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Rudisill SS, Hornung AL, Akosman I, Amen TB, Lovecchio FC, Nwachukwu BU. Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting? J Shoulder Elbow Surg 2024; 33:1536-1546. [PMID: 38182016 DOI: 10.1016/j.jse.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database. METHODS White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities. RESULTS A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673). CONCLUSION Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.
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Affiliation(s)
| | - Alexander L Hornung
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Izzet Akosman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Francis C Lovecchio
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Wang L, Wang Y, Xu H, Li W. Effect of dapagliflozin on ferroptosis through the gut microbiota metabolite TMAO during myocardial ischemia-reperfusion injury in diabetes mellitus rats. Sci Rep 2024; 14:13851. [PMID: 38879701 PMCID: PMC11180094 DOI: 10.1038/s41598-024-64909-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/14/2024] [Indexed: 06/19/2024] Open
Abstract
Dapagliflozin (DAPA) demonstrates promise in the management of diabetic mellitus (DM) and cardiomyopathy. Trimethylamine N-oxide (TMAO) is synthesized by the gut microbiota through the metabolic conversion of choline and phosphatidylcholine. Ferroptosis may offer novel therapeutic avenues for the management of diabetes and myocardial ischemia-reperfusion injury (IRI). However, the precise mechanism underlying ferroptosis in cardiomyocytes and the specific role of TMAO generated by gut microbiota in the therapeutic approach for DM and myocardial IRI utilizing DAPA need to be further explored. Nine male SD rats with specific pathogen-free (SPF) status were randomly divided equally into the normal group, the DM + IRI (DIR) group, and the DAPA group. The diversity of the gut microbiota was analyzed using 16S rRNA gene sequencing. Additionally, the Wekell technique was employed to measure the levels of TMAO in the three groups. Application of network pharmacology to search for intersection targets of DAPA, DIR, and ferroptosis, and RT-PCR experimental verification. Ultimately, the overlapping targets that were acquired were subjected to molecular docking analysis with TMAO. The changes of Bacteroidetes and Firmicutes in the gut microbiota of DIR rats were most significantly affected by DAPA. Escherichia-Shigella and Prevotella_9 within the phylum Bacteroidetes could be identified as the primary effects of DAPA on DIR. Compared with the normal group, the TMAO content in the DIR group was significantly increased, while the TMAO content in the DAPA group was decreased compared to the DIR group. For the network pharmacology analysis, DAPA and DIR generated 43 intersecting target genes, and then further intersected with ferroptosis-related genes, resulting in 11 overlapping target genes. The mRNA expression of ALB, HMOX1, PPARG, CBS, LCN2, and PPARA decreased in the DIR group through reverse transcription polymerase chain reaction (RT-PCR) validation, while the opposite trend was observed in the DAPA group. The docking score between TMAO and DPP4 was - 5.44, and the MM-GBSA result of - 22.02 kcal/mol. It epitomizes the finest docking performance among all the target genes with the lowest score. DAPA could reduce the levels of metabolite TMAO produced by gut microbiota, thereby regulating related target genes to decrease ferroptosis in DIR cardiomyocytes.
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Affiliation(s)
- Lian Wang
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
- College of Medicine, Wuhan University of Science and Technology, Wuhan, 430070, Hubei, China
| | - Yao Wang
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Heng Xu
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Wenyuan Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China.
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Yoon JP, Park SJ, Choi YS, Kim DH, Lee HJ, Park EJJ, Chung SW. Current research trends on the effect of diabetes mellitus on rotator cuff tendon healing/tendinopathy. Arch Orthop Trauma Surg 2024; 144:2491-2500. [PMID: 38698293 DOI: 10.1007/s00402-024-05350-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/18/2024] [Indexed: 05/05/2024]
Abstract
Rotator cuff tendon tears are a leading cause of shoulder pain. They are challenging to treat, and tendon-bone healing has a high failure rate despite successful surgery. Tendons connect the muscles and bones, which make them important for the body's overall mobility and stability. Metabolic diseases, including diabetes or high blood pressure, can affect the healing process after repair of a damaged tendon. With a global incidence of 9.3%, diabetes is considered as a significant risk factor for rotator cuff tendon healing because it causes structural, inflammatory, and vascular changes in the tendon. However, the mechanisms of how diabetes affects tendon healing remain unknown. Several factors have been suggested, including glycation product accumulation, adipokine dysregulation, increased levels of reactive oxygen species, apoptosis, inflammatory cytokines, imbalanced matrix-metalloproteinase-to-tissue-inhibitor ratio, and impaired angiogenesis and differentiation of the tendon sheath. Despite the effects of diabetes on tendon function and healing, few treatments are available to improve recovery in these patients. This review summarizes the current literature on the pathophysiological changes of the tendon in diabetes and hyperlipidemia. Preclinical and clinical evidence regarding the association between diabetes and tendon healing is presented. Moreover, current approaches to improve tendon healing in patients with diabetes are reviewed.
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Affiliation(s)
- Jong Pil Yoon
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, 130 Dongdeok-Ro, Jung-Gu, Daegu, 41944, Korea
| | - Sung-Jin Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, 130 Dongdeok-Ro, Jung-Gu, Daegu, 41944, Korea.
| | - Yoon Seong Choi
- Department of Carbon Hybrid Fiber Science, Kyungpook National University, Daegu, Korea
| | - Dong-Hyun Kim
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, 130 Dongdeok-Ro, Jung-Gu, Daegu, 41944, Korea
| | - Hyun Joo Lee
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, 130 Dongdeok-Ro, Jung-Gu, Daegu, 41944, Korea
| | - Eugene Jae Jin Park
- Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, 130 Dongdeok-Ro, Jung-Gu, Daegu, 41944, Korea
| | - Seok Won Chung
- Department of Orthopaedic Surgery, School of Medicine, Konkuk University Medical Center, Seoul, Korea
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Hachadorian M, Chang RN, Prentice HA, Paxton EW, Rao AG, Navarro RA, Singh A. Association between same-day discharge shoulder arthroplasty and risk of adverse events in patients with American Society of Anesthesiologists classification ≥3: a cohort study. J Shoulder Elbow Surg 2023; 32:e556-e564. [PMID: 37268285 DOI: 10.1016/j.jse.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Same-day discharge for shoulder arthroplasty (SA) is well-supported in the literature; however, most studies have focused on healthier patients. Indications for same-day discharge SA have expanded to include patients with more comorbidities, but safety of same-day discharge in this population remains unknown. We sought to compare outcomes following same-day discharge vs. inpatient SA in a cohort of patients considered higher risk for adverse events, defined as an American Society of Anesthesiologists (ASA) classification of ≥3. METHODS Data from Kaiser Permanente's SA registry were utilized to conduct a retrospective cohort study. All patients with an ASA classification of ≥3 who underwent primary elective anatomic or reverse SA in a hospital from 2018 to 2020 were included. The exposure of interest was in-hospital length of stay: same-day discharge vs. ≥1-night hospital inpatient stay. The likelihood of 90-day post-discharge events, including emergency department (ED) visit, readmission, cardiac complication, venous thromboembolism, and mortality, was evaluated using propensity score-weighted logistic regression with noninferiority testing using a margin of 1.10. RESULTS The cohort included a total of 1814 SA patients, of whom 1005 (55.4%) had same-day discharge. In propensity score-weighted models, same-day discharge was not inferior to an inpatient stay SA regarding 90-day readmission (odds ratio [OR] = 0.64, one-sided 95% upper bound [UB] = 0.89) and overall complications (OR = 0.67, 95% UB = 1.00). We lacked evidence in support of noninferiority for 90-day ED visit (OR = 0.96, 95% UB = 1.18), cardiac event (OR = 0.68, 95% UB = 1.11), or venous thromboembolism (OR = 0.91, 95% UB = 2.15). Infections, revisions for instability, and mortality were too rare to evaluate using regression analysis. CONCLUSIONS In a cohort of over 1800 patients with an ASA of ≥3, we found same-day discharge SA did not increase the likelihood of ED visits, readmissions, or complications compared with an inpatient stay, and same-day discharge was not inferior to an inpatient stay with regard to readmissions and overall complications. These findings suggest that it is possible to expand indications for same-day discharge SA in the hospital setting.
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Affiliation(s)
- Michael Hachadorian
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Richard N Chang
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Heather A Prentice
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Elizabeth W Paxton
- Medical Device Surveillance and Assessment, Kaiser Permanente, San Diego, CA, USA
| | - Anita G Rao
- Department of Orthopaedic Surgery, Northwest Permanente Medical Group, Vancouver, WA, USA
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, South Bay, CA, USA
| | - Anshuman Singh
- Department of Orthopaedic Surgery, Southern California Permanente Medical Group, San Diego, CA, USA.
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Lu H, Jin E, Xie H, Fu J, Chen X, Liu W, Yang Q, Yu F. Incidence and risk factors of in-hospital prosthesis-related complications following total shoulder arthroplasty. J Orthop Surg (Hong Kong) 2023; 31:10225536231214055. [PMID: 37971330 DOI: 10.1177/10225536231214055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The occurrence of prosthesis-related complications after total shoulder arthroplasty is devastating and costly. The purpose was to determine the incidence and risk of in-hospital prosthesis-related complications after total shoulder arthroplasty utilizing a large-scale sample database. METHODS A retrospective database analysis was performed based on Nationwide Inpatient Sample from 2010 to 2014. Patients who underwent total shoulder arthroplasty were included. Patient demographics, hospital characteristics, length of stay, economic indicators, in-hospital mortality, comorbidities, and peri-operative complications were evaluated. RESULTS A total of 34,198 cases were capture from the Nationwide Inpatient Sample database. There were 343 cases of in-hospital prosthesis-related complications after total shoulder arthroplasty and the overall incidence was 1%, with a more than 2.5-fold decrease from 2010 to 2014. Dislocation was the most common category among prosthesis-related complications (0.1%). The occurrence of in-hospital prosthesis-related complications was associated with significantly more total charges and slightly longer length of stay while less usage of Medicare. Risk factors of prosthesis-related complications were identified including younger age (<64 years), female, the native American, hospital in the South, alcohol abuse, depression, uncomplicated diabetes, diabetes with chronic complications, fluid and electrolyte disorders, metastatic cancer, neurological disorders, and renal failure. Interestingly, advanced age (≥65 years) and proprietary hospital were found as protective factors. Furthermore, prosthesis-related complications were associated with aseptic necrosis, rheumatoid arthritis, rotator cuff tear arthropathy, Parkinson's disease, prior shoulder arthroscopy, and blood transfusion. CONCLUSIONS It is of benefit to study risk factors of prosthesis-related complications following total shoulder arthroplasty to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.
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Affiliation(s)
- Huishan Lu
- Department of Nursing, Dongguan Hospital of Traditional Chinese Medicine, Dongguan, China
| | - Enyou Jin
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macao, China
| | - Hao Xie
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jinlang Fu
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xianhui Chen
- Division of Orthopaedic Surgery, Department of Orthopedic Surgery, The First People's Hospital of Foshan, Foshan, China
| | - Wenqian Liu
- Division of Critical Care Medicine, Department of HuiQiao Medical Unit, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qinfeng Yang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fang Yu
- Division of Orthopaedic Surgery, People's Hospital of Ganzhou, Ganzhou, China
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Alenazi AM, Alhowimel AS, Alshehri MM, Alqahtani BA, Alhwoaimel NA, Segal NA, Kluding PM. Osteoarthritis and Diabetes: Where Are We and Where Should We Go? Diagnostics (Basel) 2023; 13:diagnostics13081386. [PMID: 37189487 DOI: 10.3390/diagnostics13081386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 05/17/2023] Open
Abstract
Diabetes mellitus (DM) and osteoarthritis (OA) are chronic noncommunicable diseases that affect millions of people worldwide. OA and DM are prevalent worldwide and associated with chronic pain and disability. Evidence suggests that DM and OA coexist within the same population. The coexistence of DM in patients with OA has been linked to the development and progression of the disease. Furthermore, DM is associated with a greater degree of osteoarthritic pain. Numerous risk factors are common to both DM and OA. Age, sex, race, and metabolic diseases (e.g., obesity, hypertension, and dyslipidemia) have been identified as risk factors. These risk factors (demographics and metabolic disorder) are associated with DM or OA. Other possible factors may include sleep disorders and depression. Medications for metabolic syndromes might be related to the incidence and progression of OA, with conflicting results. Given the growing body of evidence indicating a relationship between DM and OA, it is vital to analyze, interpret, and integrate these findings. Therefore, the purpose of this review was to evaluate the evidence on the prevalence, relationship, pain, and risk factors of both DM and OA. The research was limited to knee, hip, and hand OA.
