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International audience; The evaluation of the wear of hip prostheses is regulated by international standards, however, the results of in vitro tests do not allow to predict the effective lifetime once the implants are in place. Our study aims to develop a new method of in vitro testing of implants, more representative of their wear in physiological conditions. We also want to develop a questionnaire that can detect the particular sensitivities of each patient to the constituent materials of the prostheses and thus guide the choice of one's implant to limit the risk of aseptic loosening.

International audience; To evaluate factors associated with failure in patients treated with DAIR (debridement, antibiotic therapy, and implant retention) for Staphylococcus aureus prosthetic joint infections (PJIs). We retrospectively analyzed consecutive patients with stable PJI due to S. aureus treated with DAIR at six hospitals between 2010 and 2014. Cox proportional hazards regression was used to study factors associated with treatment failure at 2 years. Of 154 eligible patients, 137 were included (mean age 73 ± 13 years; male 56%). The estimated success rate according to the Kaplan–Meier method was 76.2 [95% CI 68–83] at 2 years of follow-up. In multivariate analysis, longer duration of treatment (hazard ratio (HR) 0.78 [0.69–0.88]; p 3 weeks and type of prosthesis (hip or knee). These results remained unchanged when the 14 patients under immunosuppressive therapy were removed from analysis. These data suggest that DAIR can be performed even if infection and symptoms are delayed but reserved to patients who are able to follow rifampin-based combination therapy for a prolonged duration that should not be different for hip and knee PJI.

Total joint replacement is the standard treatment of advancedosteoarthritis. Metal-on-Metal (MoM) hip resurfacing and hiparthroplasty are associated with long durability and low rates ofdislocations and used to be the standard surgical treatments.Complications due to MoM prostheses have however beenwidely reported. Adverse reactions to metal debris (ARMD)such as metallosis result from the progressive degradation of themetal surface and from metal ions deposition in the surroundingtissues. The formation of 'pseudotumors' leading to prosthe-sis malfunction has been reported after MoM resurfacing. Totalarthroplasty can also lead to the infection of the prosthesis asa consequence of contamination during surgery or bacteremicinfection not related to the prosthesis. Infections remain quitecommon (1-3% of surgical procedures) but reports of associ-ated ARMD are limited. We report the case of three patientspresenting with metallosis-associated infection on joint pros-thesis.

International audience; OBJECTIVES: The high microbiologic diversity encountered in prosthetic joint infection (PJI) makes the choice of empirical antimicrobial therapies challenging, especially in cases of implant retention or one-stage exchange. Despite the risk of dysbiosis and toxicity, the combination of vancomycin with a broad-spectrum β-lactam is currently recommended in all cases, even if Gram-negative bacilli (GNB) might be less represented in late PJI. In this context, this study aimed to describe the microbiologic epidemiology of PJI according to the chronology of infection. METHODS: This prospective cohort study (2011-2016) evaluated the microbiologic aetiology of 567 PJI according to time of occurrence from prosthesis implantation-early (\textless3~months), delayed (3-12~months) and late (\textgreater12~months)-as well as mechanism of acquisition. RESULTS: Initial microbiologic documentation (n~=~511; 90.1%) disclosed 164 (28.9%) Staphylococcus aureus (including 26 (16.1%) methicillin-resistant S.~aureus), 162 (28.6%) coagulase-negative staphylococci (including 81 (59.1%) methicillin-resistant coagulase-negative staphylococci), 80 (14.1%) Enterobacteriaceae, 74 (13.1%) streptococci and 60 (10.6%) Cutibacterium acnes. Considering nonhaematogenous late PJI (n~=~182), Enterobacteriaceae (n~=~7; 3.8%) were less represented than in the first year after implantation (n~=~56; 17.2%; p \textless0.001), without difference regarding nonfermenting GNB (4.6% and 2.7%, respectively). The prevalence of anaerobes (n~=~40; 21.9%; including 32 (80.0%) C.~acnes) was higher in late PJI (p \textless0.001). Consequently, a broad-spectrum β-lactam might be useful in 12 patients (6.6%) with late PJI only compared to 66 patients (20.3%) with early/delayed PJI (p \textless0.001). CONCLUSIONS: Considering the minority amount of GNB in late postoperative PJI, the empirical use of a broad-spectrum β-lactam should be reconsidered, especially when a two-stage exchange is planned.

