Obesity does not adversely impact the outcome of unicompartmental knee arthroplasty for osteoarthritis: a meta-analysis of 80,798 subjects

BACKGROUND

Patients with end-stage single compartment osteoarthritis benefit from the less invasive unicompartmental knee arthroplasty (UKA). With increasing financial restraints, some healthcare services have set specific BMI cut-offs when determining patient eligibility for knee arthroplasty due to perceived obesity-related complications. The aim of this systematic review is to determine the effect obesity has on outcomes following UKA, and thus elucidate whether obesity should be a contraindication for UKA.

METHODS

A PRISMA systematic review was conducted using five databases (MEDLINE, EMBASE, Cochrane, PubMed and Web of Science) to identify all clinical studies that examined the effect of obesity on outcomes following UKA. Quantitative meta-analysis was carried out using RevMan 5.3 software. Quality assessment was carried out using the Critical Appraisal Skills Programme (CASP) checklist.

RESULTS

Thirty studies, including a total of 80 798 patients were analysed. The mean follow- up duration was 5.42 years. Subgroup meta-analyses showed no statistically significant difference following UKA between patients cohorts with and without obesity in overall complication rates (95% CI, P = 0.52), infection rates (95% CI, P = 0.81), and revision surgeries (95% CI, P = 0.06). When further analysing complications, no differences were identified in minor (95% CI, P = 0.23) and major complications (95% CI, P = 0.68), or venous thromboembolism rates (95% CI, P = 0.06). When further analysing revision surgeries, no differences were identified for revisions specifically for infection (95% CI, P = 0.71) or aseptic loosening (95% CI, P = 0.75).

CONCLUSIONS

This meta-analysis shows that obesity does not result in poorer post-operative outcomes following UKA and should not be considered a contraindication for UKA. Future studies, including long-term follow-up RCTs and registry-level analyses, should examine factors associated with obesity and consider stratifying obesity to better delineate any potential differences in outcomes.

Clinical and Radiological Outcomes in Robotic-Assisted Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

The aim of this systematic review is to determine if robotic-assisted total knee arthroplasty (RATKA) results in improved clinical and radiological outcomes, and to elucidate the breadth and depth of studies conducted on this topic.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review was conducted using 4 databases (MEDLINE, EMBASE, Cochrane, and Web of Science) to identify all clinical studies that investigate clinical or radiological outcomes using RATKA. The Critical Appraisal Skills Program checklist for cohort studies was employed for critical appraisal and evaluation of all 22 studies that met the inclusion criteria.

RESULTS

All studies reviewed determined that knee arthroplasty improved clinical outcomes. Twelve studies found statistically better clinical outcomes with RATKA compared with conventional TKA, whereas 9 studies found no difference. One study did not assess clinical outcomes. When assessing radiological outcomes, 14 studies reported that RATKA resulted in more consistent and accurate postoperative mechanical alignment, whereas 2 studies reported no difference. Six studies did not assess radiological outcomes.

CONCLUSION

Although knee arthroplasty is one of the most commonly performed orthopedic operations, the level of patient satisfaction varies. The meta-analyses conducted in our systematic review shows that RATKA results in greater improvements in postoperative Hospital for Special Surgery score and Western Ontario and McMaster Universities scores compared to conventional TKA. Furthermore, it shows that RATKA results in more accurate postoperative alignment of prostheses. These together can explain the improved postoperative outcomes. More randomized controlled trials must be conducted before this technique is integrated into routine clinical practice.

Celiac Disease in Indian Children and Adolescents with Type 1 Diabetes

To estimate the time trend and prevalence of celiac disease in 208 children with type 1 diabetes by retrospective case review. Tissue transglutaminase (TTG IgA) levels were done within the first six months of diagnosis and annually on follow-up. Celiac disease was diagnosed in 35 (16.8%; 3 before diagnosis, 18 at initial screening and 14 on follow-up). 14 subjects with negative TTG serology at presentation, developed celiac disease after 3.9 (2.9) years (range 1.4 - 12.6 years, 85.7% within 5 years). Celiac disease is common in Indian children and adolescents with type I diabetes, developing in most within five years of diagnosis.