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Affiliation(s)
- Aqeel M Alenazi
- Department of Health and Rehabilitation Sciences, Prince Sattam Bin Abdulaziz University, Alkharj 11942, Saudi Arabia
| | - Ahmed S Alhowimel
- Department of Health and Rehabilitation Sciences, Prince Sattam Bin Abdulaziz University, Alkharj 11942, Saudi Arabia
| | - Mohammed M Alshehri
- Departement of Physical Therapy, Jazan University, Jazan 45142, Saudi Arabia
| | - Bader A Alqahtani
- Department of Health and Rehabilitation Sciences, Prince Sattam Bin Abdulaziz University, Alkharj 11942, Saudi Arabia
| | - Norah A Alhwoaimel
- Department of Health and Rehabilitation Sciences, Prince Sattam Bin Abdulaziz University, Alkharj 11942, Saudi Arabia
| | - Neil A Segal
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, MI 66160, USA
| | - Patricia M Kluding
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, MI 66160, USA
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Duey AH, White CA, Levy KH, Li T, Tang JE, Patel AV, Kim JS, Cho SK, Cagle PJ. Diabetes increases risk for readmission and infection after shoulder arthroplasty: A national readmissions study of 113,713 patients. J Orthop 2023; 38:25-29. [PMID: 36937225 PMCID: PMC10018384 DOI: 10.1016/j.jor.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/21/2023] [Accepted: 03/03/2023] [Indexed: 03/17/2023] Open
Abstract
Background The recent increasing popularity of shoulder arthroplasty has been paralleled by a rise in prevalence of diabetes in the United States. We aimed to evaluate the impact of diabetes status on readmission and short-term complications among patients undergoing shoulder arthroplasty. Methods We analyzed the Healthcare Cost and Utilization Project National Readmissions Database (NRD) between the years 2016-2018. Patients were included in the study if they underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) according to ICD-10 procedure codes. Postoperative complications including surgical site/joint infection, dislocation, prosthetic complications, hardware-related complications, non-infectious wound complications, 30-day, and 90-day readmission were collected. Results A total of 113,713 shoulder arthroplasty patients were included. 23,749 (20.9%) had a diagnosis of diabetes and 89,964 (79.1%) did not. On multivariate analysis, a diagnosis of diabetes led to an increased risk of 30-day (OR: 1.24; 95% CI: [1.14, 1.34]; p < 0.001) and 90-day (OR: 1.18; 95% CI: [1.12, 1.25]; p < 0.001) readmission, surgical site/joint infection (OR: 1.21; 95% CI: [1.06, 1.38]; p = 0.005), respiratory complication (OR: 1.34; 95% CI: [1.09, 1.64]; p = 0.005), postoperative infection (OR: 1.22; 95% CI [1.07, 1.39]; p = 0.003), and deep vein thrombosis (OR: 1.38; 95% CI: [1.09, 1.74]; p = 0.007). Conclusions Our findings suggest that patients with diabetes may be at an increased risk of readmission, infection, respiratory complication, and deep vein thrombosis following shoulder arthroplasty. Shoulder surgeons should consider these potential adverse events when planning postoperative care for patients with diabetes.
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Affiliation(s)
- Akiro H. Duey
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Christopher A. White
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Kenneth H. Levy
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Troy Li
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Justin E. Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Akshar V. Patel
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Jun S. Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Paul J. Cagle
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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Seok HG, Park JJ, Park SG. Risk Factors for Periprosthetic Joint Infection after Shoulder Arthroplasty: Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11144245. [PMID: 35888008 PMCID: PMC9316575 DOI: 10.3390/jcm11144245] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/08/2022] [Accepted: 07/19/2022] [Indexed: 12/04/2022] Open
Abstract
Periprosthetic joint infection (PJI) after shoulder arthroplasty is a devastating complication that requires several additional surgeries. The purpose of this study was to assess the evidence regarding risk factors for PJI and identify those that contribute to infection by performing a meta-analysis. We searched the PubMed, Embase, and Cochrane Library databases for studies that assessed the risk factors for infection after shoulder arthroplasty. After performing screening and quality assessment on the articles, we obtained two case-control studies and six retrospective cohort studies (total of 420 infected cases and 28,464 controls). Review Manager 5.4 was used to assess the heterogeneity and odds ratio for 20 different factors that broadly included demographic factors, perioperative factors, and comorbidities. Factors that are markedly associated with PJI after shoulder arthroplasty were male sex, operation history, revision arthroplasty, acute trauma, and non-osteoarthritis as a preoperative diagnosis. Statistical analysis revealed that diabetes mellitus, liver disease, alcohol overuse, iron-deficiency anemia, and rheumatoid arthritis were risk factors for PJI after shoulder arthroplasty. The result of analysis shows that several specific factors can be targeted to prevent infections after shoulder arthroplasty. Surgeons should consider the risk factors and perform the appropriate management for patients.
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9
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Gupta P, Quan T, Patel CJ, Manzi JE, Gu A, Tabaie S, Campbell JC. Extended length of stay in diabetic octogenarians following revision total hip arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1217-1222. [PMID: 35536487 DOI: 10.1007/s00590-022-03277-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/20/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Past research has shown diabetic patients, including those of geriatric age, to be at an increased risk of postoperative complications following various surgeries, including revision total hip arthroplasty (rTHA). However, whether these risks are disproportionately greater in octogenarian patients has not been well investigated. This study aimed to determine whether diabetic octogenarians are at an increased risk of postoperative complications following rTHA. METHODS The national surgical quality improvement program database was used to identify all diabetic patients who underwent rTHA from 2007 to 2018. Patients were divided into two groups: an aged 65 to 79 cohort and an aged 80 to 89 cohort. Patient demographics, comorbidities, and postoperative complications were assessed and compared between the two aged cohorts, with the utilization of bivariate and multivariate analyses. RESULTS Of the 1184 diabetic patients who underwent rTHA, 906 (76.5%) patients were in the aged 65 to 79 cohort and 278 (23.5%) patients were in the aged 80 to 89 cohort. After adjusting for patient demographics and medical comorbidities, compared to patients in the aged 65 to 79 group, diabetic patients who were 80 to 89 years old were found to have an increased risk of extended length of hospital stay (OR 1.67; p = 0.017). CONCLUSION Diabetic octogenarian patients have an increased risk for a prolonged hospital stay following rTHA relative to their younger diabetic geriatric counterparts. Orthopedic surgeons should be aware of these increased risks to properly educate diabetic octogenarians and assist in surgical management decision making in these patients considering rTHA.
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Affiliation(s)
- Puneet Gupta
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, 2300 Eye St NW, Washington, DC, 20037, USA
| | - Theodore Quan
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, 2300 Eye St NW, Washington, DC, 20037, USA.
| | - Chirag J Patel
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, 2300 Eye St NW, Washington, DC, 20037, USA
| | - Joseph E Manzi
- Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, 2300 Eye St NW, Washington, DC, 20037, USA
| | - Sean Tabaie
- Department of Orthopaedic Surgery, Children's National Health System, Washington, DC, USA
| | - Joshua C Campbell
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, 2300 Eye St NW, Washington, DC, 20037, USA
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Hyperglycemia-triggered ATF6-CHOP pathway aggravates acute inflammatory liver injury by β-catenin signaling. Cell Death Dis 2022; 8:115. [PMID: 35289326 PMCID: PMC8921205 DOI: 10.1038/s41420-022-00910-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/08/2022] [Accepted: 02/18/2022] [Indexed: 12/12/2022]
Abstract
Although hyperglycemia has been documented as an unfavorable element that can further induce liver ischemia–reperfusion injury (IRI), the related molecular mechanisms remain to be clearly elaborated. This study investigated the effective manner of endoplasmic reticulum (ER) stress signaling in hyperglycemia-exacerbated liver IRI. Here we demonstrated that in the liver tissues and Kupffer cells (KCs) of DM patients and STZ-induced hyperglycemic mice, the ER stress-ATF6-CHOP signaling pathway is activated. TLR4-mediated pro-inflammatory activation was greatly attenuated by the addition of 4-phenylbutyrate (PBA), one common ER stress inhibitor. The liver IRI in hyperglycemic mice was also significantly reduced after PBA treatment. In addition, deficiency of CHOP (CHOP−/−) obviously alleviates the hepatic IRI, and pro-inflammatory effects deteriorated by hyperglycemia. In hyperglycemic mice, β-catenin expression was suppressed while the ATF6-CHOP signal was activated. In the liver tissues of PBA-treated or CHOP−/− hyperglycemic mice, the expression of β-catenin was restored. Furthermore, CHOP deficiency can induce protection against hyperglycemia-related liver IRI, which was disrupted by the knockdown of β-catenin will cause this protection to disappear. High glucose (HG) treatment stimulated ATF6-CHOP signaling, reduced cellular β-catenin accumulation, and promoted the TLR4-related inflammation of BMDMs. But the above effects were partially rescued in BMDMs with CHOP deficiency or by PBA treatment. In BMDMs cultured in HG conditions, the anti-inflammatory functions of CHOP−/− were destroyed by the knockdown of β-catenin. Finally, chimeric mice carrying WT or CHOP−/− BMDMs by bone marrow transplantation were adopted to verify the above conclusion. The current study suggested that hyperglycemia could trigger ER stress-ATF6-CHOP axis, inhibit β-catenin activation, accelerate inflammation, and deteriorate liver IRI, thus providing the treatment potential for management of sterile liver inflammation in DM patients.
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Vargas M, Sanchez G, Gordon AM, Horn AR, Conway CA, Razi AE, Sadeghpour R. Comparison of patient-demographics, causes, and costs of 90-day readmissions following primary total shoulder arthroplasty for glenohumeral osteoarthritis. J Orthop 2022; 31:52-56. [PMID: 35392136 PMCID: PMC8980302 DOI: 10.1016/j.jor.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Readmissions following orthopaedic surgery are associated with worse outcomes and increased healthcare costs. Studies investigating trends, causes, and costs of readmissions following primary total shoulder arthroplasty (TSA) for the indication of glenohumeral osteoarthritis (OA) are limited. The objective was to compare: 1) patient-demographics of those readmitted and not readmitted within 90-days following primary TSA for OA; 2) causes of readmissions and 3) associated costs. Methods A retrospective query from 2005 to 2014 was performed using a nationwide administrative claims database. The study group consisted of patients readmitted within 90-days following primary TSA for glenohumeral OA, whereas patients not readmitted served as controls. Causes of readmission were stratified into the following groups: cardiovascular, hematological, endocrine, gastrointestinal (GI), musculoskeletal (MSK), neoplastic, neurological, pulmonary, infectious, renal, and miscellaneous causes. Patient demographics were compared, in addition to the frequency of the causes of readmissions, and their associated costs. Chi-square analyses compared demographics between groups. Analysis of variance was utilized to determine differences in 90-day costs for the causes of readmission. A p-value less than 0.001 was significant. Results The overall 90-day readmission rate was 2.4% (3432/143,878). Patients readmitted following primary TSA were more likely to be over the age of 75, female, and higher prevalence of comorbid conditions, including psychiatric and medical conditions. Readmitted patients had a higher overall comorbidity burden per mean Elixhauser-Comorbidity Index (ECI) scores (10 vs. 7,p < .0001). The leading cause of readmissions were due to MSK (17.34%), cardiac (16.28%), infectious (16.26%), and gastrointestinal (11.64%) etiologies. There were differences in the mean 90-day costs of care for the various causes of readmissions, with the leading cost of readmissions being cardiac causes ($10,913.70) and MSK ($10,590.50) etiologies. Conclusion Patients with greater comorbidities experienced increased incidence of readmission following TSA for glenohumeral OA. Cardiac and MSK etiologies were the primary cause of readmissions. Level of evidence III.
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Affiliation(s)
- Marcos Vargas
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
- State University of New York (SUNY) Downstate, College of Medicine, Brooklyn, NY, USA
| | - Giovanni Sanchez
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
- State University of New York (SUNY) Downstate, College of Medicine, Brooklyn, NY, USA
| | - Adam M. Gordon
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
- Corresponding author. Maimonides Medical Center, Department of Orthopaedic Surgery, 927 49th Street, Brooklyn, New York, 11219, USA.
| | - Andrew R. Horn
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Charles A. Conway
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Afshin E. Razi
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Ramin Sadeghpour
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
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Zhang X, Hou A, Cao J, Liu Y, Lou J, Li H, Ma Y, Song Y, Mi W, Liu J. Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review. Front Endocrinol (Lausanne) 2022; 13:841256. [PMID: 35721703 PMCID: PMC9204286 DOI: 10.3389/fendo.2022.841256] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/12/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery. METHODS We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery. RESULTS This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]). CONCLUSIONS DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Weidong Mi
- *Correspondence: Jing Liu, ; Weidong Mi,
| | - Jing Liu
- *Correspondence: Jing Liu, ; Weidong Mi,
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de Ponte MC, Cardoso VG, Gonçalves GL, Costa-Pessoa JM, Oliveira-Souza M. Early type 1 diabetes aggravates renal ischemia/reperfusion-induced acute kidney injury. Sci Rep 2021; 11:19028. [PMID: 34561469 PMCID: PMC8463569 DOI: 10.1038/s41598-021-97839-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 08/23/2021] [Indexed: 12/15/2022] Open
Abstract
The present study aimed to investigate the interaction between early diabetes and renal IR-induced AKI and to clarify the mechanisms involved. C57BL/6J mice were assigned to the following groups: (1) sham-operated; (2) renal IR; (3) streptozotocin (STZ-55 mg/kg/day) and sham operation; and (4) STZ and renal IR. On the 12th day after treatments, the animals were subjected to bilateral IR for 30 min followed by reperfusion for 48 h, at which time the animals were euthanized. Renal function was assessed by plasma creatinine and urea levels, as well urinary protein contents. Kidney morphology and gene and protein expression were also evaluated. Compared to the sham group, renal IR increased plasma creatinine, urea and albuminuria levels and decreased Nphs1 mRNA expression and nephrin and WT1 protein staining. Tubular injury was observed with increased Havcr1 and Mki67 mRNA expression accompanied by reduced megalin staining. Renal IR also resulted in increased SQSTM1 protein expression and increased proinflammatory and profibrotic factors mRNA expression. Although STZ treatment resulted in hyperglycemia, it did not induce significant changes in renal function. On the other hand, STZ treatment aggravated renal IR-induced AKI by exacerbating renal dysfunction, glomerular and tubular injury, inflammation, and profibrotic responses. Thus, early diabetes constitutes a relevant risk factor for renal IR-induced AKI.
