Perioperative safety of two-team simultaneous bilateral total knee arthroplasty in the obese patient

<p>Abstract</p> <p>Background</p> <p>Although the rates of perioperative morbidity and mortality with simultaneous bilateral total knee arthroplasty remain a concern, multiple studies have shown the procedure to be safe in selected patient populations. Evidence also remains mixed regarding the outcomes of total knee arthroplasty in obese patients. The purpose of this paper is to compare the rates of perioperative morbidity and mortality in consecutive obese patients undergoing two-team simultaneous bilateral total knee arthroplasty and unilateral total knee arthroplasty.</p> <p>Methods</p> <p>The records on all two-team simultaneous total knee arthroplasties and unilateral total knee arthroplasties from October 1997 to December 2007 were reviewed. A total of 151 patients with a body mass index (BMI) >30 undergoing two-team simultaneous total knee arthroplasty and 148 patients with a BMI >30 undergoing unilateral total knee arthroplasty were retrospectively reviewed and analyzed to determine perioperative morbidity and mortality as well as one-year mortality rates.</p> <p>Results</p> <p>Preoperative patient characteristics did not show any significant differences between groups. The simultaneous bilateral group had significantly longer operative times (127.4 versus 112.7 minutes, p < 0.01), estimated blood loss (176.7 versus 111.6 mL, p = 0.01), percentage of patients requiring blood transfusion (64.9% versus 13.9%, p < 0.01), length of hospital stay (3.72 versus 3.30 days, p < 0.01), and percentage of patients requiring extended care facility usage at discharge (63.6% versus 27.8%, p < 0.01). No significant difference between unilateral and bilateral groups was seen in regards to total complication rate, major or minor complication subgroup rate, or any particular complication noted. Doubling the variables in the unilateral group for a staged total knee arthroplasty scenario did create significant increases over the simultaneous data in almost every data category.</p> <p>Conclusions</p> <p>Two-team simultaneous total knee arthroplasty appears to be safe in obese patients, with similar complication rates as compared to unilateral procedures. Two-team simultaneous total knee arthroplasty also appears to have potential benefits over a staged procedure in the obese patient, although more study is required regarding this topic.</p

Anomalous insulator metal transition in boron nitride-graphene hybrid atomic layers

The study of two-dimensional (2D) electronic systems is of great fundamental significance in physics. Atomic layers containing hybridized domains of graphene and hexagonal boron nitride (h-BNC) constitute a new kind of disordered 2D electronic system. Magneto-electric transport measurements performed at low temperature in vapor phase synthesized h-BNC atomic layers show a clear and anomalous transition from an insulating to a metallic behavior upon cooling. The observed insulator to metal transition can be modulated by electron and hole doping and by the application of an external magnetic field. These results supported by ab-initio calculations suggest that this transition in h-BNC has distinctly different characteristics when compared to other 2D electron systems and is the result of the coexistence between two distinct mechanisms, namely, percolation through metallic graphene networks and hopping conduction between edge states on randomly distributed insulating h-BN domains.Comment: 9 pages, 15 figure

Trends in Metal Oxide Stability for Nanorods, Nanotubes, and Surfaces

The formation energies of nanostructures play an important role in determining their properties, including the catalytic activity. For the case of 15 different rutile and 8 different perovskite metal oxides, we find that the density functional theory (DFT) calculated formation energies of (2,2) nanorods, (3,3) nanotubes, and the (110) and (100) surfaces may be described semi-quantitatively by the fraction of metal--oxygen bonds broken and the bonding band centers in the bulk metal oxide

Lessons from Peer Support Among Individuals with Mental Health Difficulties: A Review of the Literature

We conducted a comprehensive narrative review and used a systematic search strategy to identify studies related to peer support among adults with mental health difficulties. The purposes of this review were to describe the principles, effects and benefits of peer support documented in the published literature, to discuss challenging aspects of peer support and to investigate lessons from peer support. Fifty-one studies, including 8 review articles and 19 qualitative studies, met the inclusion criteria for this review. Most of the challenges for peer support were related to “role” and “relationship” issues; that is, how peer support providers relate to people who receive peer support and how peer support providers are treated in the system. The knowledge gained from peer support relationships, such as mutual responsibility and interdependence, might be a clue toward redefining the helper-helper relationship as well as the concepts of help and support

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

A Late Role for bmp2b in the Morphogenesis of Semicircular Canal Ducts in the Zebrafish Inner Ear

