Total Replacement Research Articles

Heterotopic ossification, osteolysis and implant failure following cervical total disc replacement with the M6-C™ artificial disc

IntroductionA recent study reported a 34% mid-term revision rate after M6-C™ cervical total disc replacement (CTDR) for wear-related osteolysis. Here, we aim to investigate the prevalence, risk factors, and radiographic characteristics of periprosthetic bony changes and implant failure of the M6-C™ artificial disc.MethodsWe retrospectively analysed radiographic (conventional X-ray, CT scan) and clinical outcomes (EQ-5D-5L, Neck Disability Index (NDI), and Visual Analog Scale (VAS) for neck and arm pain) data collected during routine follow-up of patients who underwent CTDR with the M6-C™ between 2011 and 2015.ResultsIn total, 85 patients underwent CTDR with the M6-C™. Follow-up data were available for 43 patients (54% female, mean age 44 years) with 50 implants and a mean follow-up of 8.1 years (6.5–11 years). Implant failure with the presence of severe osteolysis was identified in 5 (12%) patients who were all male (p = 0.016) and implanted at the C5/6 level (p = 0.11). All failed implants required revision surgery. The overall prevalence of osteolysis was 44% (22/50 implants) and 34% (17/50 implants) for significant heterotopic ossification. Patients with high-grade osteolysis showed higher VAS arm pain (p = 0.05) and lower EQ-5D-VAS health VAS (p = 0.03).ConclusionWe report a lower reoperation rate for failed M6-C™ implants than previously published, but confirmed that osteolysis and heterotopic ossification are common following CTDR with the M6-C™ and may be asymptomatic. Therefore, we strongly recommend ongoing clinical and radiographic monitoring after CTDR with the M6-C™, particularly for male patients implanted at the C5/6 level.

Measurement Properties of the Oxford Shoulder Score and Minimal Clinically Important Changes After Primary Total Shoulder Replacement Surgery.

We evaluated the measurement properties of the Oxford Shoulder Score (OSS) and estimated the minimal clinically important change (MCIC) in patients undergoing primary total shoulder replacement in Australia. Deidentified data from the Australian Orthopaedic Association National Joint Replacement Registry were used for this analysis. Pre- and 6-month postoperative OSS scores were used, with the 5-level EuroQoL quality of life instrument and shoulder pain scores used as comparators. Floor and ceiling effects, internal consistency reliability, construct validity, and responsiveness to change were evaluated using standard psychometric methods. Mean change and predictive modeling approaches (with and without adjustment for the proportion of improved patients) were used to calculate MCIC thresholds, with patient-perceived improvement after surgery as the anchor. Preoperative OSS data were available for 1,117 patients (59% female; 90% aged ≥60 years) undergoing primary total shoulder replacement. No floor or ceiling effects were observed pre- or postoperatively. The OSS showed high internal consistency reliability (Cronbach alpha >0.89), good construct validity, and high responsiveness to change (effect size 1.88). The MCIC derived from the mean change method was 6.50 points (95% confidence interval [95% CI] 4.41-8.61). The predictive modeling approach produced an MCIC estimate of 8.42 points (95% CI 5.68-12.23) after adjustment. The OSS has good measurement properties to capture pain and function outcomes after shoulder replacement procedures and is highly responsive to change. Based on robust methods, an increase in OSS scores of at least eight points can be considered as meaningful improvement after surgery from the patient's perspective.

Translation of a Diabetes Remission Service into Australian Primary Care: Findings from the Evaluation of DiRECT-Australia.