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Affiliation(s)
- Mariana Charleaux de Ponte
- Laboratory of Renal Physiology, Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, São Paulo, SP, 05508-900, Brazil
| | - Vanessa Gerolde Cardoso
- Laboratory of Renal Physiology, Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, São Paulo, SP, 05508-900, Brazil
| | - Guilherme Lopes Gonçalves
- Laboratory of Renal Physiology, Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, São Paulo, SP, 05508-900, Brazil
| | - Juliana Martins Costa-Pessoa
- Laboratory of Renal Physiology, Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, São Paulo, SP, 05508-900, Brazil
| | - Maria Oliveira-Souza
- Laboratory of Renal Physiology, Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of Sao Paulo, São Paulo, SP, 05508-900, Brazil.
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14
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Menendez ME, Mahendraraj KA, Grubhofer F, Muniz AR, Warner JJP, Jawa A. Variation in the value of total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:1924-1930. [PMID: 33290854 DOI: 10.1016/j.jse.2020.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is growing interest in maximizing value for patients undergoing discretionary orthopedic surgery but little data to guide improvement efforts. Integrating patient-reported outcomes with time-driven activity-based costing, we explored patient-level variation in the value of total shoulder arthroplasty (TSA) and characterized factors that contribute to this variation. METHODS Using our institutional registry, we identified 239 patients undergoing elective primary TSA (anatomic or reverse) between 2016-2017 with minimum 2-year follow-up. We calculated value as 2-year postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores divided by hospitalization time-driven activity-based costs. This number was multiplied by a constant to set the minimum value of TSA to 100. Multivariable linear regression modeling was performed to characterize factors underlying variation in value. RESULTS The value of shoulder arthroplasty ranged from 100 to 680, resulting in a variation of 580%. Reverse shoulder arthroplasty was associated with decreased value (79-point decrease vs. anatomic arthroplasty; P < .001; partial R2 = 0.089), as were prior ipsilateral shoulder surgery (38-point decrease; P = .002; partial R2 = 0.031), more self-reported allergies (4-point decrease per 1-unit increase; P = .029; partial R2 = 0.015), diabetes (33-point decrease; P = .045; partial R2 = 0.013), and lower preoperative ASES score (0.7-point increase per 1-unit increase; P = .045; partial R2 = 0.012). CONCLUSIONS We observed wide variation in the value of shoulder arthroplasty that was most strongly associated with procedure type and certain preoperative characteristics (eg, prior shoulder surgery, number of self-reported allergies, diabetes, ASES score). Awareness of these associations is important for implementation of targeted strategies to effectively reduce variation and redirect resources toward higher-value, cost-conscious care.
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Affiliation(s)
- Mariano E Menendez
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA
| | | | - Florian Grubhofer
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andres R Muniz
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon J P Warner
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Jawa
- Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA.
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15
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Ling DI, Schneider B, Ode G, Lai EY, Gulotta LV. The impact of Charlson and Elixhauser comorbidities on patient outcomes following shoulder arthroplasty. Bone Joint J 2021; 103-B:964-970. [PMID: 33934663 DOI: 10.1302/0301-620x.103b5.bjj-2020-1503.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To investigate the impact of the Charlson and Elixhauser comorbidity indices on patient-reported outcomes measures (PROMs) following shoulder arthroplasty. METHODS Patients undergoing total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or hemiarthroplasty (HA) from 2016 to 2018 were identified, along with the Charlson and Elixhauser comorbidities listed as their secondary diagnoses in the electronic medical records. Patients were matched to our institution's registry to obtain their PROMs, including shoulder-specific (American Shoulder and Elbow Society (ASES) and Shoulder Activity Scale (SAS)) and general health scales (12-Item Short Form Survey (SF-12) and Patient-Reported Outcomes Measurement Information System-Pain Interference). Linear regression models adjusting for age and sex were used to evaluate the association between increasing number of comorbidities and PROM scores. A total of 1,817 shoulder arthroplasties were performed: 1,017 (56%) TSA, 726 (40%) RSA, and 74 (4%) HA. The mean age was 67 years (SD 10), and 936 (52%) of the patients were female. RESULTS The most common comorbidities were obesity (1,256, 69%) and hypertension (990, 55%). Patients with more comorbidities had lower ASES and SAS scores at baseline (p < 0.001). Elixhauser comorbidities continued to negatively impact ASES and SAS scores at one year (p = 0.002) and two-year follow-up (p = 0.002). Patients with more comorbidities reported greater pain interference on PROMIS at baseline (p = 0.007), but not at two years. Higher number of Charlson comorbidities were associated with lower scores on the SF-12 mental component at baseline (p < 0.001) and two years (p = 0.020). Higher number of Elixhauser comorbidities were associated with lower SF-12 physical component scores at baseline (p < 0.001) and two years (p = 0.004). CONCLUSION Higher number of comorbidities was associated with lower baseline scores and worse outcomes on both shoulder-specific and general health PROMs. The presence of specific comorbidities may be used during shared decision-making to manage expectations for patients undergoing shoulder arthroplasty. Cite this article: Bone Joint J 2021;103-B(5):964-970.
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Affiliation(s)
- Daphne I Ling
- Sports Medicine Institute, Hospital for Special Surgery, New York, USA.,Department of Population Health Sciences, Weill Cornell Medical College, New York, USA
| | - Brandon Schneider
- Sports Medicine Institute, Hospital for Special Surgery, New York, USA
| | - Gabriella Ode
- Department of Orthopaedic Surgery, Prisma Health-Upstate, Blue Ridge Orthopaedics, Greenville, South Carolina, USA
| | - Emily Y Lai
- Sports Medicine Institute, Hospital for Special Surgery, New York, USA
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Bitzer A, Mikula JD, Aziz KT, Best MJ, Nayar SK, Srikumaran U. Diabetes is an independent risk factor for infection after non-arthroplasty shoulder surgery: a national database study. PHYSICIAN SPORTSMED 2021; 49:229-235. [PMID: 32811250 DOI: 10.1080/00913847.2020.1811617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Diabetes has been associated with poor healing and prior literature has shown worse functional outcomes in diabetic patients undergoing both open and arthroscopic shoulder surgery. However, the effects of diabetes on perioperative complications for patients undergoing non-arthroplasty type shoulder procedures are not well defined. The purpose of this study was to analyze the effects of diabetes on 30-day complications following non-arthroplasty shoulder surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open and arthroscopic shoulder procedures (excluding arthroplasty) from 2011 to 2018. Diabetic patients were identified and compared to a non-diabetic cohort. Demographic data and postoperative complications within 30 days were analyzed. Multivariable regression was used to determine the effect of diabetes on shoulder surgery. RESULTS We identified 99,970 patients who underwent shoulder surgery in our cohort and 13.9% (13,857 patients) of these patients were diabetics. Within the diabetic cohort, 4,394 (31.7%) were insulin dependent. Diabetics were more likely to be older, female, and have a higher body mass index (P < 0.01). Diabetics had a higher rate of associated medial comorbidities (P < 0.05). Diabetics were less likely to be smokers and on average had shorter surgeries (P < 0.05). Univariate analysis showed that diabetes was associated with increased risk for infectious and other major and minor complications; however, multivariate regression revealed that diabetes was only independently associated with infection (OR 1.33, P = 0.38). CONCLUSION While diabetes is associated with increased likelihood of infection following shoulder surgery, absent commonly associated comorbidities, they are not at increased risk for other 30-day postoperative complications.
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Affiliation(s)
- Alexander Bitzer
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jacob D Mikula
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Keith T Aziz
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Suresh K Nayar
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Chronic Kidney Disease Is Associated with High Mortality Risk in Patients with Diabetes after Primary Shoulder Arthroplasty: A Nationwide Population-Based Cohort Study. Diagnostics (Basel) 2021; 11:diagnostics11050822. [PMID: 34062879 PMCID: PMC8147363 DOI: 10.3390/diagnostics11050822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/17/2022] Open
Abstract
The number of diabetic patients with chronic kidney disease (CKD) undergoing shoulder arthroplasty is growing. This study aims to compare perioperative outcomes of shoulder arthroplasty in diabetic patients at different renal function stages. Between 1998 and 2013, a total of 4443 diabetic patients with shoulder arthroplasty were enrolled: 1174 (26%) had CKD without dialysis (CKD group), 427 (9%) underwent dialysis (dialysis group), and 3042 (68%) had no CKD (non-CKD group). Compared with the non-CKD group, the CKD (odds ratio [OR], 4.69; 95% confidence interval [CI], 2.02–10.89) and dialysis (OR, 6.71; 95% CI, 1.63–27.73) groups had a high risk of in-hospital death. The dialysis group had a high risk of infection after shoulder arthroplasty compared with the CKD (subdistribution hazard ratio [SHR], 1.69; 95% CI, 1.07–2.69) and non-CKD (SHR, 1.76; 95% CI, 1.14–2.73) groups. The dialysis group showed higher risks of all-cause readmission and mortality than the CKD and non-CKD groups after a 3-month follow-up. In conclusion, CKD was associated with worse outcomes after shoulder arthroplasty. Compared with those without CKD, CKD patients had significantly increased readmission and mortality risks but did not have an increased risk of surgical complications, including superficial infection or implant removal.
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Kriechling P, Loucas R, Loucas M, Künzler T, Gerber C, Wieser K. Primary reverse total shoulder arthroplasty in patients older than 80 years: clinical and radiologic outcome measures. J Shoulder Elbow Surg 2021; 30:877-883. [PMID: 32777476 DOI: 10.1016/j.jse.2020.07.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of reverse total shoulder arthroplasty (RTSA) has spread worldwide as a result of an expansion of indications and an aging society. However, the value of RTSA for very old patients is rarely analyzed. This study was conducted to investigate the outcome of primary RTSA in patients older than 80 years. METHODS We identified 171 shoulders (159 patients) treated with RTSA at an age of more than 80 years between January 2005 and March 2018. The primary outcome parameters were Subjective Shoulder Value (SSV) and the Constant-Murley score, mortality, complications, and reoperation rates. Secondary outcomes were adverse radiographic outcomes. A minimum follow-up of 1 year was accepted in 14 patients (8%) because of these patients' older age. RESULTS We included 171 cases (159 patients; 120 female) with a mean age of 84 ± 3 years (range 80.1-94). The main indication for RTSA was cuff tear arthropathy (43%), isolated rotator cuff tear (22%), and fracture (21%). A total of 136 patients (79%) were eligible for physical examination with a mean follow-up of 41 ± 25 months (12-121). Relative Constant-Murley scores improved significantly from 39% ± 19% to 77% ± 16% and SSV from 31% ± 18% to 74% ± 22%. The range of motion and force improved significantly as well. The surgical site complication rate was 30%, with a reoperation rate of 8% (13 patients) mainly due to fracture and glenoid loosening. The overall mortality was 16% with a mean time to death of 53 ± 31 months (95% confidence interval 15, 120), thereby no higher than the age-adjusted, expected mortality rate without this procedure. CONCLUSION Despite a quite high postoperative complication rate, RTSA is a valid therapeutic option in patients older than 80 years, with an unexpectedly low medical complication rate and good to excellent improvement of shoulder function and pain.
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Affiliation(s)
- Philipp Kriechling
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland.
| | - Rafael Loucas
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Marios Loucas
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Tabea Künzler
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
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Rao AJ, Yeatts NC, Reid RT, Trofa DP, Scarola G, Schiffern SC, Hamid N, Saltzman BM. Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty? J Shoulder Elbow Surg 2021; 30:616-624. [PMID: 32711107 DOI: 10.1016/j.jse.2020.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation. RESULTS In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness. CONCLUSION We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.