BACKGROUND:The Bone Morphogenetic Protein (BMP) genes bmp2 and bmp4 are expressed in highly conserved patterns in the developing vertebrate inner ear. It has, however, proved difficult to elucidate the function of BMPs during ear development as mutations in these genes cause early embryonic lethality. Previous studies using conditional approaches in mouse and chicken have shown that Bmp4 has a role in semicircular canal and crista development, but there is currently no direct evidence for the role of Bmp2 in the developing inner ear. METHODOLOGY/PRINCIPAL FINDINGS:We have used an RNA rescue strategy to test the role of bmp2b in the zebrafish inner ear directly. Injection of bmp2b or smad5 mRNA into homozygous mutant swirl (bmp2b(-/-)) embryos rescues the early patterning defects in these mutants and the fish survive to adulthood. As injected RNA will only last, at most, for the first few days of embryogenesis, all later development occurs in the absence of bmp2b function. Although rescued swirl adult fish are viable, they have balance defects suggestive of vestibular dysfunction. Analysis of the inner ears of these fish reveals a total absence of semicircular canal ducts, structures involved in the detection of angular motion. All other regions of the ear, including the ampullae and cristae, are present and appear normal. Early stages of otic development in rescued swirl embryos are also normal. CONCLUSIONS/SIGNIFICANCE:Our findings demonstrate a critical late role for bmp2b in the morphogenesis of semicircular canals in the zebrafish inner ear. This is the first demonstration of a developmental role for any gene during post-embryonic stages of otic morphogenesis in the zebrafish. Despite differences in the early stages of semicircular canal formation between zebrafish and amniotes, the role of Bmp2 in semicircular canal duct outgrowth is likely to be conserved between different vertebrate species

Development of a measure of model fidelity for mental health Crisis Resolution Teams

Background Crisis Resolution Teams (CRTs) provide short-term intensive home treatment to people experiencing mental health crisis. Trial evidence suggests CRTs can be effective at reducing hospital admissions and increasing satisfaction with acute care. When scaled up to national level however, CRT implementation and outcomes have been variable. We aimed to develop and test a fidelity scale to assess adherence to a model of best practice for CRTs, based on best available evidence. Methods A concept mapping process was used to develop a CRT fidelity scale. Participants (n = 68) from a range of stakeholder groups prioritised and grouped statements (n = 72) about important components of the CRT model, generated from a literature review, national survey and qualitative interviews. These data were analysed using Ariadne software and the resultant cluster solution informed item selection for a CRT fidelity scale. Operational criteria and scoring anchor points were developed for each item. The CORE CRT fidelity scale was then piloted in 75 CRTs in the UK to assess the range of scores achieved and feasibility for use in a 1-day fidelity review process. Trained reviewers (n = 16) rated CRT service fidelity in a vignette exercise to test the scale’s inter-rater reliability. Results There were high levels of agreement within and between stakeholder groups regarding the most important components of the CRT model. A 39-item measure of CRT model fidelity was developed. Piloting indicated that the scale was feasible for use to assess CRT model fidelity and had good face validity. The wide range of item scores and total scores across CRT services in the pilot demonstrate the measure can distinguish lower and higher fidelity services. Moderately good inter-rater reliability was found, with an estimated correlation between individual ratings of 0.65 (95% CI: 0.54 to 0.76). Conclusions The CORE CRT Fidelity Scale has been developed through a rigorous and systematic process. Promising initial testing indicates its value in assessing adherence to a model of CRT best practice and to support service improvement monitoring and planning. Further research is required to establish its psychometric properties and international applicability

Peer Support Workers in Health:A Qualitative Metasynthesis of Their Experiences

Peer support models, where an individual has a specific illness or lifestyle experience and supports others experiencing similar challenges, have frequently been used in different fields of healthcare to successfully engage hard-to-reach groups. Despite recognition of their value, the impact of these roles on the peer has not been systematically assessed. By synthesising the qualitative literature we sought to review such an impact, providing a foundation for designing future clinical peer models.Systematic review and qualitative metasynthesis of studies found in Medline, CINAHL or Scopus documenting peer worker experiences.1,528 papers were found, with 34 meeting the criteria of this study. Findings were synthesised to reveal core constructs of reframing identity through reciprocal relations and the therapeutic use of self, enhancing responsibility.The ability of the Peer Support Worker to actively engage with other marginalised or excluded individuals based on their unique insight into their own experience supports a therapeutic model of care based on appropriately sharing their story. Our findings have key implications for maximising the effectiveness of Peer Support Workers and in contributing their perspective to the development of a therapeutic model of care