Increasing Reoperations and Failures With Increasing BMI in Patients Undergoing 2-Stage Exchange for Infected Total Hip Arthroplasty

BackgroundWhile morbid obesity is associated with increased infection after total hip arthroplasty, little is known on the outcomes after 2-stage reimplantation for prosthetic joint infection (PJI) in this population. The purpose of this study is to evaluate the impact of morbid obesity (body mass index>40 kg/m2) on reinfection, postoperative complications, readmissions, and reoperations.MethodsWe conducted a retrospective review of 107 patients undergoing first time 2-stage reimplantation for PJI from 2013 to 2019. 18 patients (50% women) with body mass index>40 kg/m2 were identified. To minimize confounders, three propensity score matched cohorts were created, yielding 16 nonobese (<30 kg/m2), 16 obese (30-39.9 kg/m2), and 18 morbidly obese (>40 kg/m2) patients. Outcomes were compared using chi-square or Fisher’s exact tests. All patients had minimum 12-month follow-up, with mean follow-up of 36.3, 30.1, and 40.0 months in the nonobese, obese, and morbidly obese cohorts, respectively.ResultsCompared with nonobese patients, morbidly obese patients had a higher rate of reinfection (0% vs 33%, P = .020 and higher likelihood of length of stay>4 days (19% vs 61%, P = .012). In addition, compared with nonobese and obese patients, morbidly obese patients had higher rate of return to the operating room for any reason (13% vs 19% vs 50%, respectively, P = .020). No differences between cohorts were found regarding complications, death, or revision surgery.ConclusionMorbidly obese patients have significantly increased risk of reinfection and reoperation after 2-stage reimplantation for PJI when compared with obese and nonobese patients. These data can be used to counsel morbidly obese patients contemplating total hip arthroplasty and supports the notion of deferring arthroplasty in this population pending optimization.     

Genomics‐based treatment in a patient with two overlapping heritable skin disorders: Epidermolysis bullosa and acrodermatitis enteropathica

Next‐generation sequencing (NGS) is helpful in diagnosing complex genetic disorders and phenotypes, particularly when more than one overlapping condition is present. From a large cohort of 362 families with clinical manifestations of skin and mucosal fragility, referred by several major medical centers, one patient was found by NGS to have two overlapping heritable skin diseases, recessive dystrophic epidermolysis bullosa (RDEB; COL7A1 mutations) and acrodermatitis enteropathica (AE; SLC39A4 mutations). The pathogenicity of the variants was studied at gene expression as well as ultrastructural and tissue levels. Although there is no specific treatment for RDEB except avoiding trauma, supplementation with oral zinc (3 mg·kg^?1·day^?1) for the AE resulted in rapid amelioration of the skin findings. This case demonstrates the power of NGS in identifying two genetically unlinked diseases that led to effective treatment with major clinical benefits as an example of genomics‐guided treatment.     

Pesticide consumption,central nervous system and cardiovascular congenital malformations in the South and Southeast region of Brazil

Objectives

To investigate the association between per capita pesticide consumption and infant mortality rates from CNS and CVS congenital malformations in microregions in the South and Southeast Region of Brazil.

Material and Methods

An ecological study was conducted using data on pesticide expenditure in 1985 and 1996, and deaths caused by CNS and CVS malformations in infants under 1 year old in 1986–1990 and 1997–2001, respectively. Per capita pesticide consumption and infant mortality rates were calculated for each microregion. Microregions were grouped according to quintiles of pesticide consumption, taking the first quintile as reference. The association between pesticide consumption and infant mortality was examined by calculating Spearman correlation coefficients (r) and mortality rate ratios (RR), stratifying by gender and type of microregion (urban or rural).

Results

Significant and positive correlations between per capita pesticide consumption and rates of mortality due to CNS and CVS defects were observed in rural but not urban microregions. In general, mortality RRs for the 2 types of malformations in rural microregions were significantly higher in each quintile of pesticide consumption compared to the lowest quintile in the 2 study periods, with elevations ranging between 10% and 30%. Likewise, mortality RRs in these microregions showed significant trends of increase across quintiles of pesticide consumption in both study periods. In urban areas, however, mortality RRs from both CNS and CVS malformations were weak and not statistically significant, and a trend of increase of mortality with increasing pesticide usage was not observed.

Conclusions

The results show the relevance of pesticide exposure in rural areas with intense agricultural activity, suggesting that such prenatal exposures may be related with the occurrence of certain congenital defects.     

