Citations

Background: Historically, symptomatic hip labral lesions were treated with arthroscopic debridement. Hip labral repair has become the standard treatment for labral pathology; however, to date, there are limited long-term studies regarding the outcomes of isolated labral debridement. Purpose: To (1) evaluate the long-term patient-reported outcomes of isolated labral debridement, (2) report reoperation and arthroplasty rates, and (3) identify risk factors contributing to reoperation or poor clinical outcomes. Study Design: Case series; Level of evidence, 4 Methods: A retrospective review of a prospectively generated cohort of 59 hips in 57 patients from 1996 to 2010 who underwent hip arthroscopy with labral debridement was performed. Only patients with Tönnis grade <3 were included. Additionally, given the time period analyzed, resection of cam morphology was not performed, and the interportal capsulotomy was not repaired. The pre- and postoperative modified Harris Hip Score; Hip Outcome Score (HOS)-Activities of Daily Living and -Sports scores; and reoperation, conversion to total hip arthroplasty, and risk factors were analyzed. Results: In total, 48 hips in 47 patients (14 men, 33 women; mean age, 48.0 ± 12.9 years) met inclusion criteria and were followed for a mean of 17 ± 3 years (range, 13-27 years). The mean preoperative Tönnis grade was 1.3 ± 0.6 (range, 0-2), the mean chondral acetabular International Cartilage Regeneration & Joint Preservation Society (ICRS) grade was 1.7 ± 1.6 (range, 0-4), the mean chondral femoral ICRS grade was 0.9 ± 1.4, and the mean acetabular labral articular cartilage grade was 2.5 ± 1.2 (range, 0-4). At the final follow-up, mean the modified Harris Hip Score, HOS-Activities of Daily Living score, and HOS-Sports score were 82.2 ± 16.6, 81.9 ± 20.5, and 82.2 ± 20.5, respectively. Nineteen hips underwent subsequent reoperation at a mean of 5.5 ± 6.2 years (range, 0.5-21.2 years) postoperatively, including 16 hips (33% overall) being converted to total hip arthroplasty. Higher acetabular ICRS chondral grades at the time of surgery were observed in patients who went on to subsequent surgery compared with those who did not (2.3 ± 1.6 vs 1.1 ± 1.5; P = .02). In reoperation-free hips, Tönnis grade demonstrated a trend of increasing over time (1.4 preoperatively vs 1.7 at radiographic follow-up; P = .08). At the final follow-up, 19 hips (40%) had undergone reoperation, and 5 additional hips (10%) were rated as “abnormal” or “severely abnormal” in function, resulting in an overall clinical failure rate of 50%. Conclusion: Isolated labral debridement was found to result in high rates of failure and reoperation, with a third of patients being converted to arthroplasty and half of patients meeting criteria for reoperation or clinical failure. Of note, for patients remaining reoperation-free, satisfactory outcome scores were observed.

Importance Bleeding is the most common cause of preventable death after trauma. Objective To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage. Design, Setting, and Participants Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days. Intervention Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44). Main Outcomes and Measures The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death. Results Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR &amp;gt;1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours. Conclusions and Relevance In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone. Trial Registration isrctn.org Identifier: ISRCTN16184981

AbstractBackgroundAs heart transplant guidelines evolve, the clinical indication for 73% of durable left ventricular assist device (LVAD) implants is now destination therapy. Although completely magnetically levitated LVAD devices have demonstrated improved durability relative to previous models, LVAD replacement procedures are still required for a variety of indications. Thus, the population of patients with a replaced LVAD is growing. There is a paucity of data regarding the outcomes and risk factors for those patients receiving first‐time LVAD replacements.MethodsThe study cohort consisted of all consecutive patients between 2006 and 2020 that received a first‐time LVAD replacement at a single institution. Preoperative clinical and laboratory variables were collected retrospectively. The primary endpoint was death or need for an additional LVAD replacement. Data were subjected to Kaplan–Meier, univariate, and multivariate Cox hazard ratio analyses.ResultsIn total, 152 patients were included in the study, of which 101 experienced the primary endpoint. On multivariate analysis, patients receiving HeartMate 3 (HM3) LVADs as the replacement device showed superior outcomes (HR 0.15, 95% CI 0.065–0.35, p < 0.0001). Independent risk factors for death or need for additional replacement included preoperative extracorporeal membrane oxygenation (ECMO) (HR 4.44, 95% CI 1.87–14.45, and p = 0.00042), increased number of sternotomies (HR 5.20, 95% CI 1.87–14.45, and p = 0.0016), and preoperative mechanical ventilation (HR 1.98, 95% CI 1.01–3.86, and p = 0.045).ConclusionsReplacement with HM3 showed superior outcomes compared to all other pump types when controlling for both initial pump type and other independent predictors of death or LVAD replacement. Preoperative ECMO, mechanical ventilation, and multiple sternotomies also increased the odds for death or the need for subsequent replacement.