The Diabetes Remission Clinical Trial (DiRECT) study demonstrated that an intensive and structured weight management program in UK primary care resulted in high rates of diabetes remission in adults with recent onset type 2 diabetes mellitus (T2DM). This study was aimed at evaluating the translation of the DiRECT intervention into an Australian primary care setting. All patients enrolled in the DiRECT-Australia Type 2 Diabetes Remission Service in a region of Sydney (Macarthur region, South Western Sydney, Australia) were included. Eligible participants were aged 20-70 years, noninsulin treated, with T2DM of ≤6 years' duration, and body mass index (BMI) ≥ 27 kg/m2. Total diet replacement of 825-853 kcal/day using meal replacements was implemented for 12 weeks, followed by an ongoing structured program until 52 weeks, with regular follow-up with a general practitioner, dietitian, and/or practice nurse. Of 39 recruited participants, 32 (82.1%) and 27 (69.2%) completed 12 weeks and 52 weeks of the structured program, respectively. Decrease in weight by -12.0 kg (95% CI: -9.6, -14.4; p < 0.001) and -9.1 kg (95% CI: -5.2, -12.9; p < 0.001) and decrease in glycated haemoglobin (HbA1c) by -1.1% (95% CI: -0.6, -1.6; p < 0.001) and -0.6% (95% CI: -0.1, -1.1; p = 0.013) were observed at 12 and 52 weeks, respectively. At the end of 12 and 52 weeks, 93.8% (30/32) and 55.6% (15/27) of those with follow-up data met the criteria for diabetes remission, respectively. Quality of life and wellbeing scores increased over the course of 12 weeks, remaining significantly higher at 52 weeks. Participants reported they would be willing to pay A$92.50 (95% CI: A$75.80, A$109.30) per fortnight for the low-calorie meal replacement shakes. These findings support the feasibility of a structured diabetes remission service in an Australian primary care setting to achieve improvements in glycaemia, weight, and quality of life and wellbeing, and suggest a substantial willingness to pay for diet replacement products among participants.

Predictors of hearing outcomes in patients undergoing ossicular chain reconstruction in a developing country.

Objective: To explore the social and clinical factors that predict audiometric outcomes in patients undergoing ossicular chain reconstruction. Methods: A retrospective analytical cohort study was conducted, including patients 18 years of age or older with a history of chronic otitis media (COM) and/or any of its complications, who underwent ossicular chain reconstruction with Partial Ossicular Replacement Prosthesis (PORP) or Total Ossicular Replacement Prosthesis (TORP), at Hospital San José and Hospital infantile Universitario de San José between 2012 and 2020. We excluded patients with ossicular chain malformations and those with incomplete information. Information about sociodemographic and clinical factors was collected. Additionally, the surgery findings information was analyzed using the Ossiculoplasty outcome parameter staging ( OOPS) index. Results: A total of 35 adult patients who underwent ossicular chain reconstruction were retrospectively studied. An improvement was evidenced in the Preoperative Pure-Tone Average (PTA) and postoperative PTA (p-value=0.036), as well as in the pre and postoperative air-bone gap (ABG) (p-value &lt; 0.01). A moderate correlation coefficient was found between the OOPS index and the postoperative PTA (p= 0.429), and between the OOPS index and the postoperative (ABG) (p= 0.653). Conclusion: We found that a higher OOPS score is correlated with worse hearing outcomes postoperatively, and there was no association between the demographic or pathologic factors with a worse postoperative hearing outcome. Therefore, OOPS index can predict audiometric outcomes in patients undergoing ossicular chain reconstruction in a developing country, regardless of the demographic or pathologic factors.

The TORP-PORP: A Tympanoplasty Technique for Isolated Defects of the Stapes Suprastructure.

Investigating the outcomes of a surgical approach to treat isolated defects of the stapes suprastructure, using a modified total ossicular replacement prosthesis (TORP) prosthesis as a PORP between the footplate and the incus, effectively creating a TORP-PORP configuration. Eleven patients (mean age, 37.2 years; 36% male and 64% female) between the years 2007 and 2022. Therapeutic (ossiculoplasty). Hearing gain (in dB) in air conduction thresholds at 0.5, 1, 2, 3, and 4 kHz, stability of bone conduction, revision rate. Significant improvement in air conduction between the preoperative and the postoperative cohorts (p = 0.002) with a mean postoperative hearing level of 30.00 ± 5.25 dB. The bone conduction remained stable. We encountered no perioperative complications, and there were no revisions surgery. The described ossiculoplasty procedure is a safe and effective approach to treat isolated defects of the stapes suprastructure.

