Do patients accurately represent their experiences after hip and knee replacements?

Background To investigate discrepancies, if any, between the complications that patients report on the patient-reported outcome measures (PROMs) questionnaire and what is formally recorded in their medical records. Methodology A retrospective analysis of PROMs-reported complications was performed at a single elective center for all patients who had an elective primary total knee or hip replacement between April 2016 and March 2017. Corresponding patient medical records were then analyzed to correlate the PROMs with any documentation of postoperative complications, which similar to the PROMs data were categorized into wound complications, urinary complications, readmission, and further operative procedures. Results A set of 54 complete patient records were compared to the corresponding PROMs data. The combined overall positive predictive value was 0.47 while the overall negative predictive value was 0.91. Concordance between patients and the medical records was 70.4% for wound complication, 66.7% for urinary complications, 83.3% for readmission, and 96.3% for reoperation. Conclusion PROMs data are becoming increasingly important in auditing and planning healthcare provision. This study highlights a significant level of discrepancy between the PROMs-reported complication rates and those documented in the medical records. There is a visible disparity between patient perception and the medical definition of postoperative complications. Further patient education and empowerment are required in preparation for arthroplasty

Determining T2 relaxation time and stroke onset relationship in ischaemic stroke within apparent diffusion coefficient-defined lesions. A user-independent method for quantifying the impact of stroke in the human brain

Background and objective:In hyperacute ischaemic stroke, T2 of cerebral water increases with time. Quantifying this change may be informative of the extent of tissue damage and onset time. Our objective was to develop a user-unbiased method to measure the effect of cerebral ischaemia on T2 to study stroke onset time-dependency in human acute stroke lesions. Methods:Six rats were subjected to permanent middle cerebral occlusion to induce focal ischaemia, and a consecutive cohort of acute stroke patients (n=38) were recruited within 9 hours from symptom onset. T1-weighted structural, T2 relaxometry, and diffusion MRI for apparent diffusion coefficient (ADC) were acquired. Ischaemic lesions were defined as regions of lowered ADC. The median T2 difference (ΔT2) between lesion and contralateral non-ischaemic control region was determined by the newly-developed spherical reference method, and data compared to that obtained by the mirror reference method. Linear regressions and receiver operating characteristics (ROC) were compared between the two methods. Results:ΔT2 increases linearly in rat brain ischaemia by 1.9 ± 0.8 ms/h during the first 6 hours, as determined by the spherical reference method. In patients, ΔT2 linearly increases by 1.6 ± 1.4 and 1.9 ± 0.9 ms/h in the lesion, as determined by the mirror reference and spherical reference method, respectively. ROC analyses produced areas under the curve of 0.83 and 0.71 for the spherical and mirror reference methods, respectively. Conclusions:Data from the spherical reference method showed that the median T2 increase in the ischaemic lesion is correlated with stroke onset time in a rat as well as in a human patient cohort, opening the possibility of using the approach as a timing tool in clinics.</p

Successful staged hip replacement in septic hip osteoarthritis in osteopetrosis: a case report

<p>Abstract</p> <p>Background</p> <p>Osteopetrosis is a rare, inherited, bone disorder, characterized by osteosclerosis, obliteration of the medullary cavity and calcified cartilage. The autosomal dominant form is compatible with a normal life span, although fractures often result from minimal trauma, due to the pathologic nature of bone. Osteomyelitis is common in patients with osteopetrosis because of a reduced resistance to infection, attributed to the lack of marrow vascularity and impairment of white cell function. Only one case of osteomyelitis of the proximal third of the femur has been previously reported, treated with several repeated debridements and finally with femoral head resection. Here we present for the first time a case of a staged implant of a cementless total hip prosthesis for the treatment of a septic hip in femoral neck nonunion in osteopetrosis.</p> <p>Case presentation</p> <p>A 36-years-old woman, affected by autosomal dominant osteopetrosis was referred to our department because of a septic hip arthritis associated with femoral neck septic non-union, with draining fistulas. The infection occurred early after a plate osteosynthesis for a closed perthrocanteric fracture of the femur and persisted in spite of osteosynthesis removal, surgical debridement and external fixation. In our hospital the patient underwent accurate debridement, femoral head and greater trochanter resection, preparation of the diaphyseal intramedullary canal and implant of an antibiotic-loaded cement spacer. The spacer was exchanged after one month, due to infection recurrence and four months later, a cementless total hip arthroplasty was implanted, with no clinical and laboratory signs of infection recurrence at two years follow-up.</p> <p>Conclusions</p> <p>In case of hip septic arthritis and proximal femur septic non-union, femoral head resection may not be the only option available and staged total hip arthroplasty can be considered.</p