Abstract Objectives Healthcare institutions implement antimicrobial stewardship (AMS) programmes to optimize the use of antibiotics. The focus is often on inpatient rather than outpatient settings. We aimed to explore perceptions of AMS stakeholders on effective interventions for appropriate antibiotic use in outpatient settings, and the role of clinical pharmacists in the AMS multidisciplinary team. Methods A qualitative semi-structured interview study using thematic analysis by two researchers independently. Participants that practice AMS programmes were recruited from healthcare facilities in the United Arab Emirates (UAE). Interviews were conducted face to face or online and transcribed verbatim. Results Four themes emerged: (i) Perceived factors leading to unnecessary or inappropriate antibiotic prescribing and their impact on patients and the community; (ii) current outpatient AMS activities and perceived barriers and facilitators for their sustainability; (iii) suggested outpatient AMS strategies to be implemented in outpatient settings; and (iv) perceived future AMS implementation barriers and suggested mitigation strategies. Conclusions Several AMS interventions, together with the presence of a clinical pharmacist, may be effective in improving antibiotic use in UAE outpatient settings. Future research should investigate the most appropriate AMS strategy considering barriers and possible mitigation strategies to ensure sustainability.

Background: Sleep disturbances are common in parkinsonian disorders; however, whether sleep disorders affect individuals with early-onset parkinsonism and whether they differ from individuals with typical-onset parkinsonism is unknown. Objective: To compare the prevalence and incidence of sleep disorders before and after parkinsonian motor symptom onset between individuals with early onset parkinsonism (age ≤50 at motor symptom onset) and typical-onset parkinsonism (age >50 at motor symptom onset). Methods: We used a population-based, 1991 to 2015 incident-cohort study of parkinsonism including 38 patients with early-onset and 1,001 patients with typical-onset parkinsonism. Presence or absence and type of sleep disorder as well as the relationship between motor and sleep symptoms were abstracted from the medical records. Rates of sleep disorders before and after onset of parkinsonism were compared with logistic regression and Cox proportional hazards models. Results: The prevalence of sleep disorders prior to the onset of parkinsonism in early vs. typical parkinsonism (24% vs. 16% p = 0.19) and incidence of sleep disorders after parkinsonism onset (5.85 cases per 100 person-years vs. 4.11 cases per 100 person-years; HR 1.15 95% CI: 0.74–1.77) were similar between the two groups. Early-onset parkinsonism had a higher risk for developing post-motor insomnia compared with typical-onset parkinsonism (HR 1.73, 95% CI: 1.02–2.93); the risk for developing all other sleep disorders considered was similar between groups. Conclusion: Sleep disorders are common in individuals with early-onset parkinsonism and occur with similar frequency to those with typical-onset parkinsonism, except for insomnia, which was more frequent in the early-onset group.

ABSTRACT We have previously reported on the susceptibility and epidemiology of Clostridioides difficile isolates from six geographically dispersed medical centers in the United States. This current survey was conducted with isolates collected in 2020–2021 from six geographically dispersed medical centers in the United States, with specific attention to susceptibility to ridinilazole as well as nine comparators. C. difficile isolates or stools from patients with C. difficile antibiotic-associated diarrhea were collected and referred to a central laboratory. After species confirmation of 300 isolates at the central laboratory, antibiotic susceptibilities were determined by the agar dilution method [M11-A9, Clinical and Laboratory Standards Institute (CLSI)] against the 10 agents. Ribotyping was performed by PCR capillary gel electrophoresis on all isolates. Ridinilazole had a minimum inhibitory concentration (MIC) 90 of 0.25 mcg/mL, and no isolate had an MIC greater than 0.5 mcg/mL. In comparison, fidaxomicin had an MIC 90 of 0.5 mcg/mL. The vancomycin MIC 90 was 2 mcg/mL with a 0.7% resistance rate [both CLSI and European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria]. The metronidazole MIC 90 was 1 mcg/mL, with none resistant by CLSI criteria, and a 0.3% resistance rate by EUCAST criteria. Among the 50 different ribotypes isolated in the survey, the most common ribotype was 014–020 (14.0%) followed by 106 (10.3%), 027 (10%), 002 (8%), and 078–126 (4.3%). Ridinilazole maintained activity against all ribotypes and all strains resistant to any other agent tested. Ridinilazole showed excellent in vitro activity against C. difficile isolates collected between 2020 and 2021 in the United States, independent of ribotype.