Rapid turnover of a pea aphid superclone mediated by thermal endurance in central Chile.

Global change drivers are imposing novel conditions on Earth's ecosystems at an unprecedented rate. Among them, biological invasions and climate change are of critical concern. It is generally thought that strictly asexual populations will be more susceptible to rapid environmental alterations due to their lack of genetic variability and, thus, of adaptive responses. In this study, we evaluated the persistence of a widely distributed asexual lineage of the alfalfa race of the pea aphid, Acyrthosiphon pisum, along a latitudinal transect of approximately 600 km in central Chile after facing environmental change for a decade. Based on microsatellite markers, we found an almost total replacement of the original aphid superclone by a new variant. Considering the unprecedented warming that this region has experienced in recent years, we experimentally evaluated the reproductive performance of these two A. pisum lineages at different thermal regimes. The new variant exhibits higher rates of population increase at warmer temperatures, and computer simulations employing a representative temperature dataset suggest that it might competitively displace the original superclone. These results support the idea of a superclone turnover mediated by differential reproductive performance under changing temperatures.

Is surgical risk of aortic arch aneurysm repair underestimated? A novel perspective based on 30-day versus 1-year mortality.

The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30-day and 1-year mortality after total arch replacement for aortic aneurysm. This was an international two-centre study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality. The median age of patients was 65.4 years (interquartile range 55.1-71.1) and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year (81%, 95% confidence interval (CI) 78-85%) survival probability compared to 30-day (92%, 95% CI 90-95%) survival probability. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke [hazard ratio (HR) 2.54, 95% CI (1.16-5.58)], renal failure [HR 3.59 (1.78-7.25)], respiratory failure [HR 3.65 (1.79-7.42)] and reoperation for bleeding [HR 2.97 (1.36-6.46)] were associated with 1-year mortality in patients who survived 30 days. There is an increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short term may be considered in assessing surgical risk in patients who are undergoing total arch replacement.

A qualitative study of the perceptions and experiences of participants and healthcare professionals in the DiRECT-Australia type 2 diabetes remission service.

The UK Diabetes Remission Clinical Trial (DiRECT) study was replicated in an Australian primary care setting. This qualitative study aimed to explore and understand the perceptions and experiences of both participants and healthcare professionals (HCPs) involved in the DiRECT-Australia Type 2 Diabetes Remission Service. All participants and HCPs delivering the service were invited to participate in semi-structured interviews via online videoconferencing. The interview guides explored perceptions and experiences in DiRECT-Australia, covering aspects such as barriers and facilitators to recruitment and participation, motivations and challenges across service phases, adequacy of support provided and the overall acceptability of the service. All interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Eight DiRECT-Australia participants and six HCPs (three general practitioners, two practice nurses and one dietitian) participated. Four overarching themes were identified: (1) Enablers and barriers to recruitment and continuous participation in DiRECT-Australia; (2) Motivators and overcoming barriers across the total diet replacement, food reintroduction and weight maintenance phases; (3) Importance of participant-HCP interactions and continuous support; (4) Acceptance and long-term need for DiRECT-Australia. Adherence to total diet replacement was less challenging than anticipated by participants. Transitioning to the food reintroduction phase was difficult but overcome through HCP support. DiRECT-Australia was well accepted by both participants and HCPs, and participants expressed willingness to continue with the service, if provided on a long-term basis. Both participants and HCPs were highly interested in the new diabetes remission service set up in an Australian primary care setting. The acceptability of DiRECT-Australia was underscored by participants emphasising the effectiveness of the service in achieving significant weight loss and diabetes remission. There is a need for long-term and wider implementation of the service to ensure that anyone with recent onset type 2 diabetes is offered the best possible chance to achieve remission.

