Analysis of Cortical Bone Fracture in Human Thigh Segment Through Finite Element

Stress intensity factor, K, and von mises stress have been obtained by using three-point bending test in twodimensional (2D) model of cortical bone in human thigh segment. This test has been done in finite element analysis (K) with respect to the continuum mechanic approach. The K values obtained from the Ansys simulation is almost similar to the K values of the equation. The differences values between them were in between 0.02% to 6.64%. The values obtained in von mises stress increases whenever the crack length decreases, while the maximum value obtained when the crack length is 1mm. The values of K is directly proportional to the ratio of crack length, where whenever the ratio of the crack length over width increases, the K values also increases

Serum screening with Down's syndrome markers to predict pre-eclampsia and small for gestational age: Systematic review and meta-analysis

<p>Abstract</p> <p>Background</p> <p>Reliable antenatal identification of pre-eclampsia and small for gestational age is crucial to judicious allocation of monitoring resources and use of preventative treatment with the prospect of improving maternal/perinatal outcome. The purpose of this systematic review was to determine the accuracy of five serum analytes used in Down's serum screening for prediction of pre-eclampsia and/or small for gestational age.</p> <p>Methods</p> <p>The data sources included Medline, Embase, Cochrane library, Medion (inception to February 2007), hand searching of relevant journals, reference list checking of included articles, contact with experts. Two reviewers independently selected the articles in which the accuracy of an analyte used in Downs's serum screening before the 25^thgestational week was associated with the occurrence of pre-eclampsia and/or small for gestational age without language restrictions. Two authors independently extracted data on study characteristics, quality and results.</p> <p>Results</p> <p>Five serum screening markers were evaluated. 44 studies, testing 169,637 pregnant women (4376 pre-eclampsia cases) and 86 studies, testing 382,005 women (20,339 fetal growth restriction cases) met the selection criteria. The results showed low predictive accuracy overall. For pre-eclampsia the best predictor was inhibin A>2.79MoM positive likelihood ratio 19.52 (8.33,45.79) and negative likelihood ratio 0.30 (0.13,0.68) (single study). For small for gestational age it was AFP>2.0MoM to predict birth weight < 10^thcentile with birth < 37 weeks positive likelihood ratio 27.96 (8.02,97.48) and negative likelihood ratio 0.78 (0.55,1.11) (single study). A potential clinical application using aspirin as a treatment is given as an example.</p> <p>There were methodological and reporting limitations in the included studies thus studies were heterogeneous giving pooled results with wide confidence intervals.</p> <p>Conclusion</p> <p>Down's serum screening analytes have low predictive accuracy for pre-eclampsia and small for gestational age. They may be a useful means of risk assessment or of use in prediction when combined with other tests.</p

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Glenoid Component Position Does Not Affect Short-Term Clinical and Radiologic Outcomes in Total Shoulder Arthroplasty

Background: Malpositioning of the glenoid component in total shoulder arthroplasty (TSA) remains the primary source of loosening. The purpose of this study is firstly, to quantify postoperative glenoid component position in patients having a TSA and secondly, to explore whether glenoid component radiolucency is associated with glenoid position, clinical outcomes and patient-reported measures in the short-term (two year) follow-up period. Methods: This study was a sub-study of a larger clinical trial that included patients who underwent a TSA and who were randomized into two different glenoid types with a minimum two-year follow-up period. Post-operative radiographic assessments (six weeks and two years) were used to measure glenoid component position (version, inclination, offset) and humeral head centering anterior–posterior (AP) and superior–inferior (SI), and to assess glenoid component radiolucent scoring (modified Lazarus). Pre-operative X-rays were used to measure glenoid version, inclination and Walch classification. Patient-reported measures (PROMs) included the EQ-5D health slider and the Western Ontario Osteoarthritis (WOOS) and American Shoulder and Elbow Surgeons (ASES) score and were captured at baseline and two years postoperative. Clinical outcomes including range of motion and complications were also documented. Statistical analysis included t-tests and regression modeling. Results: Ninety-one patients with an average age of 69.9 ± 6.2 years were included in this study. Glenoid component position improved significantly in version (−19.4 ± 8.6° to −17.7 ± 8.5°; p < 0.045) and inclination (11.5 ± 7.1° to 5.9 ± 6.3°; p < 0.00001) from preoperative to six weeks postoperative. Glenoid component offset in SI and humeral head centering in AP remained unchanged throughout the follow-up. Radiolucency (Lazarus classification) was recorded in 21 cases (17.3%) with a Lazarus score of 1 (15 cases) and 2 (6 cases). The EQ-5D health slider, WOOS and ASES, and ROM confirmed continuous improvements from the preoperative scores to the two-year follow-up (p < 0.05). Regression models showed no correlation between glenoid component radiolucency at two years and the postoperative week six glenoid component position; however, female gender was a significant variable. Conclusion: Glenoid component changes from its original native glenoid were observed following TSA. Glenoid inclination was improved more than version from baseline, and the humeral head remained well-centered in AP and SI at two years. Radiolucency of the glenoid at two years is not negatively associated with PROMs or component position; however, female gender was identified as a significant predictor and warrants further investigation. Complications are not associated with glenoid position or radiolucency, but longer-term follow-up is required.Medicine, Faculty ofNon UBCOrthopaedic Surgery, Department ofReviewedFacult

