Author(s): Nagle, D. | Abstract: More than 500,000 joint replacements are performed in the United States each year and this is expected to increase by at least 50% over the next 10 years [1]. Along with this increasing volume of joint replacements, the rate of revisions for failed hip and knee replacements is expected to increase at a similar rate over time. With all ‘failures’ it is important to carefully analyze the cause of failure in a continual effort to improve patient outcomes. The broad purpose of this study was to allow and facilitate ongoing research at UC San Diego into the mechanisms of failure of joint replacements in general.
We evaluated the effects of esmolol, a short acting (t½ β = 9 min) β-blocker on hemodynamics during noxious stimulation associated with aortocoronary bypass surgery. Group E (n = 10) and P (n = 10) patients had their morning dose of β- or calcium blockers withheld except for nifedipine, and were given infusions of esmolol (E) or placebo (P) beginning prior to anesthetic induction and continuing until mediastinal dissection. Group S (n = 10) patients received their usual medication the morning of surgery and received neither esmolol nor placebo. All patients received fentanyl infusions for anesthesia and pancuronium for relaxation. Esmolol patients had no changes in heart rate throughout the study. In contrast, significant increases in heart rate occurred during induction, intubation, and surgical stimulation in Groups P and S. Esmolol patients had a statistically significant but transient increase in pulmonary capillary wedge pressure (PCWP) after intubation, which did not require treatment. There were no significant changes in PCWP in Group S and a decrease in PCWP in Group P patients. We conclude that esmolol was effective in attenuating potentially deleterious responses to noxious stimulation during fentanyl-pancuronium anesthesia.
Displaced tibial shaft fractures are common in adolescent patients, yet there is no standardized management strategy. We compared surgical fixation and closed reduction and casting (CRC) of these fractures to assess treatment outcomes and determine predictors of failure.We retrospectively reviewed all patients aged 12 to 18 who presented with a displaced tibial shaft fracture that required reduction over an 8-year period. Exclusion criteria included open fractures and lack of follow-up to radiographic union or to 6 months from the index procedure. Fractures were initially treated based on surgeon preference either with CRC or with immediate intramedullary nailing. Seventy-four patients met inclusion criteria: 57 were initially managed with CRC and 17 with operative fixation. Radiographic healing was defined as bridging of 3 cortices and adequacy of final alignment was defined as <5 degrees of angular deformity in both planes and <1.0 cm of shortening. Outcomes were analyzed both on intent-to-treat principles and by definitive treatment method.Although all fractures in both groups achieved bony healing, 23 of the 57 patients who underwent CRC failed closed treatment and ultimately required surgery (40.3%). Multivariate analysis of patient and fracture characteristics revealed fracture displacement of >20% (odds ratio=7.8, P<0.05) and the presence of a fibula fracture (odds ratio=5.06, P=0.05) as predictors of closed treatment failure. Patients ultimately managed with intramedullary nailing trended toward increased adequacy of final alignment (92.5% vs. 72.4%, P=0.10) but required longer hospitalization (5.4 vs. 1.9 d, P<0.001) and had a higher incidence of anterior knee pain (20% vs. 0%, P<0.01). There was no significant difference between groups with respect to time to healing.Treatment outcomes between initial operative fixation and closed reduction of displaced tibia fractures in adolescents are similar, but patients must be counseled about the high failure rates with CRC. Predictors of CRC failure include initial fracture displacement and the presence of a fibula fracture-these variables should be considered when selecting a treatment method.Level III-Therapeutic study.
This study examined a simple technique for reducing contamination during catheterization of the internal jugular vein. Sixty patients were assigned randomly to receive either a traditional iodophor skin cleansing or an alcohol cleansing, followed by application of an iodophor-impregnated sterile film. In the cleansed with iodophor alone group, 83% of the anesthesiologists' glove tips were contaminated, and 13% of the catheter tips were contaminated. In contrast, in the group in which the sterile film was employed, contamination of gloves and catheters was virtually eliminated.
Introduction: High-resolution manometry (HRM) has provided more nuanced understanding of the relationship between esophageal body and lower esophageal sphincter pressures in patients with upper gastrointestinal symptoms. The major disorders of peristalsis are defined by an elevated integrated relaxation pressure (IRP), and further classified into achalasia or esophagogastric outflow obstruction (EGJOO) based upon the absence or presence of preserved peristalsis. While pneumatic balloon dilation or myotomy are effective therapies in patients with EJGOO, it is unclear which patients are more likely to benefit from treatment. The relationships between EGJOO and other routinely obtained measurements on HRM have yet to be elucidated and may help define the patient population which may benefit from treatment. Methods: In this single-center retrospective cohort study, we identified patients with symptoms of dysphagia and controls without dysphagia who underwent HRM from 8/2017 until present with the manometric findings of EGJOO (IRP >15 with intact peristalsis). Manometric data were obtained and the electronic medical record was used to obtain clinical data including demographics, clinical history, and imaging findings. Results: 76 patients were screened for inclusion over the study period. Two patients were excluded due to incomplete manometric data. Of the remaining 74 patients with EGJOO, 48 patients reported dysphagia as an indication for manometry, and 26 patients had an alternative indication. Only 20/76 patients (11.4%) with EGJOO were found to have a hiatal hernia. Patients with an IRP >25mmHg were more likely to report dysphagia than subgroups of 15-20mmHg and 20-25mmHg though the difference was not significant. Of the 6 symptomatic patients with dysphagia with incomplete bolus clearance, 4 were noted to have compartmentalization of pressures (66%), and 5 had an IRP >25mmHg (83%, P=0.08). Conclusion: EGJOO is not associated with the presence of hiatal hernia and is never the cause of this manometric finding. Among those with EGJOO, higher degrees of IRP elevation may correlate with the presence of symptomatic dysphagia. Among those with EGJOO, a higher degree of IRP elevation and compartmentalization of pressures may correlate with functionally relevant impaired bolus clearance. In EGJOO, concomitant high IRP elevation and compartmentalization of pressures may help identify patients that would preferentially benefit from endoscopic therapy.