Technique and early outcomes of total thoracoscopic double-valve replacement

ObjectiveReports on aortic and mitral double-valve replacement through total thoracoscopy are scarce, with surgical techniques constantly evolving. We aimed to compare the feasibility and safety between total thoracoscopic double-valve replacement and median sternotomy double-valve replacement. MethodsFrom November 2021 to March 2023, we performed double-valve replacements in 76 patients using the total thoracoscopic double-valve replacement. The control group comprised 77 patients who underwent median sternotomy double-valve replacement. We analyzed data on baseline characteristics, perioperative events, and early postoperative outcomes. ResultsIn the total thoracoscopic double-valve replacement group, the cardiopulmonary bypass and aortic crossclamping times were 174.20 ± 38.87 minutes and 120.20 ± 19.54 minutes, respectively; both were significantly longer compared with those in the median sternotomy double-valve replacement group (cardiopulmonary bypass: 123.65 ± 15.33 minutes; aortic crossclamping: 82.86 ± 9.51 minutes, P < .001). The total thoracoscopic double-valve replacement group exhibited an extended operative duration, with a mean of 4.40 ± 0.76 hours, in contrast to 3.21 ± 0.68 hours in the median sternotomy double-valve replacement group (P < .001). Postoperatively, the total thoracoscopic double-valve replacement group demonstrated a significantly shorter mechanical ventilation duration (9.29 ± 3.12 hours) and reduced intensive care unit stay time (24.31 ± 7.29 hours) than the median sternotomy double-valve replacement group (11.49 ± 4.27 hours and 26.76 ± 5.89 hours, respectively; P values of .019 and .040, respectively). Furthermore, the total thoracoscopic double-valve replacement group experienced a shorter postoperative hospitalization time, averaging 6.21 ± 1.58 days, than the median sternotomy double-valve replacement group (8.35 ± 1.07 days, P < .001). The total thoracoscopic double-valve replacement group also exhibited significantly lower chest drainage volume (average 223.91 ± 53.93 mL) than the median sternotomy double-valve replacement group (382.56 ± 61.87 mL, P < .001). In terms of transfusion rates, the total thoracoscopic double-valve replacement group (9.21%) showed a marked reduction compared with the median sternotomy double-valve replacement group (36.36%, P < .001). Both groups had similar major complications. ConclusionsThe initial results of the total thoracoscopic double-valve replacement underscore its safety and efficacy. This approach extends the applicability of total thoracoscopic cardiac surgery and warrants deeper exploration.

Insertion Multi-Parachute Suturing and Knotting (IMS-K) Technique for Aortic Surgery.

Successful surgical interventions for aortic surgery, such as hemiarch repair and total arch replacement, pivot on the foundation of optimal anastomosis. We propose an alternative approach to anastomosis. The "insertion multi-parachute suturing and knotting" (IMS-K) technique entails the deployment of two parachute sutures, which can be effectively employed for both proximal and distal anastomoses. The first suture is applied loosely to the posterior half of the anastomosis and subsequently parachuted down, tightening the suture with a nerve hook. The second suture replicates the procedure in the anterior half of the anastomosis, loosely securing it in a similar manner and tightening it with a nerve hook at the end. As a result, the artificial graft is completely inserted into the aorta with a substantial grip. This technique simplifies the aortic anastomosis by ensuring procedural simplicity while minimizing bleeding risk, thus potentially advancing surgical outcomes.

Extending the usefulness of the Stryker Growing Prosthesis in pediatric patients.

Osteosarcoma is a highly invasive primary bone tumor that predominantly occurs in childhood and adolescence. The Stryker Growing Prosthesis provides a means of reconstructing large bone defects resulting from bone resection in skeletally immature patients. This device can be expanded as the patient grows. The possible length of extension depends on the length of the prosthesis. Because further expansion was not possible, by turning the adjustable part of the extension back to zero and adding a new permanent extension allow the prosthesis to be further adjusted as growth ensues. Using this method/device only, a separate endoprosthesis was required to be attached onto the extension. Therefore, the applicable cases are limited, because of the fact that extensive resection usually means total femoral replacement is best indicated. However, this method is still useful for reducing the number of revision surgeries in such cases. This reduces costs and increases savings for insurers/countries.