Insights into Metatranscriptome, and CAZymes of Buffalo Rumen Supplemented with Blend of Essential Oils

The aim of this study was to investigate the rumen microbial diversity and functionality in buffaloes fed with a blend of essential oils (BEO) using LSD switch over design. The BEO consisting of blend of Trachyspermum copticum (Ajwain) oil, Cymbopogon citratus (lemon grass) oil and Syzygium aromaticum (clove bud) oleoresin mixed in equal proportion, was fed at the rate of 0, 0.75 and 1.5 ml/100 kg of body weight in 0 (control), 0.75 and 1.5 groups, respectively. The metatranscriptomic libraries of the rumen microbiome were represented by 7 domains, 84 phyla, 64 archeal genera and 663 bacterial genera with Bacteroidetes and Firmicutes constituting 80% of phyla abundance irrespective of feeding regime. Methanogenic archaea was represented by 22 phyla with Methanobrevibacter as the major genus. BEO feeding reduced the abundance of Methanococcus and Thermoplasma (P < 0.05) at all levels. The results revealed that the feeding of BEO shifted the archeal and bacterial population at very low magnitude. The study explored the vast diversity of buffalo rumen bacteria and archaea, and the diverse wealth of rumen enzymes (CAZymes), which revealed that a major part of CAZymes comes from the less known rumen microbes indicating alternative paths of fiber degradation along with the very well known ones.

Factors Associated With Cerebral Edema at Admission in Indian Children with Diabetic Ketoacidosis

OBJECTIVE

To evaluate the time course and predictors of cerebral edema in diabetic ketoacidosis (DKA).

METHODS

Review of hospital records of 107 episodes of DKA between January 2013 to March 2019.

RESULTS

Cerebral edema was identified in 26 (24.3%; 22 at presentation and 4 during treatment). Cerebral edema at presentation was associated with lower (<10 mmHg) arterial carbon dioxide (OR 3.6, 95% CI 1.0,12.7; P=0.04), prior fluid treatment (OR 4.7, 95% CI 1.8,12.7; P=0.001) and new onset diabetes (OR 3.5, 95% CI 1.1,11.1; P=0.03). Prior fluid was the only significant predictor on multivariate analysis (P=0.013). Cerebral edema resulted in a longer ICU stay [4.1 (2.3) vs 1.8 (0.9) d; P<0.001].

CONCLUSIONS

Cerebral edema at admission is common in Indian children with DKA and should be suspected with severe metabolic acidosis and inappropriate prior fluid treatment.

Chronic Thromboembolic Pulmonary Hypertension-Management Strategies and Outcomes

Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. Pulmonary endarterectomy is the surgical procedure of choice with good postoperative survival and functional outcomes, especially when done at high-volume centers with a multidisciplinary approach. There has been a resurgence of balloon pulmonary angioplasty (BPA) as salvage therapy for inoperable CTEPH or in its newfound hybrid role for persistent postoperative pulmonary hypertension with excellent 1-year and 3-year survival. Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.

Perioperative management of patients with rheumatoid arthritis undergoing orthopaedic surgery

Rheumatoid arthritis is an autoimmune disease which is characterised by systemic inflammation. In the recent decades, the advent of disease modifying anti-rheumatic drugs have reduced the need for orthopaedic procedures. However, there are numerous patients in which pharmacological treatment fails and these patients require surgical intervention. Complications can arise due to the underlying pathology and multitude of medications these patients can be on, specifically increased infection rates due to use of immunosuppressive agents. An understanding into the disease itself, as well as perioperative management, may improve overall patient outcomes and prevent future complications.

Management of latex hypersensitivity in the perioperative setting

Despite the introduction and use of latex-free gloves, natural rubber latex hypersensitivity is still an issue in hospital medicine both for patients and healthcare professionals. Clear understanding of the groups at risk as well as perioperative assessment and management is key to reducing complications and improving safety. In this literature review, we cover the perioperative management of patients with latex hypersensitivity, as well as the implications for healthcare professionals. We also review the cost analyses of latex hypersensitivity in the healthcare system and the evidence available.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.