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Affiliation(s)
- Allison J Rao
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | - Nicholas C Yeatts
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | - Risa T Reid
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, NC, USA
| | - David P Trofa
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | | | - Shadley C Schiffern
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | - Nady Hamid
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | - Bryan M Saltzman
- OrthoCarolina Sports Medicine Center, Charlotte, NC, USA; Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA; Department of Orthopaedic Surgery, Atrium Health, Charlotte, NC, USA.
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Wagner ER, Muniz AR, Chang MJ, Hunt T, Welp KM, Woodmass JM, Higgins L, Chen N. Neuroapraxia and early complications after reverse shoulder arthroplasty with glenoid bone grafting. J Shoulder Elbow Surg 2021; 30:258-264. [PMID: 32838952 DOI: 10.1016/j.jse.2020.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bone grafting during primary reverse shoulder arthroplasty (RSA) is a technique used to restore poor glenoid bone, increase lateralization, and restore abnormal inclination or version. The purpose of this article is to analyze early outcomes of bone grafting during RSA, assessing the influence of technical and patient considerations. METHODS In a 4.5-year time period, 137 RSAs with glenoid bone grafting were performed with a minimum 3 months' follow-up. The mean follow-up was 17 months (range, 3-38). The mean age was 71 years (range, 45-89), and body mass index was 28 (range, 19-44). The source of the autografts were humeral head (n = 113) and iliac crest autograft (ICBG; n = 24). The humeral components included 84 onlay and 53 inlay designs. RESULTS Overall, there were 16 complications (12%), of which 6 were major (5%) (3 graft nonunions and 3 infections) and 10 minor (8%) (1 carpal tunnel syndrome and 9 transient axillary neuropraxias). Of the 9 axillary neuropraxias, 8 resolved by the most recent follow-up, whereas 1 patient was lost to follow-up. There were 4 reoperations (3%): 2 for glenoid baseplate loosening, 1 for severe notching associated with severe glenoid bone loss, and 1 for deep periprosthetic infection. One additional patient had a baseplate failure and is undergoing further treatment. There was no difference in the occurrence of graft nonunions, revision surgery, or glenoid component loosening when comparing type of graft or humeral component used. There was an association of revision surgery (P = .02) with ICBG and older age at the time of surgery (P = .02) and an association of transient neuroapraxia with onlay humeral components (P = .01) and workers' compensation cases (P = .04). CONCLUSIONS There is a high union rate and low complication rate after bone grafting of the glenoid performed with RSA. Transient neuropraxias are the most frequent complication, but the majority resolve within the first postoperative year. These early findings can serve as the basis for future long-term, comprehensive analysis of complications and outcomes after bone grafting during RSA.
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Affiliation(s)
- Eric R Wagner
- Department of Orthopedic Surgery, Emory University, Atlanta, GA, USA.
| | - Andres R Muniz
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle J Chang
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | - Tyler Hunt
- Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | | | | | | | - Neal Chen
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Wilson JM, Holzgrefe RE, Staley CA, Karas S, Gottschalk MB, Wagner ER. The effect of operative time on early postoperative complications in total shoulder arthroplasty: An analysis of the ACS-NSQIP database. Shoulder Elbow 2021; 13:79-88. [PMID: 33717221 PMCID: PMC7905503 DOI: 10.1177/1758573219876573] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/30/2019] [Accepted: 08/21/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Total shoulder arthroplasty has been demonstrated to be an effective treatment for arthritis of the glenohumeral joint. Prior studies have identified longer operative times as a risk factor for complications after numerous types of procedures. We hypothesized that increased operative time, in 20-min intervals, would be associated with complications following total shoulder arthroplasty. METHODS Patients undergoing total shoulder arthroplasty from 2006 to 2015 were identified from the ACS-NSQIP database. Patient demographic information, perioperative parameters, and 30-day outcomes were retrieved. Pearson's Chi-square test and multivariate Poisson regression with robust error variance were used to analyze the relationship of operative time and outcomes. RESULTS A total of 10,082 patients were included. Multivariate analysis revealed that for each increase in 20 min of operative time, there were significantly increased rates of any complication (relative risk (RR) 1.24, 95% confidence interval (CI) 1.19-1.26), anemia requiring transfusion (RR 1.33, 95%CI 1.26-1.4), peripheral nerve injury (RR 1.88, 95%CI 1.53-2.31), and urinary tract infection (RR 1.24, 95%CI 1.09-1.41). DISCUSSION This study indicates that increasing operative time confers increased risk for postoperative complications following total shoulder arthroplasty. We anticipate the results of this manuscript will be used for provider education, policy decision-making, and potentially to derive algorithms that can improve safety and efficiency in total shoulder arthroplasty. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | | | | | | | - Eric R Wagner
- Eric R Wagner, Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park Dr. S, Atlanta, GA 30324, USA.
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22
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Alenazi AM, Alshehri MM, Alothman S, Alqahtani BA, Rucker J, Sharma NK, Bindawas SM, Kluding PM. The Association of Diabetes With Knee Pain Locations, Pain While Walking, and Walking Speed: Data From the Osteoarthritis Initiative. Phys Ther 2020; 100:1977-1986. [PMID: 32750122 PMCID: PMC7596886 DOI: 10.1093/ptj/pzaa144] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Osteoarthritis (OA) and diabetes mellitus (DM) often coexist and can result in negative outcomes. DM can affect pain and walking speed in people with knee OA; however, the impact of DM on OA is understudied. The purpose of this study was to investigate the association between diabetes and knee pain locations, pain severity while walking, and walking speed in people with knee OA. METHODS A cross-sectional analysis was used. Data from 1790 individuals from the Osteoarthritis Initiative (mean [SD] age = 69 [8.7] years) with knee pain were included and grouped into knee OA and diabetes (n = 236) or knee OA only (n = 1554). Knee pain locations were categorized as no pain, localized pain, regional pain, or diffuse pain. Knee pain during a 20-m walk test was categorized as no pain, mild, moderate, or severe knee pain. Walking speed was measured using the 20-m walk test. Multinomial and linear regression analyses were performed. RESULTS Diabetes was associated with regional knee pain (odds ratio [OR] = 1.77; 95% CI = 1.01-3.11). Diabetes was associated only with moderate (OR = 1.78; 95% CI = 1.02-3.10) or severe (OR = 2.52; 95% CI = 1.01-6.28) pain while walking. Diabetes was associated with decreased walking speed (B = -0.064; 95% CI = -0.09 to -0.03). CONCLUSIONS Diabetes was associated with regional knee pain but not with localized or diffuse knee pain and was associated with moderate to severe knee pain while walking and slower walking speed in people with knee OA. IMPACT Clinicians can use a knee pain map for examining knee pain locations for people with diabetes and knee OA. Knee pain during walking and walking speed should be screened for people with knee OA and diabetes because of the influence of diabetes on these parameters in this population. LAY SUMMARY Diabetes might be associated with specific knee pain locations, pain during activities such as walking, and reduced walking speed in people with knee OA.
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Affiliation(s)
| | | | - Shaima Alothman
- Lifestyle and Health Research Center, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
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Bixby EC, Boddapati V, Anderson MJJ, Mueller JD, Jobin CM, Levine WN. Trends in total shoulder arthroplasty from 2005 to 2018: lower complications rates and shorter lengths of stay despite patients with more comorbidities. JSES Int 2020; 4:657-661. [PMID: 32939502 PMCID: PMC7479025 DOI: 10.1016/j.jseint.2020.04.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Total shoulder arthroplasty (TSA) is an increasingly common procedure. This study looked at trends in TSA using a nationwide registry, with a focus on patient demographics, comorbidities, and complications. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent TSA from 2005 to 2018. Cohorts were created based on year of surgery: 2005-2010 (N = 1116), 2011-2014 (N = 5920), and 2015-2018 (N = 16,717). Patient demographics, comorbidities, operative time, hospital length of stay, discharge location, and complications within 30 days of surgery were compared between cohorts using bivariate and multivariate analysis. Results Bivariate analysis revealed significantly more comorbidities among patients in the 2015-2018 cohort compared with the 2005-2010 cohort, specifically American Society of Anesthesiologist class III or IV (57.0% vs. 44.3%, P < .001), morbid obesity (10.8% vs. 7.8%, P < .001), diabetes (17.8% vs. 12.1%, P < .001), and chronic obstructive pulmonary disease (6.7% vs. 4.1%, P = .003). The use of regional anesthesia has decreased (5.6% in 2005-2010 vs. 2.8% in 2015-2018, P < .001), as has operative time (▵: −16 minutes, P < .001) and length of stay (▵: −0.6 days, P < .001). There were also significant decreased rates of perioperative blood transfusion (OR [odds ratio], 0.46), non-home discharge (OR, 0.79), urinary tract infection (OR, 0.47), and sepsis (OR, 0.17), (P < .001 for all comparisons) between the 2005-2010 and 2015-2018 cohorts. Conclusions Between 2005 and 2018, patients undergoing TSA had increasingly more comorbidities but experienced lower rates of short-term complications, in the context of shorter hospitalizations and more frequent discharge to home.
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Affiliation(s)
- Elise C Bixby
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Matthew J J Anderson
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - John D Mueller
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Charles M Jobin
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - William N Levine
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, USA
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Borton Z, Shivji F, Simeen S, Williams R, Tambe A, Espag M, Cresswell T, Clark D. Diabetic patients are almost twice as likely to experience complications from arthroscopic rotator cuff repair. Shoulder Elbow 2020; 12:109-113. [PMID: 32313560 PMCID: PMC7153207 DOI: 10.1177/1758573219831691] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/25/2019] [Indexed: 11/15/2022]
Abstract
AIMS Large population-based studies have demonstrated increased prevalence of rotator cuff disease amongst diabetics. Recent studies have suggested comparable clinical outcomes from rotator cuff repair despite suggestions of increased complication rates amongst diabetics. However, there is a relative paucity of studies considering the effect of diabetes upon complication rate. We aim to report and quantify the effect of diabetes on complication rates following arthroscopic rotator cuff repair. MATERIALS AND METHODS A retrospective review of a consecutive series of patients undergoing arthroscopic rotator cuff repair between January 2011 and December 2014 was performed. Diabetic status and complication data defined as infection, frozen shoulder, re-tear or re-operation were collected and interrogated. RESULTS A total of 462 patients were included at median follow-up of 5.6 years. Diabetics were significantly more likely to experience frozen shoulder (15.8% vs. 4.4%, p = 0.001), re-tear (26.3% vs. 15.6%, p = 0.042) or at least one complication following surgery (35.1% vs. 22.7%, p = 0.041) compared to non-diabetics. These equated to odds ratios of 4.03, 1.94 and 1.84, respectively. CONCLUSIONS Diabetic patients are almost twice as likely to experience complications following arthroscopic rotator cuff repair, including double the risk of repair failure and more than four times the risk of frozen shoulder.
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Affiliation(s)
- Z Borton
- Z Borton, C/o Mr D Clark, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK.
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The Association of Diabetes with Knee Pain Severity and Distribution in People with Knee Osteoarthritis using Data from the Osteoarthritis Initiative. Sci Rep 2020; 10:3985. [PMID: 32132621 PMCID: PMC7055209 DOI: 10.1038/s41598-020-60989-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/20/2020] [Indexed: 11/08/2022] Open
Abstract
Limited research has examined the association between diabetes mellitus (DM) and knee pain in people with osteoarthritis (OA). Therefore, this study aimed at examining the association between DM and knee pain severity, and to explore the association between DM and knee pain distribution (unilateral or bilateral versus no pain) in subjects with knee OA. This is a cross-sectional analysis of the baseline visit of individuals who were enrolled in the Osteoarthritis Initiative. Data of participants with knee OA were used for this analysis (n = 1319), and grouped into subjects with both knee OA and DM (n = 148) or knee OA only without DM (n = 1171). Pain severity was measured using a numeric rating scale from 0 to 10 over the past 7 and 30 days for each knee, and the more symptomatic knee with higher pain severity was chosen for analysis. DM was significantly associated with increased knee pain severity over 7 days (B 0.68; 95% CI 0.25-1.11) and over 30 days (B 0.59; 95% CI 0.17-1.01) after adjustments for all covariates, including age, gender, BMI, race, depression symptoms, composite OA score, use of pain medications, and knee injections. Multinomial regression showed that participants with knee OA and DM had 2.45 (95% CI 1.07-5.61) to 2.55 (95% CI 1.12-5.79) times higher likelihood of having unilateral and bilateral knee pain than those without DM and without knee pain. This study found that DM was associated with higher pain severity and unilateral and bilateral knee pain distribution.
