Patient Attitudes Regarding High-Risk Low-Volume Surgery

INTRODUCTION

Significant controversy surrounds the "Take the Volume Pledge" campaign and the use of volume as a surrogate for quality. However, data on patient-reported attitudes toward this initiative are limited. We sought to examine patient preferences and perceptions regarding the location of their health care and the factors that may influence that decision.

MATERIALS AND METHODS

After IRB approval, we conducted a prospective study at a 109-bed tertiary referral military hospital, which performs 8 of the 10 defined high-risk low-volume surgeries. From 2018 to 2019, patients from all specialties completed anonymous questionnaires during preoperative registration. Univariate and multivariable analyses were performed to identify factors associated with patients desiring referral. Additional investigations into patient risk tolerance and thresholds regarding hospital/surgeon volume, postoperative complication risk, and cancer survival were analyzed.

RESULTS

Six hundred and three surveys were completed and available for analysis. Only 1.5% expressed a desire to seek care from a high-volume subspecialist. On multivariable analysis, the only independent predictors for patients desiring referral were perceived displeasure with their care (P = .02) and not being asked their opinion on where to have surgery (P = .04). Most patients (57.6%) expressed willingness to stay at their home institution even if only half of the recommended volume of surgeries are performed. Of patients, 49.8% would accept a 10% increased risk of postoperative complications, and 55.3% would accept decreased long-term cancer survival to stay at their home institution.

CONCLUSIONS

Only 1.5% of our population desired referral to a high-volume center. Our study showed that an open discussion and shared decision-making are the most important factors for patients when deciding where to have surgery. Moreover, most were willing to accept greater risk and lower volume to stay at their local hospital. Although performed at a single military facility, this study showed that patient preferences are extremely important and should not be understudied.

Does endoscopy at the time of revisional bariatric surgery decrease complication rates? an analysis of the NSQIP database

BACKGROUND

Endoscopy is performed routinely during bariatric surgery. It is often used for provocative testing and intraluminal inspection during Roux-en-Y gastric bypass (RNYGB) and sleeve gastrectomy (SG). Recent publications would indicate about one-quarter of bariatric cases are performed with concurrent endoscopy, resulting in a slight increase in time but no increase in complications within 30 days compared with cases where no endoscopy is performed. Do these results persist for endoscopy during revisional bariatric surgery (RBS)?

METHODS

An analysis of the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) was conducted for the years 2005-2017. Seventeen postoperative outcomes were analyzed in this database. A 1:1 propensity score matching analysis was completed for 13 patient comorbidities and demographics. A McNemar's test for paired categorical variables and a paired t-test for continuous variables were completed, with a significant P value of 0.05. The results were reported as the frequency and percentage for categorical variables and the mean (± standard deviation) for continuous variables.

RESULTS

A total of 7249 RBS cases were identified. After propensity score matching for patient comorbidities and demographics 2329 cases remained. Esophagogastroduodenoscopy (EGD) was performed in 375 (16%) of these patients. There were no differences in complication rates between the two groups.

CONCLUSIONS

Similar to non-revisional bariatric surgery, there is no difference in 30-day postoperative complications when endoscopy is performed in RBS. Endoscopy is performed in about one-sixth of RBS cases.

Gender Differences in Medical Specialty Decision Making: The Importance of Mentorship

INTRODUCTION

While there have been many studies reviewing factors considered by medical students in deciding on a specialty, there is a relative paucity of data in how these factors differ between males and females. The aim of this study was to determine if there are differences in how male and female medical students' value various factors in choosing a career path in medicine.

METHODS

A survey of basic demographic information and a Likert-based questionnaire addressing various factors in specialty choice was sent to all military medical students in the class of 2019.

RESULTS

The survey response rate was 30%. Amongst the students that completed the survey, 72% were male and 28% were female. The majority of students were less than 27 years old (52%) and Caucasian (76%). Female medical students placed more importance in exposure to third year clerkships (P = 0.004) and gender diversity within the specialty (P = 0.03) than their male counterparts. There was no statistical difference in opinions of significant others or family members, desire to have a family, or having a well-balanced life between female, and male medical students.

CONCLUSION

Female medical students valued exposure to third year clerkships and gender diversity more than their male colleagues when choosing a future specialty. These findings suggest that a strategic focus should be placed on mentoring female medical students in order to promote a diverse medical workforce.

Synthesis, Crystallization, and Electrochemical Characterization of Room Temperature Ionic Liquid Bromidostannates(II/IV)

Ionic liquids (IL) are valuable in a variety of applications due to their high electrochemical stability and physical properties. Using the cation 1-methyl-3-octylimidazolium, [OMIM]⁺, the bromidostannate RTIL [OMIM][Sn^+IIBr₃], "undercooled melt" [OMIM][Sn^+IVBr₅], and IL [OMIM]₂[Sn^+IVBr₆] were synthesized. The uncommon solid state structure of [SnBr₅]^- was elucidated in the form of its RTIL salt. Additionally, the IL based on tribromine-monoanion [OMIM][Br₃] was used to dissolve metallic Sn, selectively resulting in the formation of [SnBr₃]^- as confirmed by Raman spectroscopy. Subsequent cyclic voltammograms (CV) of [SnBr₃]^- confirmed the deposition potential of metallic Sn and renewal of the polybromide [Br₃]^-. The RTIL bromidostannates were stable compounds, making a selective electrochemical investigation of the deposition of metallic Sn(0) to Sn(+II)/Sn(+IV) redox process possible, via conductance and CV measurements. The CVs of the RTILs and of solutions in propylene carbonate had the redox couples of Sn(0)/[Sn^+IIBr₃]^-/[Sn^+IVBr₅]^-.