Rates of Infection in Myelofibrosis Patients Treated with Ruxolitinib

Abstract Ruxolitinib is the only JAK 1/2 inhibitor approved by the FDA for the treatment of myelofibrosis (MF). It has been established that ruxolitinib helps improve disease-related constitutional symptoms and splenomegaly. However, studies have shown that ruxolitinib affects several cytokines (IL1, IL6, and TNF-α) and other immune processes (dendritic cells function and T-cell response) and has been linked to increased incidence of opportunistic and non-opportunistic infections. Here we report our experience at the Cleveland Clinic. A total of 50 patients (pts) with MF treated with ruxolitinib were included. The median age of the cohort was 68 years (range: 41-89), 28 of them were males and 22 were females. According to the Dynamic International Prognostic Scoring System (DIPSS), 5 pts had high risk, 23 had intermediate-2 risk, 21 had intermediate-1 risk and 1 had low risk disease. Of these pts, 18 developed infections during their treatment course. Of these infections, 12 were CTCAEv4.0 grade 1-2 and 6 were grade 3-4. Median age of the group was 66 years-old ranging between 50 and 83. Males=9 and females =9. The group was risk-stratified with DIPSS into high risk (N=3), intermediate-2 risk (N=7) and intermediate-1 risk (N=8).The infection started several months after initiation of JAK inhibitor treatment ranging between 2 weeks to 22 months (median of 8 months). Of note, 10 pts had episodes of infections prior to starting ruxolitinib (pneumonia N=5, cellulitis N=3, oral herpes N=2, UTI N=2, genital herpes N=1, Clostiridium difficile diarrhea N=1, viral diarrhea N=1, neutropenic fever N=1, spontaneous bacterial peritonitis N=1 and psoas muscle abscess N=1) . None of the patients had an active infection at the time of starting ruxolitinib. The median total dose given to the pts who developed grade1-2 infection was 20 mg daily, and for those who had grade 3-4 infection it was 15 mg daily. A variety of infections have been reported including pneumonia (N=4), cellulitis\folliculitis (N=4), Clostridium Difficile diarrhea (N=2), URI (N=1), neutropenic fever (N=1), MSSA bacteremia (N=1), herpes zoster activation (N=2), spontaneous bacterial peritonitis (N=1), perineal abscess (N=1) and one pt had a gluteal abscess after a bone marrow biopsy. Most of these infections resolved using oral or topical antibiotics (N=12). However, 6 pts required hospital admissions, and 5 of them required intravenous antibiotics. One of them required admission to the intensive care unit and two others required surgical interventions. Duration of treatment ranged between 1 to 8 weeks (median 2 weeks). Ruxolitinib had to be discontinued due to the severity of the infection in 2 pts, while the others either had a dose reduction or no dose alteration. Two pts required prophylactic antibiotics; one had recurrent SBP despite antimicrobial prophylaxis, while another pt required acyclovir prophylaxis while receiving glucocorticoids with ruxolitinib with no reactivation of Zoster infection. Predisposing factors for infections included a procedure (BMBx N=1), the concurrent use of other immunosuppressive drugs (steroids N=3, other agents N=3) and the prior use of systemic antibiotics in the pts who had C Diff infections (N=2). Only 2 pts had subsequent infections, one had oral herpes and the other had candida esophagitis which required hospitalization and treatment with IV antifungal drugs while on high dose steroids (dexamethasone 4 mg PO twice daily) for immune thrombocytopenia at the time of infection. Though 5 pts had already died at the time of the chart review, none of them died of infectious complications. In summary, infections can occur in patients treated with ruxolitinib but are generally mild. Most infections resolve after an adequate course of oral antimicrobial therapy suggesting that prophylactic antimicrobial agents may not be necessary or cost-effective in the vast majority of MF pts treated with ruxolitinib. Disclosures No relevant conflicts of interest to declare