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26
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Gong DJ, Wang L, Yang YY, Zhang JJ, Liu XH. Diabetes aggravates renal ischemia and reperfusion injury in rats by exacerbating oxidative stress, inflammation, and apoptosis. Ren Fail 2020; 41:750-761. [PMID: 31441362 PMCID: PMC6720228 DOI: 10.1080/0886022x.2019.1643737] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Diabetic patients are more susceptible to renal ischemia/reperfusion (I/R) injury (RI/RI) and have a poor prognosis, but the underlying mechanism remains unclear. The present study aimed to examine whether diabetes could worsen acute kidney injury induced by I/R in rats and clarify its mechanism. Control and streptozotocin-induced diabetic rats were subjected to 45 min renal pedicle occlusion followed by 24 h reperfusion. Tert-butylhydroquinone (TBHQ, 16.7 mg/kg) was administrated intraperitoneally 3 times at intervals of 8 h before ischemia. Serum and kidneys were harvested after reperfusion to evaluate renal function and histological injury. Enzyme-linked immunosorbent assays were used to test pro-inflammatory cytokines. Terminal deoxynucleotidyl-transferase-mediated dUTP nick-end labeling assays were used to detect apoptotic cells, and western blotting was performed to determine the expression of B-cell lymphoma-2 (Bcl-2), Bcl-2-associated X protein (Bax), and cleaved caspase-3, as well as oxidative stress and inflammation-related proteins, such as nuclear factor-erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), Toll-like receptor 4 (TLR4), and nuclear factor-κB (NF-κB). Compared with control animals, diabetic rats undergoing I/R exhibited more severe tubular damage and renal dysfunction. Diabetes exacerbated oxidative stress, the inflammatory response, and apoptosis after renal I/R by enhancing TLR4/NF-κB signaling and blocking the Nrf2/HO-1 pathway. RI/RI in diabetic rats was attenuated by pretreatment with TBHQ (a Nrf2 agonist), which exerted anti-inflammatory and anti-apoptotic properties by inhibiting NF-κB signaling. These findings indicate that hyperglycemia exacerbates RI/RI by intensifying oxidative stress, inflammation, and apoptosis. Antioxidant pretreatment may alleviate RI/RI in diabetic patients.
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Affiliation(s)
- Dao-Jing Gong
- Department of Urology, Renmin Hospital of Wuhan University , Wuhan , Hubei , P.R. China
| | - Lei Wang
- Department of Urology, Renmin Hospital of Wuhan University , Wuhan , Hubei , P.R. China
| | - Yuan-Yuan Yang
- Department of Urology, Renmin Hospital of Wuhan University , Wuhan , Hubei , P.R. China
| | - Jian-Jian Zhang
- Department of Urology, Renmin Hospital of Wuhan University , Wuhan , Hubei , P.R. China
| | - Xiu-Heng Liu
- Department of Urology, Renmin Hospital of Wuhan University , Wuhan , Hubei , P.R. China
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Predictors of Length of Stay and Discharge Disposition After Shoulder Arthroplasty: A Systematic Review. J Am Acad Orthop Surg 2019; 27:e696-e701. [PMID: 30499894 DOI: 10.5435/jaaos-d-18-00244] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Identifying patient factors that affect length of stay (LOS) and discharge disposition after shoulder arthroplasty is key in managing patient expectations. In this systematic review, we identify patient-specific covariates that correlate with increased LOS and need for discharge to a facility. METHODS We searched biomedical databases to identify associations between patient-specific factors and LOS and discharge disposition after shoulder arthroplasty. We included all studies involving hemiarthroplasty, anatomic shoulder arthroplasty, and reverse shoulder arthroplasty. Reported patient and provider factors were evaluated for their association with increased LOS and discharge to a facility. RESULTS Twenty-two studies were identified. Age >65 years, female sex, obesity, and reverse shoulder arthroplasty were associated with extended LOS and correlated with discharge to a facility. Greater hospital and surgeon volume were associated with decreased LOS and decreased risk of discharge to a facility. Local injection of liposomal bupivacaine combined with intravenous dexamethasone was associated with reduced LOS. DISCUSSION Patient factors affecting LOS and likelihood of discharge to a facility include age >65 years, female sex, diabetes, obesity, and reverse shoulder arthroplasty. These factors can be used to develop studies to preoperatively predict outcomes after shoulder arthroplasty and to help identify patients who may be at risk of prolonged postoperative admission. LEVEL OF EVIDENCE Prognostic level IV.
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Singh JA, Cleveland JD. Insurance Payer Type and Patient Income Are Associated with Outcomes after Total Shoulder Arthroplasty. J Rheumatol 2019; 47:589-596. [PMID: 31154417 DOI: 10.3899/jrheum.190287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To assess the independent association of insurance and patient income with total shoulder arthroplasty (TSA) outcomes. METHODS We used the 1998-2014 US National Inpatient Sample. We used multivariable-adjusted logistic regression to examine whether insurance type and the patient's median household income (based on postal code) were independently associated with healthcare use (discharge destination, hospital stay duration, total hospital charges) and in-hospital complications post-TSA based on the diagnostic codes (fracture, infection, transfusion, or revision surgery). We calculated the OR and 95% CI. RESULTS Among the 349,046 projected TSA hospitalizations, the mean age was 68.6 years, 54% were female, and 73% white. Compared to private insurance, Medicaid and Medicare (government insurance) users were associated with significantly higher adjusted OR (95% CI) of (1) discharge to a rehabilitation facility, 2.16 (1.72-2.70) and 2.27 (2.04-2.52); (2) hospital stay > 2 days, 1.65 (1.45-1.87) and 1.60 (1.52-1.69); and (3) transfusion, 1.35 (1.05-1.75) and 1.39 (1.24-1.56), respectively. Medicaid was associated with a higher risk of fracture [1.74 (1.07-2.84)] and Medicare user with a higher risk of infection [2.63 (1.24-5.57)]; neither were associated with revision. Compared to the highest income quartile, the lowest income quartile was significantly associated with (OR, 95% CI): (1) discharge to a rehabilitation facility (0.89, 0.83-0.96); (2) hospital stay > 2 days (0.84, 0.80-0.89); (3) hospital charges above the median (1.19, 1.14-1.25); (4) transfusion (0.73, 0.66-0.81); and (5) revision (0.49, 0.30-0.80), but not infection or fracture. CONCLUSION This information can help to risk-stratify patients post-TSA. Future assessments of modifiable mediators of these complications are needed.
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Affiliation(s)
- Jasvinder A Singh
- From the Birmingham Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. .,J.A. Singh, MBBS, MPH, Birmingham VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J.D. Cleveland, MS, Department of Medicine at the School of Medicine, University of Alabama at Birmingham.
| | - John D Cleveland
- From the Birmingham Veterans Affairs (VA) Medical Center; Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA.,J.A. Singh, MBBS, MPH, Birmingham VA Medical Center, and Department of Medicine at the School of Medicine, and Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham; J.D. Cleveland, MS, Department of Medicine at the School of Medicine, University of Alabama at Birmingham
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McElvany MD, Chan PH, Prentice HA, Paxton EW, Dillon MT, Navarro RA. Diabetes Disease Severity Was Not Associated with Risk of Deep Infection or Revision After Shoulder Arthroplasty. Clin Orthop Relat Res 2019; 477:1358-1369. [PMID: 31136435 PMCID: PMC6554133 DOI: 10.1097/corr.0000000000000642] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior studies have identified diabetes and disease severity (defined using hemoglobin A1c [HbA1c]) as potential risk factors for complications after shoulder arthroplasty. Evaluations of diabetes status and risk of adverse outcomes beyond the 30-day window either are limited or have not accounted for disease severity. Further, measures of diabetes severity other than HbA1c have yet to be investigated in a shoulder arthroplasty population. QUESTIONS/PURPOSES (1) Are diabetes status and glycemic control associated with adverse events, including deep infection, all-cause revision, and 90-day readmission after shoulder arthroplasty? (2) Is postoperative HbA1c associated with revision risk? (3) Is there a threshold of preoperative HbA1c that best identifies patients with diabetes who are at higher risk of 3-year deep infection, 1-year all-cause revision, or 90-day readmission? (4) Can the Adapted Diabetes Complications Severity index (aDCSI) be used as an alternative measure of diabetes severity in evaluating the risk of deep infection, all-cause revision, and 90-day readmission and identification of patients with diabetes at higher risk for these events? (5) Is there a difference between elective and traumatic shoulder arthroplasty patients? METHODS We conducted a retrospective registry-based cohort study using Kaiser Permanente's Shoulder Arthroplasty Registry (2005-2015). Primary shoulder arthroplasties were classified as patients with and without diabetes. Patients with diabetes were further evaluated using two disease severity measures (1) HbA1c, with good glycemic control classified as preoperative HbA1c < 7.0% and poor control defined as HbA1c ≥ 7.0%; and (2) aDCSI, classified as mild (score of 0-2) or severe (score ≥ 3) diabetes. Cox regression was used to evaluate the risk of deep infection and revision according to diabetes status and disease severity; conditional logistic regression was used for 90-day readmission. Time-dependent 1-year postoperative HbA1c was used to evaluate revision risk in Cox regression. All models were adjusted for covariates and stratified by elective versus trauma shoulder arthroplasty. Receiver operating characteristic curves were generated for HbA1c and aDCSI to determine whether a threshold exists to identify patients at higher risk of deep infection, all-cause revision, or 90-day readmission. The study sample consisted of 8819 patients; 7353 underwent elective shoulder arthroplasty and 1466 underwent shoulder arthroplasty due to trauma. For elective shoulder arthroplasty, 1430 patients (19%) had diabetes, and among the patients who underwent arthroplasty due to trauma, 444 (30%) had diabetes. RESULTS Patients with diabetes who underwent elective shoulder arthroplasty and had poor glycemic control had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.5; 95% CI, 1.0-2.1; p = 0.032). No association was found for patients with diabetes who underwent shoulder arthroplasty due to trauma. No association was found between postoperative HbA1c and revision risk. Receiver operating characteristic curve analysis suggested preoperative HbA1c performed poorly at differentiating adverse events. When using aDCSI, patients with severe diabetes who underwent both elective and traumatic shoulder arthroplasty had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.6; 95% CI, 1.2-2.2; p = 0.001 and OR, 1.8; 95% CI, 1.2-2.7; p = 0.005, respectively). Similar to HbA1c, the aDCSI was a poor classifier in differentiating adverse events. CONCLUSIONS Of the longer-term outcomes evaluated, more-severe diabetes was only found to be associated with an increase in 90-day readmissions after shoulder arthroplasty; a stronger association was found when using the aDCSI in identifying diabetes severity. Arbitrary cutoffs in HbA1c may not be the best method for determining risk of postoperative outcomes. Future work investigating perioperative diabetes management should work to identify and validate measures, such as the aDCSI, that better identify patients at higher risk for postoperative outcomes and, more importantly, whether outcomes can be improved by modifying these measures with targeted interventions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Matthew D McElvany
- M. D. McElvany, Department of Orthopaedics, The Permanente Medical Group, Santa Rosa, CA, USA P. H. Chan, H. A. Prentice, E. W. Paxton, Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA M. T. Dillon, Department of Orthopaedics, The Permanente Medical Group, Sacramento, CA, USA R. A. Navarro, Department of Orthopaedics, Southern California Permanente Medical Group, Harbor City, CA, USA
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Lung BE, Bisogno M, Kanjiya S, Komatsu DE, Wang ED. Early postoperative complications and discharge time in diabetic patients undergoing total shoulder arthroplasty. J Orthop Surg Res 2019; 14:9. [PMID: 30621737 PMCID: PMC6325881 DOI: 10.1186/s13018-018-1051-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 12/27/2018] [Indexed: 01/16/2023] Open
Abstract
PURPOSE With the increasing elderly population and obesity epidemic, diabetes is an important factor in arthroplasty planning. Although research suggests diabetes is associated with increased postoperative morbidity after hip and knee replacement, the effect of diabetes and varying management with insulin versus non-insulin agents on total shoulder arthroplasty (TSA) is not established. METHODS All TSAs from 2015 to 2016 were queried from the American College of Surgeons National Surgical Quality Improvement Program database. Age, gender, BMI, steroid, ASA, operative time, and smoking status were compared between all diabetics, diabetics on insulin, diabetics on non-insulin agents, and non-diabetics to account for confounding variables. Thirty-day postoperative complications, readmission rate, surgical site infection (SSI), and non-routine discharge to rehabilitation were compared using bivariate and multivariate binary logistic regression. Postoperative time to discharge between diabetic groups was analyzed using univariate ANOVA with Tukey's test. RESULTS The analysis included 7246 patients (insulin in 5% (n = 380), non-insulin in 13% (n = 922), and non-diabetics in 82% (n = 5944)). Diabetics were more likely to have an ASA ≥ 3 compared to non-diabetics (89.5% vs 50.1%; p < 0.001). Bivariate logistic regression showed statistical significance in readmission and non-routine discharge between all diabetics and non-diabetics (OR 1.7, 1.4; p = 0.001, 0.001), but there was no significance between SSI rate (0.3% vs 0.4%; p = 0.924). Multivariate logistic regression between groups showed significance in readmission between non-insulin diabetics vs non-diabetics (OR 1.5; p = 0.027), readmission and non-routine discharge in insulin vs non-diabetics (OR 2.1, 1.7; p = 0.003, < 0.001), and no significance between insulin and non-insulin diabetics. Postoperative days to discharge were 2.4, 2.0, and 1.8 days in insulin, non-insulin, and non-diabetics respectively. Mean differences were significant between all groups. CONCLUSIONS Diabetic patients are at a higher risk for readmission and non-routine discharge compared to non-diabetics. Despite no increased risk in SSI, longer postoperative discharge time in diabetics should be considered in TSA planning. TRIAL REGISTRATION Not applicable LEVEL OF EVIDENCE: Level III, case-control study.