Synthesis and Characterization of Poly(hydrogen halide) Halogenates (-I)

Herein, we report the synthesis and characterization of a variety of novel poly(hydrogen halide) halogenates (-I). The bifluoride ion, which is known to have the highest hydrogen bond energy of ≈160 kJ mol-1 , is the most famous among many examples of [X(HX)n ]- anions (X=F, Cl) known in the literature. In contrast, little is known about poly(hydrogen halide) halogenates containing two different halogens, ([X(HY)n ]- ). In this work we present the synthesis of anions of the type [X(HY)n ]- (X=Br, I, ClO4 ; Y=Cl, Br, CN) stabilized by the [PPh4 ]+ and [PPN]+ cation. The obtained compounds have been characterized by single-crystal X-ray diffraction, Raman spectroscopy and quantum-chemical calculations. In addition, the behavior of halide ions in hydrogen fluoride was investigated by using experimental and quantum-chemical methods in order to gain knowledge on the acidity of hydrogen halides in HF.

The safety of additional procedures at the time of revisional bariatric surgery

BACKGROUND

The third most common bariatric operation is revisions of previous bariatric surgeries. Patients may require revisional bariatric surgery for inadequate weight loss or complications. Patients undergoing revisional bariatric surgery may also have other conditions that require surgery. This study evaluates the 30-day postoperative outcomes of patients undergoing revisional bariatric surgery and additional procedures.

METHODS

A retrospective review of the 2005-2017 ACS NSQIP database identified 7249 patients who underwent revisional bariatric surgery with 3115 (48%) occurring with additional procedures. A 1:1 propensity score matching analysis was completed for 13 patient demographics and comorbidities. Postoperative variables were then analyzed as available in the NSQIP database. Subgroup analyses were completed for those undergoing paraesophageal hernia repair and abdominal wall hernia repair at the time of revisional bariatric surgery.

RESULTS

The most common bariatric surgery that was converted or revised was the AGB (57%) and the most common additional procedure was paraesophageal hernia repair (n = 181, 15%). When additional procedures were completed at the time of revisional bariatric surgery, overall complications (p < 0.001), major systemic complications (p = 0.009) and mortality/major complications (p = 0.018) were all significantly increased. After matching for operative time, only postoperative sepsis remained significant with additional procedures (p = 0.042). In the subgroup analyses on paraesophageal and abdominal wall hernias there were no differences in postoperative complications after matching for operative time.

CONCLUSIONS

Additional procedures, including paraesophageal and abdominal wall hernia repairs at the time of revisional bariatric surgery increase postoperative complications. Operative time was longer when additional procedures were performed. Postoperative sepsis was the only complication which remained significant after propensity matching when additional procedures are completed at the time of revisional bariatric surgery.

Femoral Hernias: Analysis of Preoperative Risk Factors and 30-Day Outcomes of Initial Groin Hernias Using ACS-NSQIP

Femoral hernias are infrequently encountered groin hernias. The purpose of this study was to describe the natural history of femoral hernias by evaluating patient demographics, comorbidities, operative details, 30-day mortality, and risk factors for postoperative complications compared with inguinal hernias and in reducible versus incarcerated hernias. Overall 5360 femoral hernia repairs and 183,173 inguinal hernia repairs were identified using the 2005 to 2015 American College of Surgeon-National Surgical Quality Improvement Program's database. Univariate analysis was used to compare patient characteristics between femoral and inguinal hernias and between reducible and nonreducible femoral hernias. Multivariable logistic regression analyses were used to identify risk factors for 30-day postoperative complications after repair. Femoral hernias accounted for 2.8 per cent of initial groin hernias and 18.9 per cent of all groin hernias in females. A total of 56.5 per cent of initial femoral hernias were nonreducible and these patients were significantly older. Rates of small bowel resection (5.7 vs 0.3%, P < 0.0001), exploratory laparotomy (2.5% vs 0.4%, P < 0.0001), and diagnostic laparoscopy (2.0% vs 0.7%, P < 0.0001) were significantly higher in incarcerated femoral hernias compared with reducible femoral hernias. There were significantly higher rates of unplanned return to the OR, postoperative sepsis, and 30-day mortality in incarcerated femoral hernias versus reducible femoral hernias. Most femoral hernias present incarcerated in older, female patients. Femoral hernias present more commonly incarcerated in patients with significant comorbid diseases and are associated with significantly increased rates of systemic, local, major, and minor complications, return to OR, and mortality. Careful consideration should be given for the evaluation of intestinal viability in the acute setting.

Femoral Hernias: Analysis of Preoperative Risk Factors and 30-Day Outcomes of Initial Groin Hernias Using ACS-NSQIP

Femoral hernias are infrequently encountered groin hernias. The purpose of this study was to describe the natural history of femoral hernias by evaluating patient demographics, comorbidities, operative details, 30-day mortality, and risk factors for postoperative complications compared with inguinal hernias and in reducible versus incarcerated hernias. Overall 5360 femoral hernia repairs and 183,173 inguinal hernia repairs were identified using the 2005 to 2015 American College of Surgeon-National Surgical Quality Improvement Program's database. Univariate analysis was used to compare patient characteristics between femoral and inguinal hernias and between reducible and nonreducible femoral hernias. Multivariable logistic regression analyses were used to identify risk factors for 30-day postoperative complications after repair. Femoral hernias accounted for 2.8 per cent of initial groin hernias and 18.9 per cent of all groin hernias in females. A total of 56.5 per cent of initial femoral hernias were nonreducible and these patients were significantly older. Rates of small bowel resection (5.7 vs 0.3%, P < 0.0001), exploratory laparotomy (2.5% vs 0.4%, P < 0.0001), and diagnostic laparoscopy (2.0% vs 0.7%, P < 0.0001) were significantly higher in incarcerated femoral hernias compared with reducible femoral hernias. There were significantly higher rates of unplanned return to the OR, postoperative sepsis, and 30-day mortality in incarcerated femoral hernias versus reducible femoral hernias. Most femoral hernias present incarcerated in older, female patients. Femoral hernias present more commonly incarcerated in patients with significant comorbid diseases and are associated with significantly increased rates of systemic, local, major, and minor complications, return to OR, and mortality. Careful consideration should be given for the evaluation of intestinal viability in the acute setting.