Analysis of the hemostatic effect of preset wrapping technique for type A aortic dissection with abnormal coagulation.

There are many techniques to reduce anastomotic bleeding for the total arch replacement, but hemostasis is sometimes difficult to achieve after surgery for acute dissection, especially in patients with abnormal coagulation (AC). This study aimed to investigate the hemostatic effect and early efficacy of a pre-set bovine pericardium wrapper in the right heart system shunt for total arch replacement in patients with type A aortic dissection (TAAD) and preoperative AC. A retrospective analysis was conducted on 85 patients with TAAD and AC who underwent total arch replacement between January 2018 and December 2022. The patients were divided into two groups: the preset pericardium group (n=30) and the control group (n=55). There were no significant differences between the two groups in terms of Bentall surgery (ascending aorta replacement with an aortic valve artificial vessel) and cardiac arrest time. However, compared to the control group, the preset pericardium group exhibited a shorter duration of cardiopulmonary bypass (CPB) and operation (P<0.001). Additionally, the preset pericardium group required fewer transfusions of blood products and hemostatic drugs (P<0.05). Moreover, the preset pericardium group had lower 24-hour postoperative mediastinal drainage volume (P<0.001), a lower proportion of bedside hemofiltration (P=0.039), and a shorter duration of mechanical ventilation and stay in the intensive care unit (P=0.014). Although the preset pericardium group showed reductions in in-hospital mortality, re-exploration for bleeding, and neurologic dysfunction, these differences were not statistically significant compared to the control group. This study represents the first investigation into the application of the preset wrapping technique in total arch replacement for TAAD with AC. The results demonstrate that this method can reduce the duration of CPB and operation, decrease postoperative bleeding, and minimize the need for blood transfusion and hemostatic drugs. Consequently, this technique may contribute to early postoperative recovery.

The Evidence for the Use of Osteobiologics in Hybrid Constructs (Anterior Cervical Discectomy and Fusion and Total Disc Replacement) in Multilevel Cervical Degenerative Disc Disease: A Systematic Review.

Systematic review. Examine the clinical evidence for the use of osteobiologics in hybrid surgery (combined anterior cervical discectomy and fusion (ACDF) and total disc replacement (TDR)) in patients with multilevel cervical degenerative disc disease (DDD). PubMed and Embase were searched between January 2000 and August 2020. Clinical studies investigating 18-80 year old patients with multilevel cervical DDD who underwent hybrid surgery with or without the use of osteobiologics were considered eligible. Two reviewers independently screened and assessed the identified articles. The methodological index for non-randomized studies (MINORS) tool and the risk of bias (RoB 2.0) assessment tool were used to assess risk of bias. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to evaluate quality of evidence across studies per outcome. Eleven studies were included. A decrease in cervical range of motion was observed in most studies for both the hybrid surgery and the control groups consisting of stand-alone ACDF or TDR. Fusion rates of 70-100% were reported in both the hybrid surgery and control groups consisting of stand-alone ACDF. The hybrid surgery group performed better or comparable to the control group in terms of adjacent segment degeneration. Studies reported an improvement in visual analogue scale for pain and neck disability index values after surgery compared to preoperative scores for both treatment groups. The included studies had moderate methodological quality. There is insufficient evidence for assessing the use of osteobiologics in multilevel hybrid surgery and additional high quality and controlled research is deemed essential.

