were visualised throughout their length with ease. Satisfactory visualisation of 86% of anastomoses was achieved. PSV was found to be the most easily reproducible haemodynamic index and the best indicator of graft function. PSV had a median value of 79 cm/sec and a range of 51-117 cm/sec in normal grafts compared to 26 cm/sec (range 19-42 cm/sec) in grafts with stenosis. Twelve pre-occlusive lesions which were not evident clinically, 5 within and 7 outside the graft, have been detected. Eight have been treated by transluminal angioplasty. Two grafts with stenosis and PSVs of less than 25 cm/sec had occluded by the time angiography was performed 2 weeks later. Duplex is an excellent, non-invasive, and repeatable method of screening of grafts at risk of failure, allowing earlier intervention with improved secondary patency.

Restrictive hemodynamic patterns after cardiac transplantation: relationship to histologic signs of rejection

Hemodynamic and echocardiographic data from 33 consecutive patients undergoing cardiac transplantation were correlated with endomyocardial biopsy results to determine whether reversible restrictive hemodynamics accompany histologic evidence of transplant rejection. During the study period 251 biopsy specimens were obtained during periods of no histologic evidence of transplant rejection and 52 episodes of mild, 20 episodes of moderate, and one episode of severe rejection. Right atrial mean pressure increased significantly during episodes of moderate transplant rejection (9.9 +/- 6.2 mm Hg, p less than 0.001) compared with pressures obtained during periods when there was no evidence of rejection (4.6 +/- 3.2 mm Hg), mild rejection (5.8 +/- 3.9 mm Hg), or resolving rejection (4.3 +/- 3.4 mm Hg). Y descent was elevated during moderate rejection (9.6 +/- 4.2 mm Hg, p less than 0.001) compared with pressures during episodes of no rejection (5.6 +/- 2.5 mm Hg), mild rejection (6.6 +/- 2.7 mm Hg), and resolving rejection (5.8 +/- 3.1 mm Hg) and showed a wave morphology consistent with a restrictive hemodynamic pattern. Pulmonary capillary wedge pressure was increased during moderate rejection (14.4 +/- 6.4 mm Hg) when compared with pressures obtained during episodes of no rejection (10.2 +/- 5.8 mm Hg) or resolving rejection (10.2 +/- 5.4 mm Hg) (p less than 0.02). Sensitivity for a right atrial mean pressure of 11 mm Hg indicating moderate rejection was 41% with a specificity of 96%. Sensitivity for Y descent (greater than or equal to 10 mm Hg) was 52% and specificity was 94%.(ABSTRACT TRUNCATED AT 250 WORDS)

Realistic expectations for the patient with intermittent claudication

To determine the natural history of intermittent claudication 112 patients were followed for a minimum of 5 years and a median period of 82 months. Thirty-seven patients (33 per cent) died during the study period. Myocardial infarction (44 per cent) and cerebrovascular disease (28 per cent) were the most common causes of death. Overall mortality rate was 8, 23 and 40 per cent, at 2, 5 and 8 years respectively. Initial ankle-brachial pressure index (ABPI) correlated with subsequent death. With an initial ABPI less than 0.5 death occurred in 20, 50 and 69 per cent at 2, 5 and 7 years respectively, compared with 5, 16 and 24 per cent respectively for those with an initial ABPI greater than or equal to 0.5 (P less than 0.0001). Of the survivors only 21 per cent had worsening claudication and 13 per cent progressed to critical ischaemia. Arterial bypass for limb salvage was required in eight patients and four limbs were lost during the study period. ABPI identifies a subgroup of claudicants with an extremely high risk of death from coronary and/or cerebral pathology. In this subgroup an aggressive approach to the correction of atherosclerotic risk factors, rather than emphasis on the peripheral vascular problem alone, may improve survival.

Abdominal aortic aneurysms: the importance of elective repair

Repair of abdominal aortic aneurysms (AAA) is being performed with a progressively lower mortality and morbidity. We reviewed 111 patients who underwent repair of their AAA. Sixty-two were electively repaired and 49 had emergency surgery. Eight patients had cocomitant non-vascular procedures carried out. Operative mortality was 3.2% and 49% for elective and emergency cases respectively. Postoperative complications occurred in 40% of elective cases and 72% of emergency cases, respiratory complications being the most common, occurring in 25% and 40% of elective and emergency cases respectively. Subsequent graft complications occurred in six patients, five following emergency surgery.

The neonatal duodenal windsock web--a case report and description of a new technique for its operative excision

Duodenal obstruction in the neonate may be caused by an intraluminal diaphram or so-called windsock web. This can present special technical difficulties at operation. This report of a case describes a new technique in the surgical treatment of such a web.