Activation of Acetonitrile with (C2 F5 )3 PF2 and Amines

Acetonitrile is deprotonated by a combination of the strong Lewis acid (C₂ F₅ )₃ PF₂ and triethylamine. The resulting cyanomethyl function is bound to the phosphorus moiety, affording the highly stable salt [HNEt₃ ][P(C₂ F₅ )₃ F₂ (CH₂ CN)]. Salt metathesis reactions furnished the corresponding [Cu(MeCN)₂ ]⁺ and [Ag(MeCN)]⁺ derivatives in which the CH₂ CN substituent of the anion [P(C₂ F₅ )₃ F₂ (CH₂ CN)]^- coordinates to the metal. An investigation of the gas separation capability of the silver salt [Ag(MeCN)][P(C₂ F₅ )₃ F₂ (CH₂ CN)] shows an uptake of 1.7 equivalents of isobutene from a propane/isobutene mixture. The reaction of (C₂ F₅ )₃ PF₂ with acetonitrile and diethylamine furnishes [P(C₂ F₅ )₃ F₂ {NHC(CH₃ )NEt₂ }]-a phosphate featuring an amidine ligand which formally results from hydroamination of acetonitrile by HNEt₂ . Exchange of HNEt₂ with the primary amines H₂ NPh and H₂ NBu leads to comparable amidine salts that exhibit a solvent-dependent conformational isomerism.

Short-Term Perioperative Complications and Mortality After Total Ankle Arthroplasty in the United States

This study sought to identify patient and operative demographics associated with 30-day perioperative complications in patients undergoing total ankle arthroplasty as recorded in the National Surgical Quality Improvement Project database. Complications were divided into local and systemic and further subcategorized as major and minor. A total of 404 patients underwent total ankle arthroplasty between 2007 and 2014 as captured in the National Surgical Quality Improvement Project database. The overall complication rate was 2.4% with 0.5% mortality and 0.2% infection rate. Length of hospital stay, both as an end point at >5 days and as a continuous variable, was associated with overall complications (odds ratio [OR] = 9.90, P = .002 and OR = 1.52, P = .006, respectively). Patient characteristics that predicted perioperative morbidity included presence of 3 or comorbidities (OR = 8.48, P = 0.038), American Society of Anesthesiologists class III, and history of previous cardiac surgery (OR = 12.22, P = .033). Correct patient selection is imperative in achieving improved outcomes and those that are at risk for complications should be counseled as such.

LEVELS OF EVIDENCE

Level III: Database case control study.

Determination of Proper Timing for the Placement of Intra-Abdominal Mesh after Incidental Enterotomy in a Rodent Model (Rattus norvegicus)

Controversy exists regarding the appropriate timing for placement of permanent intra-abdominal mesh after inadvertent enterotomy during elective hernia repair. The aim of this study was to examine mesh placement at variable postoperative periods and the subsequent risk of infection. Fifty rodents were divided into five groups. Groups one to four underwent laparotomy, enterotomy, and repair. Physiomesh® was placed at the index operation one, three, or seven days postoperatively in Groups 1,2,3, and 4. Group 5 underwent mesh placement only. Necropsy with mesh harvest was performed seven days after placement. Cultures of mesh were obtained and Fisher's exact test was used to compare groups. Bacterial growth postsonication was identified in 30,30, 50, and 90 per cent versus 20 per cent in controls. Compared with controls, there was significantly increased risk of mesh infection when it was placed seven days after enterotomy ( P = 0.006). There was no significant difference in bacterial growth when mesh was placed at the time of enterotomy, one or three days later. The risk of bacterial contamination of permanent mesh placed immediately after inadvertent enterotomy during elective hernia repair is as safe as placing mesh at one or three days. Placing mesh at seven days significantly increased the risk of mesh contamination.

Determination of Proper Timing for the Placement of Intra-Abdominal Mesh after Incidental Enterotomy in a Rodent Model (Rattus norvegicus)

Controversy exists regarding the appropriate timing for placement of permanent intra-abdominal mesh after inadvertent enterotomy during elective hernia repair. The aim of this study was to examine mesh placement at variable postoperative periods and the subsequent risk of infection. Fifty rodents were divided into five groups. Groups one to four underwent laparotomy, enterotomy, and repair. Physiomesh® was placed at the index operation one, three, or seven days postoperatively in Groups 1, 2, 3, and 4. Group 5 underwent mesh placement only. Necropsy with mesh harvest was performed seven days after placement. Cultures of mesh were obtained and Fisher's exact test was used to compare groups. Bacterial growth postsonication was identified in 30, 30, 50, and 90 per cent versus 20 per cent in controls. Compared with controls, there was significantly increased risk of mesh infection when it was placed seven days after enterotomy (P = 0.006). There was no significant difference in bacterial growth when mesh was placed at the time of enterotomy, one or three days later. The risk of bacterial contamination of permanent mesh placed immediately after inadvertent enterotomy during elective hernia repair is as safe as placing mesh at one or three days. Placing mesh at seven days significantly increased the risk of mesh contamination.