Distal Repair After Total Aortic Arch Replacement With Frozen Elephant Trunk in Patients With Chronic Multilevel Thoracic Aortic Disease

To examine the management of distal aortic disease after total arch replacement with the frozen elephant trunk (TAR + FET) in patients with chronic thoracic aortic disease. Two centre retrospective study of consecutive patients treated between January 2010 and December 2019. Primary endpoint was 30 day/in hospital mortality. Secondary end point was mid-term survival. Data are presented as median (IQR). Chi squared or Fisher's exact test was used as appropriate. Estimated survival (standard error) was assessed by the calculating Kaplan-Meier product limit estimator with right censoring of survival data. A p value of < .050 was considered to be statistically significant. STROBE guidelines were followed. A total of 158 patients (72 men; median age 70, IQR 64, 75; median distal aortic diameter 58 mm (46, 68; 127 aneurysmal disease, 31 chronic dissection) underwent TAR + FET. Peri-operative mortality was 10.1% (9/107 elective, 7/51 non-elective). Of 74 (46.8%) patients with a primary distal seal, seven (9.5%) died peri-operatively, distal seal was maintained during follow up in 51, nine underwent late distal repair (two planned, seven unplanned; one open, eight endovascular; one peri-operative death) with a median interval to unplanned repair of 777 days (462, 1480), and seven with loss of seal had no intervention. Distal seal failed in 2/28 (7%) patients with a distal seal length > 30 mm and device oversizing > 10%, compared with 12/39 (31%) patients who did not meet these criteria (p = .031). In 84 patients without primary distal seal, nine (10.7%) died peri-operatively, the distal aorta remained below the size threshold for repair during follow up in 12 patients, 44 had distal repair (median aortic diameter 64 mm, 60, 75; eight open, one hybrid, 35 endovascular repairs; no mortality) at a median of 256 days (135, 740), and 19 did not have distal repair at the end of the follow up period: six died before planned repair at a median interval of 115 days (85, 120); eight were considered unfit; one was assessed as fit but declined; and four patients were awaiting assessment). Median follow up was 46 months (26, 75): no patients were lost to follow up. Estimated ± standard error five year survival was 61.5 ± 4.1%: elective 70.6 ± 4.7%, non-elective 43.2 ± 7.2%. TAR + FET achieved primary distal seal in 47% of patients, but late failure occurred in 21% of patients. Distal repair was ultimately indicated in 84% of survivors without primary distal seal and of these 70% underwent repair, almost 10% died before planned repair, and 13% were considered unfit. Earlier distal endovascular repair and better assessment of patient fitness may improve mid-term outcomes.

Analysis of the effect of reconstructing the ossicular chain under otoendoscopy with and without a stapes superstructure

Background Numerous studies have been conducted on the effect of the stapes superstructure after ossicular chain reconstruction, but the findings are not uniform. Objective To compare the hearing outcomes of ossicular chain reconstruction with partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP) under otoendoscopy. Materials and methods The records of 111 patients diagnosed with chronic suppurative otitis media were retrospectively analyzed. These patients were divided into PORP group (n = 57) and TORP group (n = 54). They were further subdivided into subgroups PORP-a (with a malleus handle) and PORP-b (without a malleus handle), subgroups TORP-a and TORP-b. Pre- and postoperative audiometric results were analyzed. Results The mean postoperative air conduction hearing thresholds improvement, mean air–bone gap improvement, and the success rate of reconstruction were significantly higher in the PORP group than in the TORP group (p < .05). The mean postoperative air conduction hearing thresholds improvement and the success rate of reconstruction were significantly higher in the PORP-a group than in the TORP-a group (p < .05); and similar results were concluded in comparison of the PORP-b group and the TORP-b group. Conclusions and significance The stapes superstructure has an important positive effect on the postoperative outcome of endoscopic ossicular chain reconstruction.