In the majority of cases, arthrosis of the patellofemoral joint (PFJ) is combined with arthrosis of the femorotibial compartment and thus assumes a somewhat secondary role. Nevertheless, it can occur as an isolated entity. Several radiological studies evidenced isolated degenerative alterations in the PFJ in the age group >55 years (13.6-24.0% in women and 11.0-15.4% in men). In younger patients the incidence is lower and is mainly associated with patellar instability or post-traumatic arthrosis. Just the same, the choice of appropriate treatment for these patients is challenging. Total replacement can be recommended for older and less active patients. In contrast, for younger and more active patients, various conservative treatment options and more demanding operative techniques are available to the surgeon to avoid arthroplasty. This article describes the different therapeutic possibilities for managing arthrosis of the PFJ in patients aged

Extensor tendon rupture is a rare but serious complication after total knee arthroplasty (TKA) that impairs active knee extension, thereby severely affecting knee function. Surgery is usually required. Surgical options range from simple suturing to allograft reconstruction of the entire extensor mechanism and include intermediate methods such as reconstruction using neighbouring tendons or muscles, synthetic ligament implantation, and partial allograft repair. Simple suturing carries a high failure rate and should therefore be routinely combined with tissue augmentation using a neighbouring tendon or a synthetic ligament. After allograft reconstruction, outcomes are variable and long-term complications common. Salvage procedures for managing the most severe cases after allograft failure involve reconstruction using gastrocnemius or vastus flaps. Regardless of the technique used, suturing must be performed under tension, with the knee fully extended, and rehabilitation must be conducted with great caution. Weaknesses of available case-series studies include small sample sizes, heterogeneity, and inadequate follow-up duration. All treatment options are associated with substantial failure rates. The patient should be informed of this fact and plans made for a salvage option. Here, the main techniques and their outcomes are discussed, and a therapeutic strategy is suggested.

To determine whether high levels of serum alpha-fetoprotein (AFP) predict increased risk of adverse pregnancy outcomes, including preterm birth (before 37 weeks), preterm birth occurring at or before 28 weeks, small for gestational age (SGA) infant, preeclampsia, and placental abnormalities, and to determine whether low levels of serum AFP predict increased or decreased risk of these outcomes.Using the mother's first name, last name, and zip code, we linked the records of 51,008 women who participated in the California Alpha-Fetoprotein Screening Program between June 15, 1986, and October 31, 1987, with California birth certificates for singleton infants born in 1987. The accuracy of the data linkage was confirmed by manually examining complete names, mother's ethnicity, and mother's age for a sample of 500 of the mother-infant linkages. Blood samples were obtained at 15-19 weeks.A strong gradient of increasing risk of preterm birth with increasing levels of serum AFP was observed (test for trend, P.01). Among women with high levels of serum AFP (at least 2.5 multiples of the median [MoM]), 24.3% had preterm births, compared with 3.8% of women with low levels of serum AFP (0.81 MoM or less), odds ratio 8.7, 95% confidence interval 7.1-10.7). This gradient persisted when preterm infants of 28 weeks or less were examined separately. Similar gradients were observed for the risk of preeclampsia and placental abnormalities. There was a weaker U-shaped relation between serum AFP level and the risk of an SGA infant.Low levels of second-trimester maternal serum AFP are associated with a very low risk of preterm birth, preeclampsia, and placental complications. High levels of serum AFP are strongly associated with preterm birth, preeclampsia, and placental abnormalities. There is a modest association between AFP levels (both low and high) and SGA birth.