A systematic surveillance programme for infectious salmon anaemia virus supports its absence in the Pacific Northwest of the United States

In response to reported findings of infectious salmon anaemia virus (ISAV) in British Columbia (BC), Canada, in 2011, U.S. national, state and tribal fisheries managers and fish health specialists developed and implemented a collaborative ISAV surveillance plan for the Pacific Northwest region of the United States. Accordingly, over a 3-1/2-year period, 4,962 salmonids were sampled and successfully tested by real-time reverse-transcription PCR. The sample set included multiple tissues from free-ranging Pacific salmonids from coastal regions of Alaska and Washington and farmed Atlantic salmon (Salmo salar L.) from Washington, all representing fish exposed to marine environments. The survey design targeted physiologically compromised or moribund animals more vulnerable to infection as well as species considered susceptible to ISAV. Samples were handled with a documented chain of custody and testing protocols, and criteria for interpretation of test results were defined in advance. All 4,962 completed tests were negative for ISAV RNA. Results of this surveillance effort provide sound evidence to support the absence of ISAV in represented populations of free-ranging and marine-farmed salmonids on the northwest coast of the United States.

Predictors of Persistent Pain After Fixation of Distal Clavicle Fractures in an Active Military Population

Patients who undergo open reduction and internal fixation of distal clavicle fractures have a high rate of hardware removal and persistence of symptoms, particularly when attempting to return to high-demand activities. This study evaluated the outcomes of military servicemembers after surgical treatment of distal clavicle fractures. The authors performed a retrospective analysis of active duty servicemembers who underwent open reduction and internal fixation of Neer type II distal clavicle fractures between October 17, 2007, and July 20, 2012, with a minimum of 2-year clinical follow-up. The electronic health record was queried to extract demographic features and clinical outcomes, primarily persistence of pain, removal of hardware, and postoperative return to high-level activity. A total of 48 patients were identified, with mean follow-up of 3.8 years. A total of 44% of patients underwent subsequent hardware removal. All fractures achieved radiographic union, and 35% of patients had persistence of symptoms. Patients who were treated with hook plating had a 3.64-fold higher risk of persistence of pain compared with those treated with conventional plating techniques. A total of 35% of patients successfully returned to full military function and completed a postoperative military deployment. Coracoclavicular reconstruction did not improve outcomes. Persistence of symptoms and requirement for hardware removal were not associated with the rate of postoperative deployment. Achieving excellent functional outcomes with open reduction and internal fixation of distal clavicle fractures remains a challenge. Where possible, conventional plate fixation should be considered over hook plate fixation. However, subsequent hardware removal and continuing shoulder pain do not preclude a return to high-level activity. [Orthopedics. 2018; 41(1):e117-e126.].

Carfilzomib resistance due to ABCB1/MDR1 overexpression is overcome by nelfinavir and lopinavir in multiple myeloma

Proteasome inhibitor (PI) carfilzomib (CFZ) has activity superior to bortezomib (BTZ) and is increasingly incorporated in multiple myeloma (MM) frontline therapy and relapsed settings. Most MM patients ultimately experience PI-refractory disease, an unmet medical need with poorly understood biology and dismal outcome. Pharmacologic targeting of ABCB1 improved patient outcomes, including MM, but suffered from adverse drug effects and insufficient plasma concentrations. Proteomics analysis identified ABCB1 overexpression as the most significant change in CFZ-resistant MM cells. We addressed the functional role of ABCB1 overexpression in MM and observed significantly upregulated ABCB1 in peripheral blood malignant plasma cells (PCs) vs untreated patients' bone marrow PC. ABCB1 overexpression reduces the proteasome-inhibiting activity of CFZ due to drug efflux, in contrast to BTZ. Likewise, the cytotoxicity of established anti-MM drugs was significantly reduced in ABCB1-expressing MM cells. In search for potential drugs targeting ABCB1 in clinical trials, we identified the HIV protease inhibitors nelfinavir (NFV) and lopinavir (LPV) as potent functional modulators of ABCB1-mediated drug export, most likely via modulation of mitochondria permeability transition pore. NFV and LPV restored CFZ activity at therapeutically relevant drug levels and thus represent ready-to-use drugs to be tested in clinical trials to target ABCB1 and to re-sensitize PC to established myeloma drugs, in particular CFZ.

Health care provider communication training in rural Tanzania empowers HIV-infected patients on antiretroviral therapy to discuss adherence problems

Objectives

Self‐reported adherence assessment in HIV‐infected patients on antiretroviral therapy (ART) is challenging and may overestimate adherence. The aim of this study was to improve the ability of health care providers to elicit patients’ reports of nonadherence using a “patient‐centred” approach in a rural sub‐Saharan African setting.

Methods

A prospective interventional cohort study of HIV‐infected patients on ART for ≥ 6 months attending an HIV clinic in rural Tanzania was carried out. The intervention consisted of a 2‐day workshop for health care providers on patient‐centred communication and the provision of an adherence assessment checklist for use in the consultations. Patients’ self‐reports of nonadherence (≥ 1 missed ART dose/4 weeks), subtherapeutic plasma ART concentrations (< 2.5th percentile of published population‐based pharmacokinetic models), and virological and immunological failure according to the World Health Organization definition were assessed before and after (1–3 and 6–9 months after) the intervention.

Results

Before the intervention, only 3.3% of 299 patients included in the study reported nonadherence. Subtherapeutic plasma ART drug concentrations and virological and immunological failure were recorded in 6.5%, 7.7% and 14.5% of the patients, respectively. Two months after the intervention, health care providers detected significantly more patients reporting nonadherence compared with baseline (10.7 vs. 3.3%, respectively; P < 0.001), decreasing to 5.7% after 6–9 months. A time trend towards higher drug concentrations was observed for efavirenz but not for other drugs. The virological failure rate remained unchanged whereas the immunological failure rate decreased from 14.4 to 8.7% at the last visit (P = 0.002).

Conclusions

Patient‐centred communication can successfully be implemented with a simple intervention in rural Africa. It increases the likelihood of HIV‐infected patients reporting problems with adherence to ART; however, sustainability remains a challenge.

