Blood management in fast-track orthopedic surgery: An evidence-based narrative review

Background and purpose: Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. Methods and materials: We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. Results: Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. Conclusion: The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens

Effects of Genotype and Sleep on Temperament

Supported by the Canadian Institutes of Health Research

Nocturnal sleep duration trajectories in early childhood and school performance at age 10 years

Summary Sleep plays a fundamental role in brain development and resultant functions. The aim was to verify whether nocturnal sleep duration during early childhood has long-term associations with academic achievement at age 10?years. The present study is part of the Quebec Longitudinal Study of Child Development, a representative cohort of infants born in 1997?1998 in the province of Quebec, Canada. Children with known neurological conditions were excluded from this cohort. Four trajectories of parent-reported nocturnal sleep duration at ages 2.5, 3, 4, 5 and 6?years were determined using a SAS procedure named PROC TRAJ. Sleep duration at age 10?years was also reported. Teachers provided data on academic performance when the children were age 10?years. These data were available for 910 children (430 boys, 480 girls; 96.6% Caucasians). Univariate and multivariable logistic regressions were performed using SPSS. Children who slept less than 8?hr per night at 2.5?years but normalized later on (Traj1) had three?five times the odds of having grades below the class average in reading, writing, mathematics and science compared with children who slept sufficiently (Traj3?4: 10?11?hr per night). Children who slept about 9?hr per night throughout childhood (Traj2) had two?three times the odds of being below the class average in mathematics and science. Sleep duration at age 10?years was not correlated with the academic performance. These results point to the presence of a very important early period during which sufficient sleep is needed to fine-tune the functions necessary for academic achievement later on

Longitudinal study of childhood sleep trajectories and adolescent mental health problems

Abstract Study objective To investigate whether childhood sleep trajectories are associated with mental health symptoms such as social phobia, generalized anxiety, depression, attention deficit hyperactivity disorder (ADHD), conduct problems, and opposition at age 15. Methods A total of 2120 children took part in the Quebec Longitudinal Study of Child Development. Childhood sleep trajectories were computed from maternal reports at 2.5, 3.5, 4, 6, 8, 10, and/or 12 years. At age 15, 1446 adolescents filled out mental health and sleep questions. A path analysis model was assessed in the full sample. Results Four childhood nocturnal sleep duration trajectories were identified: (1) a short pattern (7.5%), (2) a short-increasing pattern (5.8%), (3) a 10 hours pattern (50.7%), and (4) an 11 hours pattern (36.0%). Three childhood sleep latency trajectories were found: (1) a short pattern (31.7%), (2) an intermediate pattern (59.9%), and (3) a long pattern (8.4%). Finally, two childhood wakefulness after sleep-onset trajectories were found: (1) a normative pattern (73.0%) and (2) a long pattern (27.0%). The path analysis model indicated that children following a long childhood sleep latency trajectory were more likely to experience symptoms of depression (β = 0.06, 95% CI: 0.01 to 0.12), ADHD (β = 0.07, 95% CI: 0.02 to 0.13), conduct problems (β = 0.05, 95% CI: 0.00 to 0.10) and opposition (β = 0.08, 95% CI: 0.02 to 0.13) at age 15. Conclusions This longitudinal study revealed that children presenting a long sleep latency throughout childhood are at greater risk of symptoms of depression, ADHD, conduct problems, and opposition in adolescence

Combined sticking: a new approach for finite-amplitude Coulomb frictional contact

Engineering-level accuracy of discretization methods for frictional contact originates from precise representation of discontinuous frictional and normal interaction laws and precise discrete contact techniques. In terms of discontinuous behavior in the quasi-static case, two themes are of concern: the normal interaction (i.e. impact) and the jumps in tangential directions arising from high frictional values. In terms of normal behavior, we use a smoothed complementarity relation. For the tangential behavior, we propose a simple and effective algorithm, which is based a stick predictor followed by corrections to the tangential velocity. This allows problems with impact and stick-slip behavior to be solved with an implicit code based on Newton–Raphson iterations. Three worked examples are shown with comparisons with published results. An extension to node-to-face form in 3D is also presented

Left ventricular mass increases with deteriorating glucose tolerance, especially in women: Independence of increased arterial stiffness or decreased flow-mediated dilation - The Hoorn Study

OBJECTIVE - Type 2 diabetes and impaired glucose metabolism (IGM) are associated with an increased cardiovascular disease (CVD) risk. Increased left ventricular mass (LVM) is thought to increase CVD risk through several unfavorable cardiac changes. Type 2 diabetes and IGM are associated with increased LVM, but the underlying mechanism is unclear. We investigated the association between glucose tolerance status (GTS) and LVM and explored whether any such association could be mediated through increased arterial stiffness, impaired endothelial function, or the presence of atherosclerosis. RESEARCH DESIGN AND METHODS - We used ultrasound to measure LVM, carotid and femoral stiffness, carotid-femoral transit time, and flow-mediated vasodilation (FMD) and tonometry to estimate compliance and augmentation index. The study population (n = 780) consisted of 287 individuals with normal glucose metabolism (NGM), 179 with IGM, and 314 with type 2 diabetes, and the mean age was 68.4 years. RESULTS - In women, after adjusting for age, height, BMI, and mean arterial pressure, LVM increased significantly with deteriorating GTS (LVM 157 g in NGM, 155 g in IGM, and 169 g in type 2 diabetes, P for trend <0.018). Additional adjustment for arterial stiffness, FMD, or the presence of atherosclerosis did not materially alter the results, even though these variables were significantly associated with both GTS and LVM. Indexes of hyperglycemia/-insulinemia or insulin resistance explained at most 7% of the association between GTS and LVM. In men, no statistically significant associations were observed. CONCLUSIONS - Our data expand the conceptual view of the pathogenesis of GTS-related changes in LVM because we show that the increase in LVM in women is independent of increased arterial stiffness, impaired FMD, or the presence of atherosclerosis. In addition, we show that this increase in LVM is only minimally explained by indexes of hyperglycemia/-insulinemia or insulin resistance. Our data may, in part, explain the increased CVD risk seen in women with deteriorating GTS