Replacing soybean meal with microalgae biomass in diets with contrasting carbohydrate profile can reduce in vitro methane production and improve short-chain fatty acids production

The objective of this study was to evaluate the interaction of dietary carbohydrate profile and soybean meal (SBM) replacement with either Chlorella pyrenoidosa (CHL) or Spirulina platensis (SPI) on in vitro fermentation. This experiment was conducted as a randomized complete block design, with fermentation run (3 runs) considered as blocks. The treatments were arranged in a 2 × 5 factorial design, where the first factor was the carbohydrate profile, which was composed of diets containing 42.5% NDF and 26.8% starch (HF-LS) or 26.8% NDF and 40.6% starch (LF-HS) and the second factor was the protein source, in which a control diet (100% SBM), partial replacement of SBM with CHL (1/2 CHL) or SPI (1/2 SPI), or total replacement of SBM with CHL or SPI were used. All experimental diets were formulated to have 17% crude protein. The ruminal fluid was collected from 2 lactating Holstein cows, buffered with Van Soest medium at a ratio of 1:2 and added to serum bottles containing 0.50 g of the experimental diets. Bottles were incubated at 39°C for 24 and 48 h in triplicate; headspace pressure was measured, along with gas collection for methane (CH4) quantification at 0, 2, 4, 8, 16, 24, 36, and 48 h after incubation. The final medium was used to measure pH, ammonia, and volatile-fatty acid (VFA). After incubation, feed bags were recovered and used for estimation of degradability of DMD, NDF, and OMD. Statistical analysis was carried out using the MIXED procedure of SAS, with carbohydrate profile, protein source, assay, and its interactions as fixed effects, with run and bottle as random effects. Orthogonal contrasts were used to compare carbohydrate profile, algae species, carbohydrate profile × algae interaction, and linear and quadratic effects of SBM replacement with CHL or SPI. There was no interaction effect between carbohydrate profile and algae source. LF-HS improved gas production, degradability of nutrients, and VFA, mainly increasing the production of butyrate and propionate. When compared with CHL, SPI had a greater degradability of nutrients and branched VFA, along with reduction in total gas production and tended to reduce total CH4 yield. The replacement of SBM with algae linearly reduced the degradability of nutrients, along with a linear reduction in gas production. When replacement of SBM with only SPI was evaluated, SPI slightly reduced the degradability of nutrients; however, it promoted a linear reduction in CH4 yield, as well as reduction in CH4 yield by unit of degraded DM, NDF, and OM. In summary, there was no interaction of carbohydrate profile and protein source, which means that SBM replacement had a similar effect, regardless of dietary carbohydrate profile. Spirulina may be a more suitable algae source when compared with Chlorella due to the potential to reduce CH4.

Meta-analysis: Bilateral and Unilateral Cerebral Perfusion in Type A Dissection.

This meta-analysis compared the outcomes of bilateral cerebral perfusion (BCP) and unilateral cerebral perfusion (UCP) in aortic surgery for acute type A aortic dissection. A systematic literature search identified 12 studies involving 4,547 patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated to analyze perioperative characteristics, short-term mortality rates, and postoperative neurological complications. No significant differences were found between the BCP and UCP groups in terms of cardiopulmonary bypass time, aortic cross clamp time, lowest body temperature, and lower body circulatory arrest time. Short-term mortality rates (OR [95% CI] = 0.87 [0.64-1.19], p = 0.40) and permanent neurological deficits (OR [95% CI] = 1.01 [0.69-1.47], p = 0.96) were comparable between the groups. However, subgroup analysis of studies exclusively involving total arch replacement showed a lower short-term mortality rate (OR [95% CI] = 0.42 [0.28-0.63], p < 0.01) and permanent neurological deficits (OR [95% CI] = 0.53 [0.30-0.92], p = 0.03) in the BCP group. The BCP group also had a lower rate of temporary neurological deficits (OR [95% CI] = 0.70 [0.53-0.93], p = 0.01), particularly in studies exclusively involving total arch replacement (OR [95% CI] = 0.58 [0.40-0.85], p < 0.01). This meta-analysis suggests that BCP and UCP yield comparable outcomes. However, BCP may be associated with lower short-term mortality rates and reduced incidence of neurological complications, particularly in cases requiring total arch replacement. BCP should be considered as a preferred cerebral perfusion in specific patient populations.

Lumbar Total Disk Replacement Device Removals and Revisions Performed During a 20-Year Experience with 2141 Patients.