Predictors of Inpatient Mortality and Systemic Complications in Acetabular Fractures Requiring Operative Treatment

Patient demographics, physiologic variables, and injury characteristics predictive of mortality and major systemic complications following operative fixation of acetabulum fractures were identified using the National Sample Program of the National Trauma Data Bank. Age older than 60 years, obesity, and Injury Severity Score greater than 15 portended a statistically significant increase in mortality and major systemic complications (P≤.05). Systolic blood pressure less than 90 mm Hg and Glasgow Coma Scale score less than 8 were also significant predictors of mortality and major systemic complications (P<.0001). Time to surgery and hospital length of stay did not affect mortality. The most common potentially modifiable risk factors were smoking (22.3%) and obesity (body mass index ≥30 kg/m²) (9.1%). Increasing age, Injury Severity Score, and obesity independently predicted a statistically significant increase in both mortality and major systemic complications. A better understanding of the associated risk factors and unique complication profile will provide orthopedic surgeons with a basis on which to effectively counsel and care for patients. [Orthopedics. 2017; 40(2):e223-e228.].

Tibial Tubercle Osteotomy for Patellar Chondral Pathology in an Active United States Military Population

PURPOSE

To quantify rates of perioperative complications, secondary surgery, subjective pain relief, and knee-related medical separation in an active military population after a tibial tubercle osteotomy (TTO) for the primary indication of chondral pathology.

METHODS

All active-duty service members undergoing TTO with a minimum of 2 years' follow-up were isolated from the Military Health System database. The exclusion criteria were patients with patellar instability, other periarticular osteotomy, and insufficient follow-up. Demographic information and surgical characteristics were abstracted from the electronic health record and correlated with improvement in pain and medical discharge from the military.

RESULTS

A total of 76 patients (86 knees) who underwent TTO for patellofemoral chondromalacia were identified with a mean age of 32.3 years. Major and minor complications occurred in four patients (4.7%) and three patients (3.5%), respectively, and the overall improvement in the visual analog scale score after TTO was 1.5 (P < .0001). At a mean follow-up of 3.4 years (range, 2.0 to 7.3 years), 37% of patients were unable to return to modified military activity because of knee-related limitations. Junior military rank group (P = .0084), age younger than 35 years (P = .0031), bilateral TTO procedures (P = .0294), and tobacco use (P = .0218; odds ratio, 3.29; 95% confidence interval, 1.19 to 9.12) were risk factors for medical separation, whereas absence of concomitant chondral repair (P = .5408), previous knee procedures (P = .9674), and greater occupational demands (P = .7062) were not.

CONCLUSIONS

At short-term to midterm follow-up, 63% of patients successfully returned to military function with a low rate of perioperative complications (8%). The postoperative decrease in pain after TTO is of unknown clinical significance. Age younger than 35 years, junior military rank, bilateral TTO procedures, and tobacco use were significant risk factors for medical separation, whereas absence of concomitant cartilage repair, previous knee procedures, and lower occupational demands were not associated with improved visual analog scale scores or prevention of knee-related medical discharge.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Characterization of Metacarpal Fractures in a Military Population

The purpose of this study was to investigate the incidence and type of metacarpal (MC) fractures in a military population, and whether these fractures are related to age, military occupational specialty, aggression, or accidental injury. A retrospective record-based review was conducted at a single military center over a 5-year period. Service members with index finger through small finger MC fracture were identified. Data were collected utilizing Armed Forces Health Longitudinal Technology Application and electronic profile (e-profile) databases. Data collected included demographic information, mechanism of injury, nature of injury, total number of visits, and estimated time on physical restriction. 400 patients met inclusion criteria. Males accounted for 94% of the study population, 75% of fractures were of the small finger MC, 54% of patients were between 20 and 24 years, 90% were sustained by junior enlisted personnel, and most occurred by punching. Men aged <25 years were more likely to have intentional injuries. Total time on limited duty profile averaged 38 days and the average medically nondeployable profile was 26 days. MC fractures most commonly affect young, male, junior enlisted service members and are often self-inflicted. As a result, these injuries account for time lost at work, reduced job performance, and decreased medical readiness.

Long versus short cephalomedullary nail for trochanteric femur fractures (OTA 31-A1, A2 and A3): a systematic review

BACKGROUND

Both long and short cephalomedullary nails (CMN) may be used to treat trochanteric femur fractures. The objective of this paper was to compare the clinical outcomes between long and short CMN in the treatment of trochanteric hip fractures.

MATERIALS AND METHODS

A literature search was performed, identifying 135 papers; 4 of which met inclusion and exclusion criteria. Papers included were those that compared cohorts of long and short nails for stable trochanteric femur fractures of level III evidence or superior. Data was pooled and analyzed, focusing on reoperation rate, secondary femoral shaft fracture rate, estimated blood loss, transfusion rate, operative time and length of stay.

RESULTS

Included in the analysis were 1276 patients, with 438 short and 838 long CMN. The average age was 82.0 years for short CMN and 79.0 years for long CMN (P = 0.0002). The average follow up was 18 months, 46 % were male, and 71 % had an ASA (American Society of Anesthesiologists score) classification ≥3. The rate of reoperation was 5.0 % and 3.8 % for short and long CMN, respectively (P = 0.31). The rate of refracture was 1.6 % and 0.95 % for short and long CMN, respectively (P = 0.41). As compared to long nails, short nails had an average blood loss of 39 mL less (P = 0.0003), an 8.8 % decrease in transfusion rate (P = 0.07), and incurred 19 min less operative time (P < 0.0001). No significant differences between short and long nails were observed for either other complications, hardware complications, non-union, or mortality.

CONCLUSIONS

For trochanteric femur fractures, short CMN have a low reoperation rate while significantly decreasing operative time and estimated blood loss with the additional benefit of being cost effective.

LEVEL OF EVIDENCE

Level 3.

Correlating HIV tropism with immunological response under combination antiretroviral therapy

OBJECTIVES

A significant percentage of patients infected with HIV-1 experience only suboptimal CD4 cell recovery while treated with combination therapy (cART). It is still unclear whether viral properties such as cell tropism play a major role in this incomplete immune response. This study therefore intended to follow the tropism evolution of the HIV-1 envelope during periods of suppressive cART.