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Affiliation(s)
- Brandon E. Lung
- School of Medicine, Stony Brook University, Stony Brook, NY USA
| | - Michael Bisogno
- Department of Orthopaedics, Stony Brook University Medical Center, HSC T-18, Room 080, Stony Brook, NY 11794-8181 USA
| | - Shrey Kanjiya
- Department of Orthopaedics, Stony Brook University Medical Center, HSC T-18, Room 080, Stony Brook, NY 11794-8181 USA
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University Medical Center, HSC T-18, Room 080, Stony Brook, NY 11794-8181 USA
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University Medical Center, HSC T-18, Room 080, Stony Brook, NY 11794-8181 USA
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Alsubheen SA, MacDermid JC, Overend TJ, Faber KJ. Does diabetes affect functional outcomes after shoulder arthroplasty? J Clin Orthop Trauma 2019; 10:544-549. [PMID: 31061587 PMCID: PMC6491921 DOI: 10.1016/j.jcot.2019.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022] Open
Affiliation(s)
- Sana'a A. Alsubheen
- School of Physical Therapy, Western University, London, Ontario, Canada,Corresponding author. School of Physical Therapy, Western University, London, Ontario, N6G 1H1, Canada.
| | - Joy C. MacDermid
- School of Physical Therapy, Western University, London, Ontario, Canada,Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Ontario, Canada
| | - Tom J. Overend
- School of Physical Therapy, Western University, London, Ontario, Canada
| | - Kenneth J. Faber
- Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Ontario, Canada
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32
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Perioperative Factors Affecting the Length of Hospitalization After Shoulder Arthroplasty. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 1:e026. [PMID: 30211358 PMCID: PMC6132328 DOI: 10.5435/jaaosglobal-d-17-00026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: To determine factors related to length of hospitalization after shoulder arthroplasty. Methods: A retrospective review identified patients who underwent shoulder arthroplasty between 2009 and 2012 at our institution. Factors were evaluated for their association with hospitalization length in a univariate model. Diagnoses were categorized into four groups: (1) osteoarthritis, cuff tear arthropathy, massive rotator cuff tear, or osteonecrosis; (2) acute fracture or fracture sequelae; (3) inflammatory arthropathy; and (4) failed shoulder arthroplasty. Significant factors were then evaluated using a multivariate model. Results: Four hundred twenty-five shoulder arthroplasties were identified (average age, 66.9 years). Arthroplasty type significantly affected hospitalization length. Significant factors for increased hospitalization using multivariate analysis were diabetes mellitus, American Society of Anesthesiologists score of 3 or 4, acute fracture or fracture sequelae diagnosis, inflammatory arthropathy, and a blood transfusion. Discussion: Independent factors using multivariate analysis are diabetes, an American Society of Anesthesiologists score ≥3, fracture or fracture sequelae, inflammatory arthritis, and a perioperative blood transfusion. Level of Evidence: Level III therapeutic study
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Abstract
Introduction Preoperative comorbidity seems to be an important factor for the functional recovery of patients after shoulder replacement, but few studies support this correlation.The purpose of this study was to clinically evaluate the influence of comorbidity in restoring function after shoulder replacement. Methods We performed a retrospective analysis of shoulder replacement accomplished at our institution from 2005 to 2016 (n = 70). Demographic data, number of comorbidities, preoperative drugs, type of arthroplasty, and postoperative complications were collected. Functional results were evaluated according to the QuickDASH questionnaire. Results QuickDASH as continuous data was directly correlated with number of drugs prior to the surgical intervention (R = 0.270, p = 0.024) and number of comorbidities (R = 0.280, p = 0,016); especially neurological disorders (R = 0.338, p = 0.004) and osteoporosis (R = 0.0242, p = 0.043). The QuickDASH score is inversely correlated with patient satisfaction (R = -0.621, p < 0.01) and with gender (male) (R = -0.469, p < 0.001).When the patients were divided into 2 equally sized groups according to the QuickDASH score, statistical significance was found between the group with the worst outcome and female sex (91.2%) (p < 0.001), neurological disorders (p = 0.004), alcohol consumption (p = 0.028) and when shoulder arthroplasty is due to proximal humeral fracture (p = 0.002). Conclusion Better functional results are obtained in patients with less comorbidities.Worse functional results are obtained in patients taking more drugs, in women, alcohol consumers and those after proximal humeral fractures. Preoperative clinical status must be optimized and the patients' comorbidities should be carefully taken into accounting order to ascertain the correct shoulder arthroplasty.
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Lack of level I evidence on how to prevent infection after elective shoulder surgery. Knee Surg Sports Traumatol Arthrosc 2018; 26:2465-2480. [PMID: 29340748 DOI: 10.1007/s00167-018-4832-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 01/05/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE Infection is a concern after all orthopedic procedures, including shoulder surgery. This systematic review of literature aimed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery. METHODS An electronic database search was performed using MEDLINE (1950-October 2017), EMBASE (1980-October 2017), CINAHL (1982-October 2017), and the Cochrane database to identify studies reporting a risk factor or preventive measure for infection after shoulder surgery. RESULTS Fifty-one studies were eligible for inclusion. Risk factors identified for infection were male sex, the presence of hair, receiving an intra-articular cortisone injection within the 3 months prior to surgery, smoking, obesity, and several comorbidities. The only preventive measure with level I evidence was for the use of chlorhexidine wipes for cleansing the skin in the days prior to surgery and for the use of ChloraPrep or DuraPrep over povodine and iodine to prep the skin at the time of surgery. Level II-IV evidence was found for other infection prevention methods such as intravenous antibiotic prophylaxis. CONCLUSION There are many risk factors associated with developing an infection after elective shoulder surgery. Many preventive measures have been described which may decrease the risk of infection; however, most lack a high level evidence to support them. The findings of this systematic review are clinically relevant as it has been shown that infection after shoulder surgery results in poor patient-reported outcomes and pose a significant financial burden. As surgeons the goal should be to prevent infections to avoid the morbidity for patients and the increased cost for society. LEVEL OF EVIDENCE IV systematic review of literature.
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Mahony GT, Werner BC, Chang B, Grawe BM, Taylor SA, Craig EV, Warren RF, Dines DM, Gulotta LV. Risk factors for failing to achieve improvement after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis. J Shoulder Elbow Surg 2018; 27:968-975. [PMID: 29482959 DOI: 10.1016/j.jse.2017.12.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 12/02/2017] [Accepted: 12/12/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although anatomic total shoulder arthroplasty (TSA) successfully improves pain and function, not all patients improve clinically. This study was conducted to determine patient-related factors for failure to achieve improvement after primary TSA for osteoarthritis at 2 years postoperatively. METHODS This prospective study reviewed an institutional shoulder registry for consecutive patients who underwent primary TSA for osteoarthritis from 2007 to 2013 with baseline and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form scores. A failed outcome was defined as (1) a failure to reach the ASES minimal clinically important difference of 16.1 points or (2) revision surgery within 2 years of the index procedure, or both. Univariate and multivariable analyses of clinical and demographic patient factors were performed using logistic regression. RESULTS Of 459 arthroplasties that met inclusion criteria, 411 were deemed successful by the aforementioned criteria, and 48 (10.5%) failed to achieve a desirable outcome. Clinical risk factors associated with failure included previous surgery to the shoulder (P = .047), presence of a torn rotator cuff (P = .025), and presence of diabetes (P = .036), after adjusting for age, sex, race, and body mass index. A higher preoperative ASES score at baseline was associated with failure (P < .001). CONCLUSION Previous shoulder surgery, a rotator cuff tear requiring repair during TSA, presence of diabetes, surgery on the nondominant arm, and a higher baseline ASES score were associated with a higher risk of failing to achieve improvement after anatomic TSA.
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Affiliation(s)
- Gregory T Mahony
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Brian C Werner
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA; Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Brenda Chang
- Epidemiology and Biostatistics, Hospital for Special Surgery, New York, NY, USA
| | - Brian M Grawe
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA; Department of Orthopaedics and Sports Medicine, University of Cincinnati Academic Health Center, Cincinnati, OH, USA.
| | - Samuel A Taylor
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Edward V Craig
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Russell F Warren
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - David M Dines
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
| | - Lawrence V Gulotta
- Sports Medicine and Shoulder Group, Hospital for Special Surgery, New York, NY, USA
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Association of Perioperative Glycemic Control With Deep Postoperative Infection After Shoulder Arthroplasty in Patients With Diabetes. J Am Acad Orthop Surg 2018; 26:e238-e245. [PMID: 29688958 DOI: 10.5435/jaaos-d-16-00784] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although diabetes mellitus (DM) has been established as a risk factor for infection after lower extremity arthroplasty, no association has been reported with shoulder arthroplasty. METHODS We queried a national database for patients with DM who underwent primary shoulder arthroplasty. We identified perioperative hemoglobin A1c (HbA1c) levels and assessed the incidence of wound complications within 6 months and deep infection that required surgical intervention within 1 year for each HbA1c level. We performed a receiver operating characteristic analysis to determine a threshold value of HbA1c. RESULTS Patients with DM had markedly higher rates of wound complications (1.4% versus 0.9%; odds ratio, 1.22; P = 0.028) and deep infection (0.7% versus 0.4%; odds ratio, 1.47; P = 0.001). The rates of wound complications (P = 0.0008) and deep postoperative infection (P = 0.002) increased markedly as the perioperative HbA1c level increased. Receiver operating characteristic analysis demonstrated an inflection point at an HbA1c level of 8.0 mg/dL (P = 0.017; sensitivity, 50%; specificity, 75%). CONCLUSIONS The risk of wound complications and deep postoperative infection in patients with DM increases as the perioperative HbA1c level increases. An HbA1c level >8.0 mg/dL could serve as a threshold for a markedly increased risk of infection. LEVEL OF EVIDENCE Therapeutic level III, case-control study, treatment study.
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Tobacco use predicts a more difficult episode of care after anatomic total shoulder arthroplasty. J Shoulder Elbow Surg 2018; 27:23-28. [PMID: 28747276 DOI: 10.1016/j.jse.2017.06.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/12/2017] [Accepted: 06/19/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the current health care environment, it is becoming increasingly important to recognize risks factors that may affect a patient's postoperative outcome. To determine the potential impact of tobacco as a risk factor, we evaluated postoperative pain, narcotic use, length of stay, reoperations, and complications in the global 90-day episode of care for patients undergoing anatomic total shoulder arthroplasty (TSA) who were current tobacco users, former users, or nonusers. METHODS Database search identified 163 patients with primary anatomic TSA done for glenohumeral arthritis; these were divided into 3 groups: current tobacco users (28), nonusers (88), and former users (47). All surgeries were done with the same technique and implants. RESULTS Patients in the current tobacco use group had significantly higher visual analog scale scores preoperatively and at 12 weeks postoperatively than nonusers and former users. Mean improvement in visual analog scale scores was significantly less in current tobacco users. Cumulative oral morphine equivalent use at 12 weeks was significantly higher in current tobacco users than in nonusers and former users. The average oral morphine equivalent per day was also significantly higher in the current tobacco users than in nonusers and former users. There were no significant differences in length of stay or complications. CONCLUSIONS Although length of stay, complication rates, hospital readmissions, and reoperation rates were not significantly different, tobacco users reported increased postoperative pain and narcotic use in the global period after TSA. Former tobacco users were found to have a postoperative course similar to that of nonusers, suggesting that discontinuation of tobacco use can improve a patient's episode of care performance after TSA.