Isolated degeneration of the medial femorotibial compartment is a common pathologic process, being the source of important social costs due to disease-related disability and treatment expenses (1–3). Simultaneously aff ecting the cartilage, the menisci and, in later stages, the ligaments, it is currently viewed as an irreversible process. In that, it is distinguished from isolated well-circumscribed cartilaginous lesions for which articular surface restoration techniques are available. Although such lesions may over time evolve into frank degenerative arthritis (4, 5), their treatment will be addressed in other sections of this book. The goal of this chapter is to present the reader with a global view of medial knee osteoarthritis (OA), focusing on the rationale of the various surgical indications.

Participants in a panel discussion sponsored by thead hoc Quality Assurance Committee of the National Society of Genetic Counselors discuss early efforts to develop and implement quality assurance instruments at institutional, state, and regional levels. Uniform guidelines and self-assessment tools can help genetic counselors and clinical geneticists to provide the best possible care to individuals affected by genetic diseases. Further work will be needed to address aspects not covered here and to assure that guidelines allow for creative variation among professionals and centers. An interdisciplinary approach to such standard-setting is recommended.

Beginning in 1977, numerous studies have reported an association between high levels of maternal serum alpha-fetoprotein, measured in early pregnancy, and low birthweight and perinatal death. It has been suggested, however, that these findings may be explained by bias. We reviewed 21 studies and found that they were unanimous in reporting this association and that the association cannot be explained by any of the proposed biases. Comparing women whose alpha-fetoprotein levels were 2.5 times the median or more with all other women, the highest relative risk of fetal death was 21.0, with a 95% confidence interval of 8.4-52.2, and the lowest relative risk of fetal death was 4.4, with a 95% confidence interval of 2.8-7.0. For low birthweight (< 2,500 grams), the highest relative risk was 6.4 (95% confidence interval = 3.1-13.1) and the lowest relative risk was 1.9 (95% confidence interval = 1.5-2.5).

In the past decades, partial, subtotal, or total meniscectomy has received ample consideration in the literature. At present, arthroscopic meniscectomy remains one of the most common orthopedic procedures, but may have severe consequences that should not be neglected. The National Center of Health Statistics [45] reported more than 450,000 arthroscopic meniscectomies being performed each year in the United States (US). The first report on degenerative knee joint changes postmeniscectomy was published by Fairbanks [34] in 1948. Since then, many different issues regarding this procedure have been a matter of debate: total or partial excision, open or arthroscopic procedures, and recent techniques of repair, suture, and grafting. The outcome is correlated to cartilage status, anterior cruciate ligament (ACL) efficiency, and amount of resection. The purpose of this chapter is to analyze the global results of meniscectomy and its complications.

The finding of an elevated level of maternal serum alpha-fetoprotein during the second trimester of pregnancy may indicate that the fetus has died or is about to die. It is uncertain, however, whether the finding is associated with an increased risk of fetal death later in gestation independent of known causes of elevation, such as the presence of neural-tube defects or multiple gestation.To address this question, we performed a case-control study of 612 women whose pregnancies ended in fetal death and 2501 women who gave birth to live infants, using reports from California vital statistics for 1987. All the women had signleton pregnancies and alpha-fetoprotein screening in the second trimester.Women with elevated levels of serum alpha-fetoprotein in the second trimester of pregnancy had an increased risk of fetal death, and the risk was increased until term. Women with the highest levels of serum alpha-fetoprotein--greater than or equal to 3.0 times the median value--had a very high risk of fetal death (odds ratio, 10.4; 95 percent confidence interval, 4.9 to 22.0) as compared with women who had normal levels of alpha-fetoprotein. Maternal serum alpha-fetoprotein levels that were 2.0 to 2.9 times the median were also associated with an elevated risk of fetal death (odds ratio, 2.4; 95 percent confidence interval, 1.7 to 3.4). Elevated levels of alpha-fetoprotein were especially likely to be associated with fetal death in cases in which maternal hypertension or placental infarction was also present. CONCLUSIONs. An unexplained elevated level of maternal serum alpha-fetoprotein in the second trimester of pregnancy is associated with an increased risk of subsequent fetal death, up to four to five months after alpha-fetoprotein screening.