METHODS

Viruses from two distinct patient groups, one with good and another one with poor CD4 recovery after 5 years of suppressive cART, were genotypically analysed for viral tropism at baseline and at the end of the study period.

RESULTS

Patients with CCR5-tropic CC-motif chemokine receptor 5 viruses at baseline tended to maintain this tropism to the study end. Patients who had a CXCR4-tropic CXC-motif chemokine receptor 4 virus at baseline were overrepresented in the poor CD4 recovery group. Overall, however, the majority of patients presented with CCR5-tropic viruses at follow-up.

CONCLUSIONS

Our data lend support to the hypothesis that tropism determination can be used as a parameter for disease progression even if analysed long before the establishment of a poorer immune response. Moreover, the lasting predominating CCR5-tropism during periods of full viral control suggests the involvement of cellular mechanisms that preferentially reduce CXCR4-tropic viruses during cART.

The effect of operative technique on ulnar nerve strain following surgery for cubital tunnel syndrome

BACKGROUND

The aim of this study is to compare the amount of strain on the ulnar nerve based on elbow position after in situ release, subcutaneous transposition, submuscular transposition, and medial epicondylectomy.

METHODS

Six matched cadaver upper extremity pairs underwent ulnar nerve decompression, transposition in a sequential fashion, while five elbows underwent medial epicondylectomy. A differential variable reluctance transducer (DVRT) was placed in the ulnar nerve. An in situ release, a subcutaneous transposition, and a submuscular transposition were performed sequentially with the strain being measured after each procedure in neutral, full elbow flexion, and extension positions. The strain was then averaged and compared for each procedure. Five cadavers underwent medial epicondylectomy and were similarly tested.

RESULTS

After the in situ release, there was no statistically significant change in strain in either flexion or extension. After a subcutaneous transposition, there was a statistically significant decrease in strain in full elbow flexion but not in extension. Similarly after a submuscular transposition, there was a statistically significant decrease in strain in full flexion but not in extension. There was not a statistically significant change in strain with medial epicondylectomy.

CONCLUSION

An in situ release of the ulnar nerve at the elbow may relieve pressure on the nerve but does not address the problem of strain which may be the underlying pathology in many cases of ulnar neuropathy at the elbow (UNE). Transposition of the ulnar nerve anterior to the medial epicondyle addresses the problem of strain on the ulnar nerve. In addition, it does not create an increased strain on the ulnar nerve with elbow extension.

Arthroscopic Shoulder Surgical Simulation Training Curriculum: Transfer Reliability and Maintenance of Skill Over Time

BACKGROUND

Surgical education is evolving as work hour constraints limit the exposure of residents to the operating room. Potential consequences may include erosion of resident education and decreased quality of patient care. Surgical simulation training has become a focus of study in an effort to counter these challenges. Previous studies have validated the use of arthroscopic surgical simulation programs both in vitro and in vivo. However, no study has examined if the gains made by residents after a simulation program are retained after a period away from training.

METHODS

In all, 17 orthopedic surgery residents were randomized into simulation or standard practice groups. All subjects were oriented to the arthroscopic simulator, a 14-point anatomic checklist, and Arthroscopic Surgery Skill Evaluation Tool (ASSET). The experimental group received 1 hour of simulation training whereas the control group had no additional training. All subjects performed a recorded, diagnostic arthroscopy intraoperatively. These videos were scored by 2 blinded, fellowship-trained orthopedic surgeons and outcome measures were compared within and between the groups. After 1 year in which neither group had exposure to surgical simulation training, all residents were retested intraoperatively and scored in the exact same fashion. Individual surgical case logs were reviewed and surgical case volume was documented.

RESULTS

There was no difference between the 2 groups after initial simulation testing and there was no correlation between case volume and initial scores. After training, the simulation group improved as compared with baseline in mean ASSET (p = 0.023) and mean time to completion (p = 0.01). After 1 year, there was no difference between the groups in any outcome measurements.

CONCLUSION

Although individual technical skills can be cultivated with surgical simulation training, these advancements can be lost without continued education. It is imperative that residency programs implement a simulation curriculum and continue to train throughout the academic year.

Pentafluoroethyl-substituted α-silanes: model compounds for new insights

To further investigate the α-effect in silanes bearing a geminal donor atom, the model compounds (C2F5)3SiCH2NMe2, (C2F5)3SiCH2OMe and (C2F5)3SiONMe2 were prepared by introduction of pentafluoroethyl groups via nucleophilic substitution of the corresponding chloro-derivatives with pentafluoroethyl lithium. The substances were characterised by NMR spectroscopy and X-ray diffraction via in situ crystallization techniques. The solid state structures of these highly electronegatively substituted α-silanes contain monomeric molecules. The Si-C-N angle in (C2F5)3SiCH2NMe2 shows a value of 115.3(2)° and the Si-C-O angle in (C2F5)3SiCH2OMe a value of 105.4(1)°. Both values are smaller than the Si-C-C angle of the reference compound (C2F5)3SiCH2CH3 with a value of 118.6(2)° indicating attractive interaction between the silicon atom and the respective donor atoms. The Si-O-N angle in (C2F5)3SiONMe2 is extremely narrow at 82.0(1)°. This behaviour was further investigated by gas electron diffraction and by quantum-chemical calculations. The NBO method finds no significant orbital interactions between Si and N/O atoms in the Si-C-N, Si-C-O and Si-O-N units. The IQA model describes the compounds as strongly stabilised by electrostatic interactions between formally non-bonded silicon and donor atoms.