Background: Arthrofibrosis (AF) after anterior cruciate ligament reconstruction (ACLR) remains a challenge. There is a paucity of data on arthroscopic interventions for AF after ACLR. Purpose: To (1) describe the patient, injury, and surgical characteristics and patient-reported outcomes (PROs) of those requiring an arthroscopic intervention for loss of motion after ACLR and (2) compare outcomes between patients undergoing an early intervention (within 3 months) versus those undergoing a late intervention (after 3 months). Study Design: Case series; Level of evidence, 4. Methods: Patients with a history of ACLR and a subsequent operative procedure for postoperative AF at a single institution between 2000 and 2018 were retrospectively identified. Arthroscopic interventions included lysis of adhesions, capsular release with or without manipulation under anesthesia, and excision of cyclops lesions. Patients were excluded if they had a knee dislocation or multiple-ligament injury, a periarticular fracture, or less than 2-year follow-up from the arthroscopic intervention. PROs including the Tegner activity score, visual analog scale pain score, and International Knee Documentation Committee score as well as knee range of motion (ROM) were recorded. Results: A total of 40 patients were included with a mean age of 27.2 years (range, 11.0-63.8 years) at surgery and a mean follow-up of 10.0 years (range, 2.9-20.7 years). The mean preoperative flexion and extension were 102° (range, 40°-150°) and 8° (range, 0°-25°), respectively. The mean postoperative flexion and extension were 131° (range, 110° to 150°) and 0° (range, –10° to 5°), respectively. After the arthroscopic intervention, the mean ROM improved from 94° (range, 40°-140°) preoperatively to 131° (range, 107°-152°) at final follow-up ( P < .001), and the visual analog scale pain score improved from 3.0 preoperatively to 1.2 postoperatively ( P = .001). Overall, 13 patients (32.5%) underwent an intervention within 3 months and 27 (67.5%) after 3 months. The early intervention group had a higher postoperative International Knee Documentation Committee score compared with the late intervention group (86.8 vs 71.7, respectively; P = .035). Conclusion: An arthroscopic intervention for AF after ACLR successfully improved knee ROM and pain. Patients who underwent either early or late surgery obtained satisfactory motion and function, although improved PROs were observed when the intervention occurred within 3 months of the primary procedure.

Purpose To (1) evaluate the efficacy of surgery for arthrofibrosis (AF), as measured by preoperative and postoperative range of motion (ROM), and (2) evaluate patient‐reported outcomes at mid‐ to long‐term follow‐up. Methods We performed a retrospective review of a prospectively collected database including patients who sustained multiligamentous knee injuries (MLKIs) managed surgically, sustained loss of ROM after surgical intervention, and underwent subsequent lysis of adhesions (LOA) and/or manipulation under anesthesia (MUA). Loss of ROM was defined as clinically symptomatic loss of terminal extension (flexion deformity) and/or flexion compared with the contralateral side. Results In total, 12 patients (6 male and 6 female patients; age, 36.0 ± 8.7 years; body mass index, 36.3 ± 8.7) met the inclusion criteria and underwent LOA and/or MUA at a mean of 14 ± 27 months (median, 4.0 months; interquartile range, 3.5‐9.3 months) after MLKI surgery. Prior to AF intervention, patients showed mean flexion of 75.9° ± 36.0° (range, 30°‐129°), mean extension of 3.2° ± 5.2° (range, 0°‐12°), and a mean arc of motion of 72.7° ± 34.1° (range, 30°‐117°). At a mean follow‐up of 7.0 ± 3.9 years (range, 2.4‐16.6 years) after AF intervention, patients showed a significant increase in knee flexion of 49° ( P = .003), a significant increase in arc of motion of 51° ( P = .002), and an increase in extension of 3° ( P = .086). The mean final International Knee Documentation Committee score was 59.5 ± 23.9; Lysholm score, 72.1 ± 20.6; Tegner activity scale score, 5.6 ± 2.8; visual analog scale score at rest, 1.0 ± 1.6; and visual analog scale score with use, 3.3 ± 2.5. At final follow‐up, 2 patients (17%) had undergone conversion to total knee arthroplasty (TKA) at 10.3 and 24.8 years after MLKI surgery. Of the 10 patients who did not go on to TKA, 9 (90%) reported that they were satisfied or very satisfied with their AF knee surgery. Conclusions At mid‐term follow‐up, LOA and/or MUA for symptomatic AF after multiligamentous knee surgery results in high rates of patient satisfaction and improved knee ROM and pain scores, as well as durable and satisfactory functional outcomes in patients not undergoing TKA. Level of Evidence Level IV, therapeutic case series.

Across multiancestry groups, we analyzed Human Leukocyte Antigen (HLA) associations in over 176,000 individuals with Parkinson’s disease (PD) and Alzheimer’s disease (AD) versus controls. We demonstrate that the two diseases share the same protective association at the HLA locus. HLA-specific fine-mapping showed that hierarchical protective effects of HLA-DRB1 *04 subtypes best accounted for the association, strongest with HLA-DRB1 *04:04 and HLA-DRB1 *04:07, and intermediary with HLA-DRB1 *04:01 and HLA-DRB1 *04:03. The same signal was associated with decreased neurofibrillary tangles in postmortem brains and was associated with reduced tau levels in cerebrospinal fluid and to a lower extent with increased Aβ42. Protective HLA-DRB1 *04 subtypes strongly bound the aggregation-prone tau PHF6 sequence, however only when acetylated at a lysine (K311), a common posttranslational modification central to tau aggregation. An HLA-DRB1 *04-mediated adaptive immune response decreases PD and AD risks, potentially by acting against tau, offering the possibility of therapeutic avenues.