Living-unrelated donors may become an additional organ source for patients on the kidney waiting list. We studied the impact of a combination of calcineurin inhibitors and mycophenolate-mofetil together with steroids on the outcomes of living-related (LRD), unrelated (LUR), and cadaver transplantation.Between September 1997 and January 2000, 129 patients underwent LRD (n = 80) or LUR (n = 49) kidney transplantation, and another 173 patients received a cadaveric kidney. Immunosuppressive protocols consisted of mycophenolate-mofetil with cyclosporine-Neoral (41%) or tacrolimus (59%) plus steroids. We compared the patient and graft survival data, rejection rate, and graft functional parameters.LRD recipients were younger (33.6 years) than LUR (47.8 years) and cadaver (43.7 years) donor recipients (P0.001). HLA matching was higher in LRD patients (P0.001). Acute rejection developed in 28.6% of LUR versus 27.5% of LRD transplants and 29.7% of cadaver kidney recipients (P = not significant). The creatinine level at 1, 2, and 3 years after transplant was 1.63, 1.73, and 1.70 mg% for LRD patients; 1.48, 1.48, and 1.32 mg% for LUR patients; and 1.75, 1.68, and 1.67 mg% for cadaver kidney recipients (P = not significant), respectively. No difference in patient survival rates was found among the groups. The 1, 2, and 3-year graft survival rates were significantly better in recipients of LRD (91.3%, 90.0%, and 87.5%, respectively) and LUR transplants (89.8%, 87.8%, and 87.8%, respectively) than in cadaver kidney recipients (81.5%, 78.6%, 76.3%, respectively; P0.01).Despite HLA disparity, the rejection and survival rates of LUR transplants under current immunosuppressive protocols are comparable to those of LRD and better than those of cadaveric transplants.

Beginning in 1977, numerous studies have reported an association between high levels of maternal serum alpha-fetoprotein, measured in early pregnancy, and low birthweight and perinatal death. It has been suggested, however, that these findings may be explained by bias. We reviewed 21 studies and found that they were unanimous in reporting this association and that the association cannot be explained by any of the proposed biases. Comparing women whose alpha-fetoprotein levels were 2.5 times the median or more with all other women, the highest relative risk of fetal death was 21.0, with a 95% confidence interval of 8.4-52.2, and the lowest relative risk of fetal death was 4.4, with a 95% confidence interval of 2.8-7.0. For low birthweight (< 2,500 grams), the highest relative risk was 6.4 (95% confidence interval = 3.1-13.1) and the lowest relative risk was 1.9 (95% confidence interval = 1.5-2.5).

PACEPAC is the acronym for “production and certification of a road dust reference material for platinum, palladium and rhodium used in automotive catalytic converters” (Schramel and Lustig 1998). The overall objective of this project is to supply the needs of a suitable CRM for PGE analysis in environmental matrices. The motivation and background generally has to be seen in the increasing research activities on PGE emissions and especially in the unacceptable analytical uncertainty concerning the determination of PGE in the (naturally relevant) ultra-low (ng L-1 - µg L-1) concentration range. So far for platinum only three CRM are available, two based on ore matrices one as a grinded catalytic converter. Regarding the high concentrations of PGE and the matrices (nickel sulphide ore, nickel-copper-cobalt ore, cordierite) they are not very useful for the analysis of environmentally relevant samples. For PACEPAC a road dust, taken from the ceiling of a tunnel, is suggested to be the ideal matrix, as it provides the PGE in the chemical form and matrix in which they were emitted from the car-catalysts.