Transition Metal Complexes of Phosphinous Acids Featuring a Quasichelating Unit: Synthesis, Characterization, and Hetero-bimetallic Complexes

Diorganophosphane oxides were employed as preligands for the synthesis of catalytically active transition metal complexes of the phosphinous acids (CF3)2POH and (C2F5)2POH. Their reactions with solid PtCl2 and PdCl2 led to the formation of mononuclear phosphinous acid complexes [Cl2M{P(R(f))2OH}2] (M = Pd, Pt; R(f) = C2F5, CF3), which can be crystallized, for example, as its pyridinium salts, 2[HPy](+)[Cl2Pd{P(CF3)2O}2](2-). In vacuo HCl is liberated from the neutral palladium complexes affording mixtures of di- and polynuclear complexes. Moreover, (C2F5)2POH was reacted with several β-diketonato complexes of palladium, platinum, and nickel yielding air- and moisture-stable complexes [(acac)M{[P(R(f))2O]2H}], featuring a quasichelating phosphinous acid phosphinito unit {P(R(f))2O···H···O(R(f))2P}(-). Treatment of [Ni(Cp)2] (Cp = cyclopentadienyl) and [(cod)RhCl]2 (cod = 1,5-cyclooctadiene) with (C2F5)2POH leads to the substitution of one Cp or chloro ligand by a quasichelating unit. The novel coordination compounds were characterized by NMR and IR spectroscopies, mass spectrometry, and X-ray diffraction analysis. The platinum complex [(acac)Pt{[P(C2F5)2O]2H}] (acac = acetylacetonato) was used for the construction of hetero-bimetallic complexes by the treatment with [(cod)RhCl]2 and [Ni(Cp)2]. The trinuclear bimetallic complex [{(acac)Pt[P(C2F5)2O]2}2Ni] is the first structurally characterized hetero-bimetallic species containing a bis(perfluoroalkyl)phosphinito bridge.

Predictors of length of stay after elective total shoulder arthroplasty in the United States

BACKGROUND

Total shoulder arthroplasty (TSA) is an increasingly used treatment of glenohumeral arthritis and proximal humerus fractures. However, patient-specific characteristics affecting length of hospital stay postoperatively have not been elucidated.

METHODS

All patients undergoing primary unilateral TSA between 2005 and 2011 were isolated from the National Surgical Quality Improvement Program database. Patient demographics, medical comorbidities, and selected surgical variables were extracted, and length of stay was established as the primary end point of interest. Risk factors were expressed as odds ratios (ORs) with 95% confidence intervals by bivariate and multivariable analysis.

RESULTS

A total of 2004 patients were identified; the average age was 68.8 years, and 57% were women. Mean length of stay after TSA was 2.2 days (standard deviation, 1.7), and 91% of cases received hospital discharge in <3 days. Multivariable logistic regression analysis identified renal insufficiency (OR, 11.35; P = .0002), increased age (OR, 2.13; P = .011), longer operative time (OR, 1.94; P = .0041), and American Society of Anesthesiologists class ≥3 (OR, 1.86; P = .0016) as the most significant risk factors for length of stay. Gender also influenced length of stay; women were more likely to stay ≥4 days (OR, 0.44; P < .0001).

CONCLUSIONS

Perioperative risk stratification and preoperative counseling are paramount for patients undergoing TSA, particularly for those individuals with cardiac and renal disease or of advancing age. These variables may effectively predict prolonged hospital stay after TSA.

Correction: Pentafluoroethyl-substituted α-silanes: model compounds for new insights

Correction for ‘Pentafluoroethyl-substituted α-silanes: model compounds for new insights’ by Benedikt Waerder et al., Dalton Trans., 2015, 44, 13347–13358.

Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors

BACKGROUND

Total shoulder arthroplasty (TSA) is an effective treatment for painful glenohumeral arthritis, but its morbidity has not been thoroughly documented.

METHODS

The National Surgical Quality Improvement Program database was queried to identify all patients undergoing primary TSA between 2006 and 2011, with extraction of selected patient-based or surgical variables and 30-day clinical course. Postoperative complications were stratified as major systemic, minor systemic, major local, and minor local, and mortality was recorded. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were derived from bivariate and multivariable analysis to express the association between risk factors and clinical outcomes.

RESULTS

Among the 2004 patients identified, the average age was 69 years, and 57% were women. Obesity was present in 46%, and 48% had an American Society of Anesthesiologists classification of ≥3. The 30-day mortality and total complication rates were 0.25% and 3.64%, respectively. Comorbid cardiac disease (OR, 85.31; 95% CI, 8.15, 892.84) and increasing chronologic age (OR, 1.19; 95% CI, 1.06, 1.33) were independent predictors of mortality, whereas peripheral vascular disease was associated with statistically significant increase in any complication (OR, 6.25; 95% CI, 1.24, 31.40). Operative time >174 minutes was an independent predictor for development of a major local complication (OR, 4.05; 95% CI, 1.45, 11.30). Obesity was not associated with any specified complication after controlling for other variables.

CONCLUSIONS

Whereas TSA has low short-term rates of perioperative complications and mortality, careful perioperative medical optimization and efficient surgical technique should be emphasized to decrease morbidity and mortality.

Synthesis of functional phosphates [P(C2F5)3F2X]- from the phosphorane adduct [P(C2F5)3F2(dmap)]

Weakly coordinating anions (WCAs) are of great academic as well as industrial interest. To advance the fluoroalkyl phosphate anion [P(C2F5)3F3](-), which is ideally suited for technical applications, functional substituents X are attached to the Lewis acid (C2F5)3PF2. In keeping with this, the reaction of (C2F5)3PF2 with 4-(dimethylamino)pyridine (DMAP) yields the corresponding adduct [P(C2F5)3F2(dmap)]. Treatment of this adduct with Brønsted acids (HX) leads to the selective formation of the corresponding phosphate anions [P(C2F5)3F2X](-) by trapping the proton with the liberated base DMAP. In this way, OH functions can be transformed in one step into WCAs, slightly increasing the coordination properties of the corresponding anion. An ion exchange to the corresponding [PPh4] salts results in solids, whereas the corresponding imidazolium salts are obtained as room-temperature ionic liquids.