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The impact of insulin dependence on short-term postoperative complications in diabetic patients undergoing total shoulder arthroplasty. J Shoulder Elbow Surg 2017; 26:2091-2096. [PMID: 28739297 DOI: 10.1016/j.jse.2017.05.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 05/25/2017] [Accepted: 05/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The number of total shoulder arthroplasty (TSA) procedures performed is steadily increasing, and it is important to characterize predictors of postoperative complications for risk assessment models. Whereas diabetes has been associated with increased morbidity after TSA, the impact of insulin dependence on the risk profile of diabetic patients has not been described. METHODS The National Surgical Quality Improvement Program database from 2011-2014 was used to identify 5918 TSA cases. Patients were categorized as non-diabetes mellitus (non-DM), non-insulin-dependent diabetes mellitus (NIDDM), or insulin-dependent diabetes mellitus (IDDM). Thirty-day postoperative complication rates, length of stay (LOS), and readmission rates were compared across the diabetes groups. Multivariable logistic regression adjusting for demographics and comorbidity burden was performed to determine the independent association between insulin dependence and postoperative outcomes. RESULTS In bivariate analysis, NIDDM and IDDM were associated with multiple postoperative complications, including stroke, sepsis, wound complications, blood transfusion, and extended LOS. With multivariable logistic regression, however, NIDDM patients did not have significantly greater odds of any study end point relative to non-DM patients. IDDM patients had significantly greater odds for having any postoperative complication (odds ratio [OR], 1.53), stroke (OR, 13.63), blood transfusion (OR, 1.67), and extended LOS (OR, 1.38). CONCLUSIONS After adjustment for demographics and comorbidity burden, NIDDM patients had risk profiles similar to those of non-DM patients. IDDM was an independent predictor of multiple postoperative complications. Insulin dependence should be considered in the preoperative risk assessment of diabetic patients undergoing TSA.
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Brophy RH, Huston LJ, Wright RW, Nwosu SK, Kaeding CC, Parker RD, Andrish JT, Marx RG, McCarty EC, Amendola A, Wolf BR, Dunn WR, Wolcott ML, Spindler KP. Outcomes of ACL Reconstruction in Patients with Diabetes. Med Sci Sports Exerc 2017; 48:969-73. [PMID: 26765634 DOI: 10.1249/mss.0000000000000876] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Diabetes has been associated with adverse outcomes after various types of surgery. There are no previously published data regarding the effect of diabetes on outcomes from anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to test the hypotheses that diabetes is associated with worse clinical outcomes and a higher prevalence of subsequent surgeries after ACLR. METHODS Anterior cruciate ligament-deficient patients (n = 2198) undergoing unilateral ACLR from a multicenter prospective study were included. Patients who self-reported diabetes on the basis of comorbidity questions before surgery were identified from the database. They were compared with the remainder of the cohort who did not self-report diabetes. All patients were followed up for a minimum of 2 yr after their index surgery. A minimum 2-yr follow-up was attained on 1905/2198 (87%) via completed outcome questionnaires and 2096/2198 (95%) regarding subsequent surgery. The primary outcome measures were three validated outcome instruments. The secondary outcome measure was the incidence of additional surgery on the ipsilateral and contralateral knees. RESULTS Patients with diabetes had a significantly higher activity level at 2 yr (OR = 2.96; 95% CI, 1.30-6.77; P = 0.01), but otherwise slightly worse clinical outcomes, compared with patients without diabetes (OR range = 0.42-0.59). The prevalence of subsequent surgeries in patients with diabetes was not significantly different from the prevalence in patients without diabetes. CONCLUSIONS Patients with diabetes maintain a higher activity level after ACLR despite slightly lower patient-reported outcome scores compared with patients without diabetes and do not have a higher rate of subsequent surgery.
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Affiliation(s)
- Robert H Brophy
- 1Department of Orthopaedics, Washington University in St. Louis, Chesterfield, MO; 2Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN; 3Department of Orthopaedics, Washington University in St. Louis, St. Louis, MO; 4Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN; 5Department of Orthopaedics, The Ohio State University, Columbus, OH; 6Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH; 7Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY; 8Department of Orthopaedics, University of Colorado Denver, Denver, CO; 9Department of Orthopaedic Surgery, Duke University, Durham, NC; 10Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA; and 11Department of Orthopaedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Tangtiphaiboontana J, Cortez A, Barry JJ, Sing DC, Ma CB, Feeley BT, Zhang AL. Effects of Prior Cervical Fusion on Patient Outcomes After Shoulder Arthroplasty. J Shoulder Elb Arthroplast 2017. [DOI: 10.1177/2471549217729282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Abigail Cortez
- San Francisco School of Medicine, University of California, San Francisco, California
| | - Jeffrey J Barry
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, North Carolina
| | - David C Sing
- Department of Orthopaedic Surgery, Boston University and Boston Medical Center, Boston, Massachusetts
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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Basques BA, Erickson BJ, Leroux T, Griffin JW, Frank RM, Verma NN, Romeo AA. Comparative outcomes of outpatient and inpatient total shoulder arthroplasty: an analysis of the Medicare dataset. Bone Joint J 2017; 99-B:934-938. [PMID: 28663400 DOI: 10.1302/0301-620x.99b7.bjj-2016-0976.r1] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 03/22/2017] [Indexed: 12/14/2022]
Abstract
AIMS The aim of the present study was to compare the 30- and 90-day re-admission rates and complication rates of outpatient and inpatient total shoulder arthroplasty (TSA). PATIENTS AND METHODS The United States Medicare Standard Analytical Files database was questioned to identify patients who had undergone outpatient or inpatient TSA between 2005 and 2012. Patient characteristics were compared between the two groups using chi-squared analysis. Multivariate logistic regression analysis was used to control for differences in baseline patient characteristics and to compare the two groups in terms of post-operative complications within 90 days and re-admission within 30 days and 90 days. RESULTS A total of 123 347 Medicare subscribers underwent TSA between 2005 and 2012; 3493 (2.8%) had the procedure performed as an outpatient. A significantly greater proportion of patients who underwent TSA as inpatients were women, had a history of smoking, and had a greater incidence of medical comorbidity including diabetes, coronary artery disease, congestive heart failure, and chronic kidney disease (p < 0.05 for all). Re-admission rates were significantly higher for inpatients at both 30 days (0.83% versus 0.60%, p = 0.016, odds ratio 1.8) and 90 days (2.87% versus 2.04%, p < 0.001, odds ratio 1.8). Complications, including thromboembolic events (p < 0.001) and surgical site infection (p = 0.002), were significantly higher in inpatients. CONCLUSION Patients who underwent TSA on an outpatient basis were overall younger and healthier than those who had inpatient surgery, which suggests that patient selection was taking place. After controlling for age, gender, and medical conditions, patients who underwent TSA as outpatients had lower rates of 30- and 90-day re-admission and a lower rate of complications than inpatients. Cite this article: Bone Joint J 2017;99-B:934-8.
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Affiliation(s)
- B A Basques
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, USA
| | - B J Erickson
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, USA
| | - T Leroux
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, USA
| | - J W Griffin
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, USA
| | - R M Frank
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, USA
| | - N N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, USA
| | - A A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, USA
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Rosas S, Sabeh KG, Buller LT, Law TY, Kalandiak SP, Levy JC. Comorbidity effects on shoulder arthroplasty costs analysis of a nationwide private payer insurance data set. J Shoulder Elbow Surg 2017; 26:e216-e221. [PMID: 28139384 PMCID: PMC6386450 DOI: 10.1016/j.jse.2016.11.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/15/2016] [Accepted: 11/25/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures. METHODS We conducted a retrospective query of a single private payer insurance claims database using PearlDiver (Warsaw, IN, USA) from 2010 to 2014. Our search included the Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for total shoulder arthroplasty (TSA), hemiarthroplasty, and reverse shoulder arthroplasty (RSA). Medical comorbidities were also searched for through International Classification of Diseases codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease, cirrhosis, depression, and chronic kidney disease (excluding end-stage renal disease). The reimbursement charges of the day of surgery, 90-day global period, and 90-day period excluding the initial surgical day of each comorbidity were analyzed and compared. Statistical analysis was conducted through analyses of variance or Kruskal-Wallis test. RESULTS Comorbidities did not have a significant effect on same-day reimbursements but instead caused a significant effect on the subsequent 89-day (interval) and 90-day reimbursements in the TSA and RSA cohorts. For TSA and RSA, the highest reimbursement costs during the 90-day period after surgery were seen with the diagnosis of hepatitis C, followed by atrial fibrillation and later chronic obstructive pulmonary disease. For hemiarthroplasty, the same was true in the following order: hepatitis C, cirrhosis, and atrial fibrillation. CONCLUSION Shoulder arthroplasty reimbursements are significantly affected by comorbidities at time intervals following the initial surgical day.
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Affiliation(s)
- Samuel Rosas
- Orthopedic Research Institute, Holy Cross Hospital, Fort Lauderdale, FL, USA,Department of Orthopedics and Rehabilitation, University of Miami, Miami, FL, USA
| | - Karim G. Sabeh
- Department of Orthopedics and Rehabilitation, University of Miami, Miami, FL, USA
| | - Leonard T. Buller
- Department of Orthopedics and Rehabilitation, University of Miami, Miami, FL, USA
| | - Tsun Yee Law
- Orthopedic Research Institute, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Steven P. Kalandiak
- Department of Orthopedics and Rehabilitation, University of Miami, Miami, FL, USA
| | - Jonathan C. Levy
- Orthopedic Research Institute, Holy Cross Hospital, Fort Lauderdale, FL, USA,Reprint requests: Jonathan C. Levy, MD, Orthopedic Research Institute, Holy Cross Hospital, 5597 N Dixie Highway, Fort Lauderdale, FL 33334, USA. (J.C. Levy)
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Upadhyaya SG, Murphree DH, Ngufor CG, Knight AM, Cronk DJ, Cima RR, Curry TB, Pathak J, Carter RE, Kor DJ. Automated Diabetes Case Identification Using Electronic Health Record Data at a Tertiary Care Facility. Mayo Clin Proc Innov Qual Outcomes 2017; 1:100-110. [PMID: 30225406 PMCID: PMC6135013 DOI: 10.1016/j.mayocpiqo.2017.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective To develop and validate a phenotyping algorithm for the identification of patients with type 1 and type 2 diabetes mellitus (DM) preoperatively using routinely available clinical data from electronic health records. Patients and Methods We used first-order logic rules (if-then-else rules) to imply the presence or absence of DM types 1 and 2. The “if” clause of each rule is a conjunction of logical and, or predicates that provides evidence toward or against the presence of DM. The rule includes International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes, outpatient prescription information, laboratory values, and positive annotation of DM in patients’ clinical notes. This study was conducted from March 2, 2015, through February 10, 2016. The performance of our rule-based approach and similar approaches proposed by other institutions was evaluated with a reference standard created by an expert reviewer and implemented for routine clinical care at an academic medical center. Results A total of 4208 surgical patients (mean age, 52 years; males, 48%) were analyzed to develop the phenotyping algorithm. Expert review identified 685 patients (16.28% of the full cohort) as having DM. Our proposed method identified 684 patients (16.25%) as having DM. The algorithm performed well—99.70% sensitivity, 99.97% specificity—and compared favorably with previous approaches. Conclusion Among patients undergoing surgery, determination of DM can be made with high accuracy using simple, computationally efficient rules. Knowledge of patients’ DM status before surgery may alter physicians’ care plan and reduce postsurgical complications. Nevertheless, future efforts are necessary to determine the effect of first-order logic rules on clinical processes and patient outcomes.
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Key Words
- CCW, Chronic Condition Data Warehouse
- DDC, Durham Diabetes Coalition
- DM, diabetes mellitus
- EHR, electronic health record
- HbA1c of NYC, Hemoglobin A1c of New York City
- HbA1c, hemoglobin A1c
- ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- MICS, Mayo Integrated Clinical Systems
- NLP, natural language processing
- SUPREME-DM, Surveillance, Prevention, and Management of Diabetes Mellitus
- T1DM, type 1 diabetes mellitus
- T2DM, type 2 diabetes mellitus
- eMERGE, Electronic Medical Records and Genomics
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Affiliation(s)
| | | | - Che G Ngufor
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Alison M Knight
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daniel J Cronk
- Department of Information Technology, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Timothy B Curry
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | | | - Rickey E Carter
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Theodoulou A, Krishnan J, Aromataris E. The influence of diabetes mellitus and obesity on upper limb arthroplasty outcomes: a systematic review protocol. ACTA ACUST UNITED AC 2017; 15:3-9. [PMID: 28085720 DOI: 10.11124/jbisrir-2016-002940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this review is to locate and synthesize the best available evidence investigating the impact of selected comorbidities on upper limb arthroplasty outcomes.The review question is: Are patients with diabetes mellitus or obesity at an increased risk of complications and/or poorer postoperative outcomes following total shoulder, reverse total shoulder and total elbow arthroplasty?