Supportive and symptomatic management of amyotrophic lateral sclerosis

The main aims in the care of individuals with amyotrophic lateral sclerosis (ALS) are to minimize morbidity and maximize quality of life. Although no cure exists for ALS, supportive and symptomatic care provided by a specialist multidisciplinary team can improve survival. The basis for supportive management is shifting from expert consensus guidelines towards an evidence-based approach, which encourages the use of effective treatments and could reduce the risk of harm caused by ineffective or unsafe interventions. For example, respiratory support using noninvasive ventilation has been demonstrated to improve survival and quality of life, whereas evidence supporting other respiratory interventions is insufficient. Increasing evidence implicates a causal role for metabolic dysfunction in ALS, suggesting that optimizing nutrition could improve quality of life and survival. The high incidence of cognitive dysfunction and its impact on prognosis is increasingly recognized, although evidence for effective treatments is lacking. A variety of strategies are used to manage the other physical and psychological symptoms, the majority of which have yet to be thoroughly evaluated. The need for specialist palliative care throughout the disease is increasingly recognized. This Review describes the current approaches to symptomatic and supportive care in ALS and outlines the current guidance and evidence for these strategies

On the Variability of the Length Weight Relationship for Atlantic Bluefin Tuna, Thunnus thynnus (L.)

Following extensive review, a model of the Atlantic bluefin tuna (ABFT), Thunnus thynnus (L.), length–weight relationship for the eastern Atlantic and Mediterranean (RW = 0.0000188 SFL3.01247; Ec 1) is presented on the basis of samples of ABFT spawners, with an average value of index K = 2.03 ± 0.15SD, collected by the Atlantic traps of Portugal and Spain in the Strait of Gibraltar (1963; 1996–1998; 2000–2012), and a set of samples of juvenile fishes from ICCAT–GBYP (n = 707). The resulting model (Ec 1), together with the model used for the eastern stock assessment (RW = 0.000019607 SFL3.0092; Ec 2) and a recently adopted by ICCAT Standing Committee on Research and Statistics (SCRS) (RW = 0.0000315551 SFL2.898454; EAST) are analyzed in using a bi-variant sample [SFL (cm), RW (kg)] of 474 pairs of data with the aim of validating them and establishing which model(s) best fit the reality represented by the sample and, therefore, will have the greatest descriptive and predictive power. The result of the analysis indicates that the model EAST clearly underestimates the weight of spawning ABFT and that model Ec 2 overestimates it slightly, being model Ec 1 that best explains the data of the sample. The result of the classical statistical analysis is confirmed by means of the quantile regression technique, selecting the quantiles 5, 25, 50, 75, and 95%. Other fisheries and biological indicators also conclude that the model EAST gradually underestimates the weight of ABFT spawners (of 2–3 m) by 9–12.5 %, and does not meet the criterion that for RW = 725 kg (Wmax), SFL = 319.93 ± 11.3 cm (Lmax).Cort, JL.; Estruch Fuster, VD.; Neves Dos Santos, M.; Di Natale, A.; Abid, N.; De La Serna, JM. (2015). On the Variability of the Length Weight Relationship for Atlantic Bluefin Tuna, Thunnus thynnus (L.). Reviews in Fisheries Science & Aquaculture. 