The effect of distal anastomotic site on PTFE graft patency in lower extremity bypass

The site of distal anastomosis of polytetrafluorethylene (PTFE) lower extremity bypass grafts may significantly affect results. We examined patency in 144 cases; 45 femoro-popliteal above knee (AK), 55 femoro-popliteal below the knee (BK) and 44 femoro-distal (D) PTFE bypasses, the groups being comparable with regard to other risk factors studied. Cumulative graft patency at 3 years was 71.3% for AK, 36.7% for BK, 16.4% for D and overall 35%. The site of distal anastomosis is an important determinant, of PTFE lower extremity bypass patency. We have abandoned the use of PTFE for BK and D, but feel that AK PTFE is a suitable alternative to autogenous reversed saphenous vein.

Limb salvage in the elderly

Sixty-eight lower extremity bypass procedures for severe lower limb ischemia were undertaken on 53 patients of 75 years of age and over. The operative mortality was 4.4%. At two years cumulative limb salvage, patient survival, graft patency and survival with an intact limb were 77%, 72%, 44%, and 56%, respectively. Of all patients who died, 66% had an intact limb at the time of death. Based on these results we continue to offer reconstructive surgery to elderly patients.

Exercise echocardiography: detection of coronary artery disease in patients with normal left ventricular wall motion at rest

Most studies investigating the ability of exercise two-dimensional echocardiography to identify patients with coronary artery disease have included patients with left ventricular wall motion abnormalities at rest. This has the effect of increasing sensitivity because patients with only abnormalities at rest are detected. To determine the diagnostic utility of exercise echocardiography in patients with normal wall motion at rest, 64 patients were studied with exercise echocardiography in conjunction with routine treadmill exercise testing before coronary cineangiography. All 24 patients who had no angiographic evidence of coronary artery disease had a negative exercise echocardiogram (100% specificity). Nine of 40 patients with coronary artery disease (defined as greater than or equal to 50% narrowing of at least one major vessel) also had a negative exercise echocardiogram (78% sensitivity). Of the nine patients with a false negative exercise echocardiographic study, six had single vessel disease. Among 25 patients with single vessel disease, exercise echocardiography was significantly more sensitive (p = 0.01) than treadmill exercise testing alone (76 versus 36%, respectively). Among 15 patients with multivessel disease, the two tests demonstrated similar sensitivity (80%). In conclusion, exercise echocardiography is highly specific and moderately sensitive for the detection of coronary artery disease in patients with normal wall motion at rest. Although exercise echocardiography is significantly more sensitive than treadmill exercise electrocardiographic testing alone in patients with single vessel disease, the two tests are similar in their ability to detect coronary artery disease in patients with multivessel disease and normal wall motion at rest.

Risk stratification after acute myocardial infarction by means of exercise two-dimensional echocardiography

To determine whether exercise two-dimensional echocardiography contributes to the prognostic information provided by exercise testing in patients recovering from acute myocardial infarction, 40 patients were prospectively studied by means of pre- and postexercise echocardiography 10 to 21 days after myocardial infarction. Patients were followed for 6 to 10 months or until one of the following clinical end points occurred: death, recurrent myocardial infarction, unstable angina, or coronary artery bypass grafting. Results of treadmill exercise tests were negative in 13 of 20 patients with good clinical outcome (65% specificity) and positive in 11 of 20 patients with poor clinical outcome (55% sensitivity). The resting echocardiogram was abnormal in 37 of 40 patients. The exercise echocardiogram was negative in 19 of 20 patients with good clinical outcome (95% specificity) and positive in 16 of 20 patients with poor clinical outcome (80% sensitivity). We conclude that exercise echocardiography is more sensitive and specific than treadmill exercise testing for predicting the occurrence of subsequent cardiac events after acute myocardial infarction.

Thoracic aortic dissections: magnetic resonance imaging

Six patients with documented dissections of the thoracic aorta (two Type A, four Type B) were examined by magnetic resonance (MR) imaging using a 0.6-Tesla superconductive magnet. Cardiac gating was applied in five cases. Correlation was made with CT and angiography. MR imaging demonstrated the dissection in all six cases and accurately differentiated Type A from Type B dissections. Coronal and sagittal MR sections were advantageous in establishing the relationship of the three arch vessels to the dissection. In addition, cardiac-gated MR was useful in demonstrating mural thrombus and in distinguishing the true from the false lumen based on differences in signal intensity resulting from different flow rates. In five cases, the information obtained by MR was equal to or surpassed that obtained by CT. In the one case of a completely thrombosed dissection, the CT scan was more helpful. MR should become an important imaging modality in the evaluation of aortic dissections.