This was a retrospective study with prospective patient contact attempted to collect current data. The purpose was to investigate the incidence and reasons for lumbar total disk replacement (TDR) removal or revision. A concern regarding lumbar TDR was safety, particularly the need for device removal or revision. This may be particularly important considering removal/revision requires repeat anterior exposure with an increased risk of vascular injury. Data were collected for a series of 2141 lumbar TDR patients, beginning with the first case experience in 2000. The mean follow-up was 78.6 months. For each case of device removal/revision, the reason, duration from index surgery, and procedure performed were recorded. Of 2141 patients, 27 (1.26%) underwent TDR removal or revision. Device removal was performed in 24 patients (1.12%), while three patients underwent revision (0.14%). Of the 24 removals, 12 were due to migration and/or loosening, three developed problems post-trauma, two developed lymphocytic reaction to device materials, two had ongoing pain, and there was one case of each: TDR was too large, vertebral body fracture (osteoporosis), lytic lesion, device subsidence and facet arthrosis, and infection seeded from a chest infection 146 months post-TDR. The three revisions were for Core repositioning (technique error), device repositioning after displacement, and core replacement due to wear/failure. With respect to timing, 37.0% of removals/revisions occurred within one-month postimplantation. Of note, 40.7% of removals/revisions occurred in the first 25 TDR cases performed by individual surgeons. There was one significant vascular complication occurring in a patient whose TDR was removed due to trauma. This was also the only patient among 258 with ≥15-year follow-up who underwent removal/revision. In this large consecutive series, 1.26% of TDRs were removed/revised. The low rate over a 20 year period supports the safety of these devices.

Andexanet alpha-induced heparin resistance treated by nafamostat mesylate in a patient undergoing total aortic arch repair for Stanford type A acute aortic dissection: a case report

BackgroundAndexanet alfa, an anti-Xa inhibitor antagonist, induces heparin resistance. Here, we report a case of successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesylate.Case presentationAn 84-year-old female, with Stanford type A acute aortic dissection, underwent an emergency surgery for total aortic arch replacement. Andexanet alfa 400 mg was administered preoperatively to antagonize edoxaban, an oral Xa inhibitor. Heparin 300 IU/kg was administered before cardiopulmonary bypass, and the activated clotting time (ACT) was 291 s. The ACT was 361 s after another administration of heparin 200 IU/kg. According to our routine therapy for heparin resistance, an initial dose of nafamostat mesylate 10 mg was administered intravenously, followed by a continuous infusion of 20–30 mg/h. The ACT was prolonged to 500 s, and cardiopulmonary bypass was successfully established thereafter.ConclusionsThis case report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate. This report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate.

High Ferritin Is Not Needed in Hemodialysis Patients: A Retrospective Study of Total Body Iron and Oral Iron Replacement Therapy.

In vivo iron levels can be adjusted through intestinal iron absorption to be maintained at a suitable level; however, optimal iron levels in hemodialysis (HD) patients are unclear. In this study, we investigated total body iron (TBI), calculated as the sum of red blood cell (RBC) iron and iron stores, during courses of low-dose oral iron replacement therapy, and evaluated in vivo iron sufficiency and its indicators in HD patients. We analyzed data on 105 courses of low-dose iron replacement therapy administered to 83 patients on maintenance HD over 7 months. We evaluated changes in TBI, RBC iron, and iron stores from the initiation of treatment to month 7 in two groups of patients, namely, iron-therapy responders and non-responders. TBI showed significant increases until month 4 and plateaued thereafter in iron-therapy responders, and tended to increase and then reached a similar plateau in non-responders (month 7: 1900 ± 447 vs. 1900 ± 408 mg). Steady-state TBI was strongly correlated with body surface area (y = 1628.6x - 791.91, R2 = 0.88, p < 0.001). We observed constant TBI during oral iron replacement therapy suggesting the activation of a "mucosal block". The results suggest that body surface area has utility for estimating the required TBI with regression equations.