Objective: To study the chromosome abnormality rate among women with elevated levels of maternal serum alpha-fetoprotein (MSAFP) and the types of chromosome abnormalities in this population, and to compare this rate with reports in the literature and the rate observed in the general population. Methods: We studied 8097 women who chose to undergo amniocentesis and fetal karyotyping after having an elevated MSAFP test of 2.5 multiples of the median (MOM) or higher. All abnormal karyotypes were reviewed and grouped according to whether the elevated MSAFP value could be explained by a ventral wall or neural tube defect. Results: The overall chromosome abnormality rate was 13.83 per 1000 amniocenteses. The rate in the "unexplained" group was 10.92 per 1000 amniocenteses. Just over half (53%) of the abnormal karyotypes were autosomal anomalies, and 47% were sex chromosome abnormalities. The autosomal aneuploidies observed most frequently were triploidy and trisomy 13. The sex chromosome abnormalities observed most frequently were the XXY and XYY karyotypes. Conclusion: Women who have unexplained elevated MSAFP values of 2.5 MOM or greater have a twofold increase in the rate of chromosome abnormalities in their fetuses compared with the general population ( P ≤ .001). This rate is consistent with other studies that used a 2.5 MOM cutoff. Studies that used a 2.0 MOM cutoff have reported chromosome abnormality rates that do not vary from general population estimates.

BK POLYOMA virus (BKV) is a newly described agent causing renal dysfunction and failure among kidney transplant recipients. The virus remains latent following primary exposure at childhood and becomes activated in immunocompromised states. Clinically, the virus rarely causes symptoms such as hemorrhagic cystitis in bone marrow transplant recipients. Although viral shedding is detected in urine specimens of many renal transplant recipients, only a few will develop BKV transplant nephropathy. This disease process is characterized by a rapidly progressive loss of graft function. Introduction of new and more aggressive immunosuppressive protocols may explain the emergence of this new infectious complication. We describe our experience with 7 patients with BKV nephropathy with specific attention to possible risk factors.

N- Methyl- d -aspartate (NMDA) receptor activation has been implicated in the pathogenesis and clinical expression of Parkinson's disease. Because some antiparkinsonian drugs have NMDA antagonist properties, we examined their effects on NMDA toxicity, measured by lactate dehydrogenase (LDH) release, in neuron-enriched cerebrocortical cultures. Amantadine reduced NMDA toxicity with half-maximal reduction at ∼ 30 μM, while trihexyphenidyl, l -3,4-dihydroxyphenylalanine ( l -DOPA), bromocriptine and selegiline were ineffective, and benztropine was itself toxic. Amantadine and related drugs could not only reduce parkinsonian symptoms, but also modify underlying neurodegenerative processes.

The main goal of the present work was the elucidation of the mechanistic characteristics of dynamic transport of various penetrants (solvents) in thin sections of coals by examining their penetrant uptake, front swelling and stress development. An important objective of this work was the study of coal network structure in different thermodynamically compatible penetrants and the analysis of dynamic swelling in terms of present anomalous transport theories. Interferometry/polariscopy, surface image analysis and related techniques were used to quantify the stresses and solvent concentration profiles in these sections. Dynamic and equilibrium swelling behavior were correlated using the polar interaction contributions of the solvent solubility parameters. The penetrant front position was followed in thin coal sections as a function of time. The initial front velocity was calculated for various coals and penetrants. Our penetrant studies with thin coal section from the same coal sample but with different thickness show that within the range of 150 {mu}m to 1500{mu}m the transport mechanism of dimethyl formamide in the macromolecular coal network is non-Fickian. In fact, for the thickest samples the transport mechanism is predominately Case-II whereas in the thinner samples penetrant uptake may be diffusion-controlled. Studies in various penetrants such as acetone, cyclohexane, methanol,more » methyl ethyl ketone, toluene and methylene chloride indicated that penetrant transport is a non-Fickian phenomenon. Stresses and cracks were observed for transport of methylene chloride. 73 refs., 88 figs., 15 tabs.« less

