Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations

Response to Dr. Bernstein's review: pressure pulse contour-derived stroke volume and cardiac output in the morbidly obese patient.

We read with interest the article by Dr. Bernstein on Pressure Pulse Contour-derived Stroke Volume and Cardiac Output in the Morbidly Obese Patient [1]. It is important to discuss the data presented in the review, considering that caution is necessary to accept his conclusion on pressure recording analytical method (PRAM) [2]. We wonder how it is possible to draw similar conclusions based on the small number of studies considered and patients enrolled [3–5].We may also highlight some discrepancies not only between the studies considered but also within each study [3–5]. It is important to distinguish between hemodynamic data measured directly, such as mean arterial pressure (MAP) or heart rate (HR), and hemodynamic data calculated by the PRAM [6–11] or other methods [12]. From an analysis of MAP and HR in reviewed studies, we can observe how [3–5] these values present different trends compared with our results (Table 1). Stroke volume (SV) of our patients [1], calculated from stroke volume index (SVI), according to the formula SV= SVI×BSA (Mosteller-derived), is similar to the data of Dumont et al. [4] until MAP and HR do not diverge from ours, while the data of Nguyen et al. [5] and Artuso et al. [3] are different from ours [1] and similar between themselves, as shown on Table 1 (we prefer to analyze stroke volume instead of cardiac index because the latter is directly related to heart rate). Our systemic vascular resistance (SVR), calculated from systemic vascular resistance index (SVRI) according to the formula SVR=SVRI/BSA, is very different from Nguyen et al. [5] and Artuso et al. [3] and slightly different from Dumont et al. [4] (Table 1

Ultrasound-guided injection of intralesional steroids in acute hidradenitis suppurativa lesions: A prospective study

The management of hidradenitis suppurativa (HS) flares with intralesional steroids lacks strong scientific evidence but limited data suggest that it may be useful. The objective of this study is to assess the clinical and ultrasound responses of HS flares to ultrasound-guided injections of intralesional triamcinolone (40 mg/ml) with a dilution 1:4 versus 1:2 at 30-day (t1), 60-day (t2), and 90-day (t3) follow-up. We recruited patients with ≤3 acute lesions, unresponsive to topical therapy. At baseline we assessed lesions clinically and by ultra-high frequency ultrasound (48 or 70 MHz) and randomly performed an ultrasound-guided injection of triamcinolone. Assessments were repeated at t1, t2, and t3 follow-up, re-injecting the lesion in the case of no or partial response. We treated 49 lesions: 38.8% showed improvements at t1; 46.9% at t2; 6% at t3; and 8.3% showed no clinical and ultrasound improvements. Long-term follow-up data confirmed a statistically significant reduction in Visual Analogue Scale (VAS)-pain, Dermatology Life Quality Index (DLQI), and HS-Physician Global Assessment (HS-PGA), as well as edema and vascular signals. No adverse effects were reported. Our study suggests that ultrasound-injections with a 1:2 dilution are beneficial for HS flares that do not respond to topical treatment and should be included in the therapeutic algorithm