The hypotensive effect of the ruthenium complex [Ru(terpy)(bdq)NO]3+ is higher in male than in female spontaneously hypertensive rats (SHR)

We have previously demonstrated that the hypotensive effect of the ruthenium complex [Ru(terpy)(bdq)NO]³⁺ (TERPY) is slow, long lasting, and does not lead to reflex tachycardia. TERPY’s hypotensive effect is increased in hypertensive rats (SHR or 2 kidney-1clip) compared with normotensive rats. We hypothesized that sexual differences could interfere in the hypotensive effects of nitric oxide (NO) donors in SHR. Therefore, here we aimed to investigate the role of sexual differences and endogenous NO in the hypotension induced by TERPY. In conscious, unrestrained animals, we evaluated the hypotensive effect of TERPY before and after the administration of N-nitro-L-arginine methyl ester (L-NAME) (nonselective NO synthase inhibitor), APOCYNIN (NADPH/NOX inhibitor), and TEMPOL (superoxide dismutase mimetic). The hypotensive effect of TERPY was higher in male than in female SHR, but this difference was not observed in the normotensive Wistar group. The effect of TERPY increased after administration of L-NAME in Wistar rats; however, this effect was not altered by L-NAME in SHR. In SHR, sexual dimorphism in TERPY effect was still observed in animals treated with L-NAME. TEMPOL increases the effect of TERPY only in female SHR. After TEMPOL, the sexual dimorphism in TERPY effect was abolished in the SHR group. APOCYNIN increased the effect of TERPY in male and female Wistar and SHR, but maintained the previously observed difference between male and female SHR. Thus, this study shows that TERPY’s hypotensive effect increased in male compared with female SHR and indicates that sexual dimorphism in TERPY effect is associated with oxidative stress.     

Acute cytomegalovirus colitis presenting during primary HIV infection: an unusual case of an immune reconstitution inflammatory syndrome.

Severe ulcerous cytomegalovirus pancolitis developed during primary human immunodeficiency virus (HIV) infection in a patient who underwent early combination antiretroviral treatment. This massive inflammatory process led to acute colon perforation. Serological testing demonstrated cytomegalovirus reactivation. Severe immunosuppression caused by primary HIV infection resulted in cytomegalovirus colitis, and initiation of early combination antiretroviral therapy triggered an immune reconstitution inflammatory syndrome potentially leading to colonic perforation.     

Gut immune deficits in LEW.1AR1‐iddm rats partially overcome by feeding a diabetes‐protective diet

The gut immune system and its modification by diet have been implicated in the pathogenesis of type 1 diabetes (T1D). Therefore, we investigated gut immune status in non‐diabetes‐prone LEW.1AR1 and diabetes‐prone LEW.1AR1‐iddm rats and evaluated the effect of a low antigen, hydrolysed casein (HC)‐based diet on gut immunity and T1D. Rats were weaned onto a cereal‐based or HC‐based diet and monitored for T1D. Strain and dietary effects on immune homeostasis were assessed in non‐diabetic rats (50–60 days old) and rats with recent‐onset diabetes using flow cytometry and immunohistochemistry. Immune gene expression was analysed in mesenteric lymph nodes (MLN) and jejunum using quantitative RT‐PCR and PCR arrays. T1D was prevented in LEW.1AR1‐iddm rats by feeding an HC diet. Diabetic LEW.1AR1‐iddm rats had fewer lymphoid tissue T cells compared with LEW.1AR1 rats. The percentage of CD4⁺ Foxp3⁺ regulatory T (Treg) cells was decreased in pancreatic lymph nodes (PLN) of diabetic rats. The jejunum of 50‐day LEW.1AR1‐iddm rats contained fewer CD3⁺ T cells, CD163⁺ M2 macrophages and Foxp3⁺ Treg cells. Ifng expression was increased in MLN and Foxp3 expression was decreased in the jejunum of LEW.1AR1‐iddm rats; Ifng/Il4 was decreased in jejunum of LEW.1AR1‐iddm rats fed HC. PCR arrays revealed decreased expression of M2‐associated macrophage factors in 50‐day LEW.1AR1‐iddm rats. Wheat peptides stimulated T‐cell proliferation and activation in MLN and PLN cells from diabetic LEW.1AR1‐iddm rats. LEW.1AR1‐iddm rats displayed gut immune cell deficits and decreased immunoregulatory capacity, which were partially corrected in animals fed a low antigen, protective HC diet consistent with other models of T1D.     

Overactive Bladder Prevalence after Surgery for Pelvic Organ Prolapse

In this review, we set out to address the clinically complex question of how patients with overactive bladder (OAB) syndrome and pelvic organ prolapse (POP) fare with respect to symptomatic improvement after surgical treatment of POP. Our objectives are to use the current literature to define appropriate patient expectations for improvement and cure and to look for factors predicting divergent outcomes, with the goal of offering realistic preoperative patient counseling. Secondary aims include highlighting areas of needed research, defining outcome measures, and examining theories regarding the relationship between OAB and POP. Relevant original papers and review articles were identified by conducting a literature search using PubMed and Medline. The cause of OAB symptoms and the relationship between vaginal wall prolapse and OAB remain unclear. However, POP repair seems to improve the symptoms of OAB syndrome in 30% to 80% of patients, with a small but significant percentage of patients (≤20%) developing de novo symptoms of OAB.