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Affiliation(s)
- Annika Theodoulou
- 1The International Musculoskeletal Research Institute Inc., Adelaide, Australia 2Department of Orthopaedics, School of Medicine, Flinders University, Adelaide, Australia 3The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Ekinci EI, Kong A, Churilov L, Nanayakkara N, Chiu WL, Sumithran P, Djukiadmodjo F, Premaratne E, Owen-Jones E, Hart GK, Robbins R, Hardidge A, Johnson D, Baker ST, Zajac JD. Using Automated HbA1c Testing to Detect Diabetes Mellitus in Orthopedic Inpatients and Its Effect on Outcomes. PLoS One 2017; 12:e0168471. [PMID: 28060831 PMCID: PMC5218571 DOI: 10.1371/journal.pone.0168471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 12/01/2016] [Indexed: 01/29/2023] Open
Abstract
Aims The prevalence of diabetes is rising, and people with diabetes have higher rates of musculoskeletal-related comorbidities. HbA1c testing is a superior option for diabetes diagnosis in the inpatient setting. This study aimed to (i) demonstrate the feasibility of routine HbA1c testing to detect the presence of diabetes mellitus, (ii) to determine the prevalence of diabetes in orthopedic inpatients and (iii) to assess the association between diabetes and hospital outcomes and post-operative complications in orthopedic inpatients. Methods All patients aged ≥54 years admitted to Austin Health between July 2013 and January 2014 had routine automated HbA1c measurements using automated clinical information systems (CERNER). Patients with HbA1c ≥6.5% were diagnosed with diabetes. Baseline demographic and clinical data were obtained from hospital records. Results Of the 416 orthopedic inpatients included in this study, 22% (n = 93) were known to have diabetes, 4% (n = 15) had previously unrecognized diabetes and 74% (n = 308) did not have diabetes. Patients with diabetes had significantly higher Charlson comorbidity scores compared to patients without diabetes (median, IQR; 1 [0,2] vs 0 [0,0], p<0.001). After adjusting for age, gender, comorbidity score and estimated glomerular filtration rate, no significant differences in the length of stay (IRR = 0.92; 95%CI: 0.79–1.07; p = 0.280), rates of intensive care unit admission (OR = 1.04; 95%CI: 0.42–2.60, p = 0.934), 6-month mortality (OR = 0.52; 95%CI: 0.17–1.60, p = 0.252), 6-month hospital readmission (OR = 0.93; 95%CI: 0.46–1.87; p = 0.828) or any post-operative complications (OR = 0.98; 95%CI: 0.53–1.80; p = 0.944) were observed between patients with and without diabetes. Conclusions Routine HbA1c measurement using CERNER allows for rapid identification of inpatients admitted with diabetes. More than one in four patients admitted to a tertiary hospital orthopedic ward have diabetes. No statistically significant differences in the rates of hospital outcomes and post-operative complications were identified between patients with and without diabetes.
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Affiliation(s)
- Elif I. Ekinci
- University of Melbourne, Department of Medicine, Austin Health, Melbourne, Australia
- Department of Endocrinology, Austin Health, Melbourne, Australia
- Menzies School of Health Research, Darwin, Australia
- * E-mail:
| | - Alvin Kong
- University of Melbourne, Department of Medicine, Austin Health, Melbourne, Australia
| | - Leonid Churilov
- The Florey Institute of Neuroscience & Mental Health, Melbourne, Australia
| | | | - Wei Ling Chiu
- Department of Endocrinology, Austin Health, Melbourne, Australia
| | - Priya Sumithran
- University of Melbourne, Department of Medicine, Austin Health, Melbourne, Australia
- Department of Endocrinology, Austin Health, Melbourne, Australia
| | | | | | - Elizabeth Owen-Jones
- Austin Centre for Applied Clinical Informatics, Austin Health, Melbourne, Australia
| | | | - Raymond Robbins
- Austin Centre for Applied Clinical Informatics, Austin Health, Melbourne, Australia
| | - Andrew Hardidge
- Department of Orthopaedic Surgery, Austin Health, Melbourne, Australia
| | - Douglas Johnson
- Department of General Medicine, Austin Health, Melbourne, Australia
| | - Scott T. Baker
- Department of Endocrinology, Austin Health, Melbourne, Australia
| | - Jeffrey D. Zajac
- University of Melbourne, Department of Medicine, Austin Health, Melbourne, Australia
- Department of Endocrinology, Austin Health, Melbourne, Australia
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Hatta T, Werthel JD, Wagner ER, Itoi E, Steinmann SP, Cofield RH, Sperling JW. Effect of smoking on complications following primary shoulder arthroplasty. J Shoulder Elbow Surg 2017; 26:1-6. [PMID: 27810265 DOI: 10.1016/j.jse.2016.09.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 09/02/2016] [Accepted: 09/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to examine the effect of smoking on the incidence of complications after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). METHODS All patients who underwent primary TSA or RSA at our institution between 2002 and 2011 and had a minimum 2-year follow-up were included. Smoking status was assessed at the time of surgery. Current smokers, former smokers, and nonsmokers were compared for periprosthetic infection, fractures (intraoperative and postoperative), and loosening after surgery. RESULTS The cohort included 1834 shoulders in 1614 patients (814 in smokers and 1020 in nonsmokers). Complications occurred in 73 patients (75 shoulders; 44 in smokers and 31 in nonsmokers). There were 20 periprosthetic infections (16 in smokers and 4 in nonsmokers), 27 periprosthetic fractures (14 in smokers and 13 in nonsmokers), and 28 loosenings (14 in smokers and 14 in nonsmokers). Smokers had lower periprosthetic infection-free survival rates (95.3%-99.4% at 10 years; P = .001) and overall complication-free survival rates (78.4%-90.2%; P = .012) than nonsmokers. Multivariable analyses showed that both current and former smokers had significantly higher risk of periprosthetic infection in comparison with nonsmokers (hazard ratio [HR], 7.27 and 4.56, respectively). In addition, current smokers showed a higher risk of postoperative fractures than both former smokers (HR, 3.63) and nonsmokers (HR, 6.99). CONCLUSIONS This study demonstrates that smoking is a significant risk factor of complications after TSA and RSA. These findings emphasize the need for preoperative collaborative interventions, including smoking cessation programs.
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Affiliation(s)
- Taku Hatta
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Eric R Wagner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Eiji Itoi
- Department of Orthopedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Robert H Cofield
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - John W Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Hyperglycemia Aggravates Hepatic Ischemia Reperfusion Injury by Inducing Chronic Oxidative Stress and Inflammation. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2016; 2016:3919627. [PMID: 27656261 PMCID: PMC5021880 DOI: 10.1155/2016/3919627] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 06/28/2016] [Accepted: 07/12/2016] [Indexed: 12/29/2022]
Abstract
Aim. To investigate whether hyperglycemia will aggravate hepatic ischemia reperfusion injury (HIRI) and the underlying mechanisms. Methods. Control and streptozotocin-induced diabetic Sprague-Dawley rats were subjected to partial hepatic ischemia reperfusion. Liver histology, transferase, inflammatory cytokines, and oxidative stress were assessed accordingly. Similarly, BRL-3A hepatocytes were subjected to hypoxia/reoxygenation (H/R) after high (25 mM) or low (5.5 mM) glucose culture. Cell viability, reactive oxygen species (ROS), and activation of nuclear factor-erythroid 2-related factor 2 (Nrf2) and nuclear factor of kappa light polypeptide gene enhancer in B-cells (NF-κB) were determined. Results. Compared with control, diabetic rats presented more severe hepatic injury and increased hepatic inflammatory cytokines and oxidative stress. HIRI in diabetic rats could be ameliorated by pretreatment of N-acetyl-L-cysteine (NAC) or apocynin. Excessive ROS generation and consequent Nrf2 and NF-κB translocation were determined after high glucose exposure. NF-κB translocation and its downstream cytokines were further increased in high glucose cultured group after H/R. While proper regulation of Nrf2 to its downstream antioxidases was observed in low glucose cultured group, no further induction of Nrf2 pathway by H/R after high glucose culture was identified. Conclusion. Hyperglycemia aggravates HIRI, which might be attributed to chronic oxidative stress and inflammation and potential malfunction of antioxidative system.
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of our study was to evaluate the differential impact of insulin dependence on lumbar surgery outcomes, including surgical and medical complications, total length of hospital stay, nonhome bound discharge, and unplanned readmissions. SUMMARY OF BACKGROUND DATA Although the negative effects of diabetes mellitus (DM) on joint arthroplasty outcomes are well documented, there is a paucity of studies evaluating those on spine surgery. METHODS Data files from 2005 to 2013 were reviewed and to collect data on patients undergoing lumbar spine surgery. χ tests, for categorical variables, and one-way ANOVA, for continuous variables, were used to identify differences in perioperative variables among patients who do not have DM, who are insulin-independent (NIDDM), and who are insulin-dependent (IDDM). Binary logistic regression analysis assessed the effect of DM status on surgical outcomes. Significance was defined as P < 0.05. RESULTS Significant differences were detected among the three groups in surgical and medical complication and unplanned readmission rates, as well as rates of nonhome-bound discharge. The NIDDM and IDDM groups experienced significantly longer mean total hospital length of stay at 3.2 and 3.9 days, respectively, compared with 2.6 days for nondiabetics (P < 0.0001). Both NIDDM (OR, 1.226; P = 0.017) and IDDM (OR, 1.499; P < 0.0001) independently increased the risk for medical complications, whereas only IDDM (OR, 2.429; P < 0.0001) was associated with surgical complications. IDDM was found to be associated with increased rate of 30-day unplanned readmission (OR, 1.353; P = 0.005). Neither NIDDM nor IDDM had an effect on the likelihood of nonhome discharge. CONCLUSION We hope our findings improve risk stratification efforts and informed consent for two DM patient populations. In addition, our findings advocate for appropriate risk stratification of a subgroup DM patients who are dependent on insulin and are at greater risk for surgical morbidity. LEVEL OF EVIDENCE 3.
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Manders IG, Stoecklein K, Lubach CHC, Bijl-Oeldrich J, Nanayakkara PWB, Rauwerda JA, Kramer MHH, Eekhoff EMW. Shift in responsibilities in diabetes care: the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT). Diabet Med 2016; 33:761-7. [PMID: 26333117 DOI: 10.1111/dme.12899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 01/05/2023]
Abstract
AIMS To investigate the feasibility, safety and efficacy of the Nurse-Driven Diabetes In-Hospital Treatment protocol (N-DIABIT), which consists of nurse-driven correctional therapy, in addition to physician-guided basal therapy, and is carried out by trained ward nurses. METHODS Data on 210 patients with diabetes consecutively admitted in the 5-month period after the introduction of N-DIABIT (intervention group) were compared with the retrospectively collected data on 200 consecutive patients with diabetes admitted in the 5-month period before N-DIABIT was introduced (control group). Additional per-protocol analyses were performed in patients in whom mean patient-based protocol adherence was ≥ 70% (intervention subgroup, n = 173 vs. control subgroup, n = 196). RESULTS There was no difference between the intervention and the control group in mean blood glucose levels (8.9 ± 0.1 and 9.1 ± 0.2 mmol/l, respectively; P = 0.38), consecutive hyperglycaemic (blood glucose ≥ 10.0 mmol/l) episodes; P = 0.15), admission duration (P = 0.79), mean number of blood glucose measurements (P = 0.21) and incidence of severe hypoglycaemia (P = 0.29). Per-protocol analyses showed significant reductions in mean blood glucose levels and consecutive hypoglycaemia and hyperglycaemia in the intervention compared with the control group. CONCLUSIONS Implementation of N-DIABIT by trained ward nurses in non-intensive care unit diabetes care is feasible, safe and non-inferior to physician-driven care alone. High protocol adherence was associated with improved glycaemic control.
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Affiliation(s)
- I G Manders
- Section of Endocrinology, VU University Medical Centre, Amsterdam, The Netherlands
| | - K Stoecklein
- Department of Anesthesiology, VU University Medical Centre, Amsterdam, The Netherlands
| | - C H C Lubach
- Diabetes Centre, VU University Medical Centre, Amsterdam, The Netherlands
| | - J Bijl-Oeldrich
- Diabetes Centre, VU University Medical Centre, Amsterdam, The Netherlands
| | - P W B Nanayakkara
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - J A Rauwerda
- Department of Vascular Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - M H H Kramer
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - E M W Eekhoff
- Section of Endocrinology, VU University Medical Centre, Amsterdam, The Netherlands
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50
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Polderman JAW, de Groot FA, Zamanbin A, Hollmann MW, Holleman F, Preckel B, Hermanides J. An automated reminder for perioperative glucose regulation improves protocol compliance. Diabetes Res Clin Pract 2016; 116:80-2. [PMID: 27321319 DOI: 10.1016/j.diabres.2016.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/03/2016] [Accepted: 04/15/2016] [Indexed: 11/17/2022]
Abstract
A growing proportion of patients presenting for surgery have diabetes. Unfortunately, perioperative diabetes protocol compliance is low. Using digitalization of the perioperative environment, an automated reminder in the preoperative assessment platform proved to increase compliance and we advocate its use throughout the perioperative process.
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Affiliation(s)
| | - Fleur A de Groot
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Alaleh Zamanbin
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology and Laboratory of Experimental Intensive Care and Anesthesiology L.E.I.C.A., Academic Medical Centre, Amsterdam, The Netherlands
| | - Frits Holleman
- Department of Internal Medicine, Academic Medical Centre, Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anesthesiology and Laboratory of Experimental Intensive Care and Anesthesiology L.E.I.C.A., Academic Medical Centre, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Academic Medical Centre, Amsterdam, The Netherlands
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