FISH OIL has been administered orally to renal transplant recipients to increase glomerular filtration rate by augmenting effective renal plasma flow and to decrease the occurrence of acute rejection. Parenteral fish oil administered to rats after heart allotransplantation episodes decreased cytokine levels within 6 hours even after cessation of the supplement. The aim of this study was to assess the renal function of kidneys obtained from heartbeating donors that had received an intravenous infusion of 20% lipid emulsion enriched in fish oil (MLF 541, B Braun, Melsungen, Germany) and administered for 5 days posttransplantation.

In order to improve patient care, provide better teaching in an ambulatory setting, and establish research opportunities for faculty staff, the medical clinic of the Children's Hospital of Philadelphia has been developed into a group practice. The entire house staff is involved in this project, and it appears that the endeavor has resulted in improved patient care and house officers who are better prepared for outpatient problems. Some of the difficulties are discussed.

A 47-year-old woman underwent thoracoplasty for tuberculosis on the right apex of the lung. A heavily scarred area remained asymptomatic. Both the long interval after surgery and the histology of the tumor are unusual.

On April 30, 1783, James Boswell called on Dr. Johnson in the course of his "morning active rounds," and later recorded in his journal that after starting the fruitful topics of religion and individual conscience, "I shewed him Verses by MALLOCH in imitation of DONAIDES, a Poem, which Lord Hailes had sent to him. I asked to have this as a Curiosity which I would preserve and he would not. He gave it me. But asked me to get him information from Lord Hailes WHO was Donaus of whom Donaides was the son."1 When Boswell translated this episode to the Life of Johnson, where it introduces a notable discourse on the merits of modern learning, he omitted all but the first sentence. This he revised and enlarged considerably: "Lord Hailes had sent him a present of a curious little printed poem, on repairing the University of Aberdeen, by David Malloch, which he thought would please Johnson, as affording clear evidence that Mallet had appeared even as a literary character by the name of Malloch; his changing which to one of softer sound, had given Johnson occasion to introduce him into his Dictionary, under the article Alias.2 This piece was, I suppose, one of Mallet's first essays. It is preserved in his works, with several variations."3

Although hypertension is a frequent complication of cyclosporin A (CSA) therapy in clinical practice, little experimental information is available on the nature and the mechanism of this form of hypertension. We studied the effect of currently recommended therapeutic dosages of CSA, i.e., 5 (CSA5) and 20 (CSA20) mg.kg-1.day-1, on blood pressure and the renin-aldosterone system (RAS) in spontaneously hypertensive rats (SHR). Influence of in vivo CSA treatment on in vitro angiotensin II (ANG II)-stimulated aldosterone secretion by isolated adrenal glomerulosa cells (AGC) was also measured. CSA treatment in SHR resulted in a consistent increase in systolic blood pressure. This increase in blood pressure occurred in the absence of significant changes in creatinine clearance in CSA5 rats, whereas in CSA20 rats a significant reduction in creatinine clearance was observed. Sodium balance and serum calcium and magnesium concentrations were not different between the control group and either of the two CSA-treated groups of rats. Plasma renin concentration (PRC) and inactive renin (IR) were markedly elevated, but plasma renin substrate remained unchanged with CSA administration. Despite the presence of hyperreninemia, plasma aldosterone was not elevated, suggesting that CSA may induce relative adrenal resistance to ANG II. This possibility was tested using AGC isolated from CSA-treated rats. ANG II-stimulated aldosterone secretion in AGC was diminished by low dose and aborted by high dose CSA-treatment. Thus CSA administration in SHR induces a predictable increase in blood pressure in association with "hyperreninemic hypoaldosteronism."