Synthesis of tris- and tetrakis(pentafluoroethyl)silanes

The synthesis and complete characterization of functional, highly Lewis acidic tris(pentafluoroethyl)silanes as well as tetrakis(perfluoroalkyl)silanes Si(C2F5)4 and Si(C2F5)3 CF3 by direct fluorination is described. The reaction of SiCl4 with LiC2F5 invariably affords (pentafluoroethyl)fluorosilicates. To avoid silicate formation by fluoride transfer from LiC2F5 the Lewis acidity of the silane has to be decreased by electron-donating substituents, such as dialkylamino groups. The easily accessible Si(C2F5)3 NEt2 is a valuable precursor for a series of tris(pentafluoroethyl)silanes.

Positive effect of reduced aeration rate on secretion of alpha-amylase and neutral proteases during pressurised fermentation of thermophilic Bacillus caldolyticus

The thermophilic microorganism Bacillus caldolyticus was incubated in laboratory scale stirred bioreactors under pressurised conditions at different aeration rates. Increased amounts of CO2/bicarbonate were solubilised under the chosen conditions. A reduction in aeration rate from 1 vvm to 0.1 vvm resulted in accumulation of CO2 and bicarbonate up to 126 mg l(-1) and 733 mg l(-1), respectively and also increased secretion of α-amylase and neutral proteases (increases of 123% and 52%, respectively). In this paper, the effect of reduced aeration rate on CO2/bicarbonate concentration and enzyme activities is presented. The selected fermentation conditions are closely related to those prevalent in large scale bioreactors and may offer the possibility of achieving high enzyme yields at reduced aeration costs on an industrial scale.

Effects of copper sulfate on seedlings of Prosopis pubescens (screwbean mesquite)

Phytoextraction is an established method of removal of heavy metals from contaminated soils worldwide. Phytoextraction is most efficient if local plants are used in the contaminated site. We propose that Prosopis pubescens (Screw bean mesquite) would be a successful phytoextractor of copper in our local soils. In order to determine the feasibility of using Screw bean mesquite, we utilized inductively-coupled plasma-optical emission spectroscopy (ICP-OES) and elemental analysis to observe the uptake of copper and the effects on macro and micro nutrients within laboratory-grown seedlings. We have previously shown that P. pubescens is a hyperaccumulator of copper in soil-grown seedlings. Light and transmission electron microscopy demonstrated death of root cells and ultrastructural changes due to the presence of copper from 50 mg/L - 600 mg/L. Ultrastructural changes included plasmolysis, starch accumulation, increased vacuolation and swollen chloroplasts with disarranged thylakoid membranes in cotyledons. Inductively coupled plasma-optical emission spectroscopy analyses of macro- and micro-nutrients revealed that the presence of copper sulfate in the growth medium of Petri-dish grown Prosopis pubescens seedlings resulted in dramatic decreases of magnesium, potassium and phosphorus. At 500-600 mg/L of copper sulfate, a substantial increase of sulfur was present in roots.

Prosopis pubescens (screw bean mesquite) seedlings are hyperaccumulators of copper

Due to health reasons, toxic metals must be removed from soils contaminated by mine tailings and smelter activities. The phytoremediation potential of Prosopis pubescens (screw bean mesquite) was examined by use of inductively-coupled plasma optical emission spectroscopy. Transmission electron microscopy was used to observe ultrastructural changes of parenchymal cells of leaves in the presence of copper. Elemental analysis was used to localize copper within leaves. A 600-ppm copper sulfate exposure to seedlings for 24 days resulted in 31,000 ppm copper in roots, 17,000 ppm in stems, 11,000 in cotyledons and 20 ppm in the true leaves. For a plant to be considered a hyperaccumulator, the plant must accumulate a leaf-to-root ratio <1. Screw bean mesquite exposed to copper had a leaf-to-root ratio of 0.355 when cotyledons were included. We showed that P. pubescens grown in soil is a hyperaccumulator of copper. We recommend that this plant should be field tested.

Nelfinavir augments proteasome inhibition by bortezomib in myeloma cells and overcomes bortezomib and carfilzomib resistance

HIV protease inhibitors (HIV-PI) are oral drugs for HIV treatment. HIV-PI have antitumor activity via induction of ER-stress, inhibition of phospho-AKT (p-AKT) and the proteasome, suggesting antimyeloma activity. We characterize the effects of all approved HIV-PI on myeloma cells. HIV-PI were compared regarding cytotoxicity, proteasome activity, ER-stress induction and AKT phosphorylation using myeloma cells in vitro. Nelfinavir is the HIV-PI with highest cytotoxic activity against primary myeloma cells and with an IC₅₀ near therapeutic drug blood levels (8–14 μM), irrespective of bortezomib sensitivity. Only nelfinavir inhibited intracellular proteasome activity in situ at drug concentrations <40 μℳ. Ritonavir, saquinavir and lopinavir inhibited p-AKT comparable to nelfinavir, and showed similar synergistic cytotoxicity with bortezomib against bortezomib-sensitive cells. Nelfinavir had superior synergistic activity with bortezomib/carfilzomib in particular against bortezomib/carfilzomib-resistant myeloma cells. It inhibited not only the proteasomal β1/β5 active sites, similar to bortezomib/carfilzomib, but in addition the β2 proteasome activity not targeted by bortezomib/carfilzomib. Additional inhibition of β2 proteasome activity is known to sensitize cells for bortezomib and carfilzomib. Nelfinavir has unique proteasome inhibiting activity in particular on the bortezomib/carfilzomib-insensitive tryptic (β2) proteasome activity in intact myeloma cells, and is active against bortezomib/carfilzomib-resistant myeloma cells in vitro.