23(1):23-38. doi:10.1080/23308249.2015.1008625S2338231Aguado-Giménez, F., & García-García, B. (2005). Changes in some morphometric relationships in Atlantic bluefin tuna (Thunnus thynnus thynnus Linnaeus, 1758) as a result of fattening process. Aquaculture, 249(1-4), 303-309. doi:10.1016/j.aquaculture.2005.04.064Block, B. A., Teo, S. L. H., Walli, A., Boustany, A., Stokesbury, M. J. W., Farwell, C. J., … Williams, T. D. (2005). Electronic tagging and population structure of Atlantic bluefin tuna. Nature, 434(7037), 1121-1127. doi:10.1038/nature03463Chapman, E. W., Jørgensen, C., & Lutcavage, M. E. (2011). Atlantic bluefin tuna (Thunnus thynnus): a state-dependent energy allocation model for growth, maturation, and reproductive investment. Canadian Journal of Fisheries and Aquatic Sciences, 68(11), 1934-1951. doi:10.1139/f2011-109Cort, J. L., Arregui, I., Estruch, V. D., & Deguara, S. (2014). Validation of the Growth Equation Applicable to the Eastern Atlantic Bluefin Tuna,Thunnus thynnus(L.), UsingLmax, Tag-Recapture, and First Dorsal Spine Analysis. Reviews in Fisheries Science & Aquaculture, 22(3), 239-255. doi:10.1080/23308249.2014.931173Cort, J. L., Deguara, S., Galaz, T., Mèlich, B., Artetxe, I., Arregi, I., … Idrissi, M. (2013). Determination ofLmaxfor Atlantic Bluefin Tuna,Thunnus thynnus(L.), from Meta-Analysis of Published and Available Biometric Data. Reviews in Fisheries Science, 21(2), 181-212. doi:10.1080/10641262.2013.793284Fraser, K.Possessed. World Record Holder for Bluefin Tuna. Kingstown, Nova Scotia: T & S Office Essentials and printing, 243 pp. (2008).Fromentin, J.-M., & Powers, J. E. (2005). Atlantic bluefin tuna: population dynamics, ecology, fisheries and management. Fish and Fisheries, 6(4), 281-306. doi:10.1111/j.1467-2979.2005.00197.xHattour, A.Contribution a l’étude des Scombridés de Tunisie. Université de Tunis. Faculté des Sciences, 168 pp. (1979).Karakulak, S., Oray, I., Corriero, A., Deflorio, M., Santamaria, N., Desantis, S., & De Metrio, G. (2004). Evidence of a spawning area for the bluefin tuna (Thunnus thynnus L.) in the eastern Mediterranean. Journal of Applied Ichthyology, 20(4), 318-320. doi:10.1111/j.1439-0426.2004.00561.xKoenker, R., & Bassett, G. (1978). Regression Quantiles. Econometrica, 46(1), 33. doi:10.2307/1913643Koenker, R. (2005). Quantile Regression. doi:10.1017/cbo9780511754098Milatou, N., & Megalofonou, P. (2014). Age structure and growth of bluefin tuna (Thunnus thynnus, L.) in the capture-based aquaculture in the Mediterranean Sea. Aquaculture, 424-425, 35-44. doi:10.1016/j.aquaculture.2013.12.037Perçin, F., & Akyol, O. (2009). Lengthâ weight and lengthâ length relationships of the bluefin tuna,Thunnus thynnusL., in the Turkish part of the eastern Mediterranean Sea. Journal of Applied Ichthyology, 25(6), 782-784. doi:10.1111/j.1439-0426.2009.01288.xPercin, F., & Akyol, O. (2010). Some Morphometric Relationships in Fattened Bluefin Tuna, Thunnus thynnus L., from the Turkish Aegean Sea. Journal of Animal and Veterinary Advances, 9(11), 1684-1688. doi:10.3923/javaa.2010.1684.1688Rooker, J. R., Alvarado Bremer, J. R., Block, B. A., Dewar, H., de Metrio, G., Corriero, A., … Secor, D. H. (2007). Life History and Stock Structure of Atlantic Bluefin Tuna (Thunnus thynnus). Reviews in Fisheries Science, 15(4), 265-310. doi:10.1080/10641260701484135Sinovcic, G., Franicevic, M., Zorica, B., & Cikes-Kec, V. (2004). Length-weight and length-length relationships for 10 pelagic fish species from the Adriatic Sea (Croatia). Journal of Applied Ichthyology, 20(2), 156-158. doi:10.1046/j.1439-0426.2003.00519.xTičina, V., Grubišić, L., Šegvić Bubić, T., & Katavić, I. (2011). Biometric characteristics of small Atlantic bluefin tuna (Thunnus thynnus, Linnaeus, 1758) of Mediterranean Sea origin. Journal of Applied Ichthyology, 27(4), 971-976. doi:10.1111/j.1439-0426.2011.01752.

Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data

Background: Patients who have had a stroke with unknown time of onset have been previously excluded from thrombolysis. We aimed to establish whether intravenous alteplase is safe and effective in such patients when salvageable tissue has been identified with imaging biomarkers. Methods: We did a systematic review and meta-analysis of individual patient data for trials published before Sept 21, 2020. Randomised trials of intravenous alteplase versus standard of care or placebo in adults with stroke with unknown time of onset with perfusion-diffusion MRI, perfusion CT, or MRI with diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch were eligible. The primary outcome was favourable functional outcome (score of 0–1 on the modified Rankin Scale [mRS]) at 90 days indicating no disability using an unconditional mixed-effect logistic-regression model fitted to estimate the treatment effect. Secondary outcomes were mRS shift towards a better functional outcome and independent outcome (mRS 0–2) at 90 days. Safety outcomes included death, severe disability or death (mRS score 4–6), and symptomatic intracranial haemorrhage. This study is registered with PROSPERO, CRD42020166903. Findings: Of 249 identified abstracts, four trials met our eligibility criteria for inclusion: WAKE-UP, EXTEND, THAWS, and ECASS-4. The four trials provided individual patient data for 843 individuals, of whom 429 (51%) were assigned to alteplase and 414 (49%) to placebo or standard care. A favourable outcome occurred in 199 (47%) of 420 patients with alteplase and in 160 (39%) of 409 patients among controls (adjusted odds ratio [OR] 1·49 [95% CI 1·10–2·03]; p=0·011), with low heterogeneity across studies (I2=27%). Alteplase was associated with a significant shift towards better functional outcome (adjusted common OR 1·38 [95% CI 1·05–1·80]; p=0·019), and a higher odds of independent outcome (adjusted OR 1·50 [1·06–2·12]; p=0·022). In the alteplase group, 90 (21%) patients were severely disabled or died (mRS score 4–6), compared with 102 (25%) patients in the control group (adjusted OR 0·76 [0·52–1·11]; p=0·15). 27 (6%) patients died in the alteplase group and 14 (3%) patients died among controls (adjusted OR 2·06 [1·03–4·09]; p=0·040). The prevalence of symptomatic intracranial haemorrhage was higher in the alteplase group than among controls (11 [3%] vs two [&lt;1%], adjusted OR 5·58 [1·22–25·50]; p=0·024). Interpretation: In patients who have had a stroke with unknown time of onset with a DWI-FLAIR or perfusion mismatch, intravenous alteplase resulted in better functional outcome at 90 days than placebo or standard care. A net benefit was observed for all functional outcomes despite an increased risk of symptomatic intracranial haemorrhage. Although there were more deaths with alteplase than placebo, there were fewer cases of severe disability or death. Funding: None

Determining the use of prophylactic antibiotics in breast cancer surgeries : a survey of practice

Q3Q2Background: Prophylactic antibiotics (PAs) are beneficial to breast cancer patients undergoing surgery because they prevent surgical site infection (SSI), but limited information regarding their use has been published. This study aims to determine the use of PAs prior to breast cancer surgery amongst breast surgeons in Colombia. Methods: An online survey was distributed amongst the breast surgeon members of the Colombian Association of Mastology, the only breast surgery society of Colombia. The scope of the questions included demographics, clinical practice characteristics, PA prescription characteristics, and the use of PAs in common breast surgical procedures. Results: The survey was distributed amongst eighty-eight breast surgeons of whom forty-seven responded (response rate: 53.4%). Forty surgeons (85.1%) reported using PAs prior to surgery of which >60% used PAs during mastectomy, axillary lymph node dissection, and/or breast reconstruction. Surgeons reported they targeted the use of PAs in cases in which patients had any of the following SSI risk factors: diabetes mellitus, drains in situ, obesity, and neoadjuvant therapy. The distribution of the self-reported PA dosing regimens was as follows: single pre-operative fixed-dose (27.7%), single preoperative dose followed by a second dose if the surgery was prolonged (44.7%), single preoperative dose followed by one or more postoperative doses for >24 hours (10.6%), and single preoperative weight-adjusted dose (2.1%). Conclusion: Although this group of breast surgeons is aware of the importance of PAs in breast cancer surgery there is a discrepancy in how they use it, specifically with regards to prescription and timeliness of drug administration. Our findings call for targeted quality-improvement initiatives, such as standardized national guidelines, which can provide sufficient evidence for all stakeholders and therefore facilitate best practice medicine for breast cancer surgery

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme