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Background Intrathecal morphine is commonly and effectively used for analgesia after joint arthroplasty, but has been associated with delayed respiratory depression. Patients with obstructive sleep apnea may be at higher risk of postoperative pulmonary complications. However, data is limited regarding the safety of intrathecal morphine in this population undergoing arthroplasty. Methods This retrospective cohort study aimed to determine the safety of intrathecal morphine in 1,326 patients with documented or suspected obstructive sleep apnea undergoing hip or knee arthroplasty. Chart review was performed to determine clinical characteristics, perioperative events, and postoperative outcomes. All patients received neuraxial anesthesia with low-dose (100 μg) intrathecal morphine (exposure) or without opioids (control). The primary outcome was any postoperative pulmonary complication including: (1) respiratory depression requiring naloxone; (2) pneumonia; (3) acute respiratory event requiring consultation with the critical care response team; (4) respiratory failure requiring intubation/mechanical ventilation; (5) unplanned admission to the intensive care unit for respiratory support; and (6) death from a respiratory cause. The authors hypothesized that intrathecal morphine would be associated with increased postoperative complications. Results In 1,326 patients, 1,042 (78.6%) received intrathecal morphine. The mean age of patients was 65 ± 9 yr and body mass index was 34.7 ± 7.0 kg/m2. Of 1,326 patients, 622 (46.9%) had suspected obstructive sleep apnea (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender [STOP-Bang] score greater than 3), while 704 of 1,326 (53.1%) had documented polysomnographic diagnosis. Postoperatively, 20 of 1,322 (1.5%) patients experienced pulmonary complications, including 14 of 1,039 (1.3%) in the exposed and 6 of 283 (2.1%) in the control group (P = 0.345). Overall, there were 6 of 1 322 (0.5%) cases of respiratory depression, 18 of 1,322 (1.4%) respiratory events requiring critical care team consultation, and 4 of 1,322 (0.3%) unplanned intensive care unit admissions; these rates were similar between both groups. After adjustment for confounding, intrathecal morphine was not significantly associated with postoperative pulmonary complication (adjusted odds ratio, 0.60 [95% CI, 0.24 to 1.67]; P = 0.308). Conclusions Low-dose intrathecal morphine, in conjunction with multimodal analgesia, was not reliably associated with postoperative pulmonary complications in patients with obstructive sleep apnea undergoing joint arthroplasty. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Within quantum theory, we can create superpositions of different causal orders of events, and observe interference between them. This raises the question of whether quantum theory can produce results that would be impossible to replicate with any classical causal model, thereby violating a causal inequality. This would be a temporal analogue of Bell inequality violation, which proves that no local hidden variable model can replicate quantum results. However, unlike the case of non-locality, we show that quantum experiments can be simulated by a classical causal model, and therefore cannot violate a causal inequality.

BACKGROUND Core outcome sets aim to select and standardize the choice of important outcomes reported in clinical trials to encourage more effective data synthesis, increase the reliability of comparing results, and minimize reporting bias. A core outcome set for elective shoulder surgery has yet to be defined, and therefore a systematic assessment of outcomes and methodology is necessary to inform the development of a core outcome set. QUESTIONS/PURPOSES The purpose of this study was to examine randomized controlled trials (RCTs) of patients having elective major or minor shoulder surgery to (1) identify the outcome domains reported; (2) determine specific outcome measurement tools that were utilized; and (3) assess the work for methodological quality and risk of bias. METHODS We conducted a scoping review (a review that identifies the nature and extent of research evidence) to explore the reported outcome domains, outcome tools, and methodological quality from RCTs conducted in shoulder surgery. We considered both major shoulder surgery (defined as arthroplasty, rotator cuff repair, stabilization procedures, biceps tenodesis, or Bankart repairs) and minor shoulder surgery (simple arthroscopy, capsular plication, lateral clavicular excisions, or subacromial decompression). We queried 10 electronic databases for studies published between January 2006 and January 2015. Studies were included if they were prospective, randomized controlled, clinical trials enrolling patients who received an elective shoulder surgical intervention. We extracted data relating to trial characteristics, primary outcomes, tools used to measure these outcomes as well as methodological quality indicators. We assessed indicators of methodological quality by exploring (1) the reproducibility of power analyses; and (2) whether the primary outcomes were powered to minimum clinically important differences. Risk of bias was also assessed with the Jadad score with scores between 0 (very high risk of bias) and 5 (very low risk). Findings were qualitatively analyzed and reported according to systematic and scoping review guidelines. We included 315 studies involving 30,232 patients; 266 studies investigated anesthetic, analgesic, or surgical interventions. RESULTS Of the 315 studies included, the most common outcome domains evaluated were analgesic (n = 104), functional (n = 87), anesthetic (n = 56), and radiologic (n = 29) outcomes, with temporal patterns noted. Studies of major shoulder surgery most commonly reported functional primary outcome domains, whereas minor shoulder surgery studies most frequently reported analgesic primary outcome domains. There were 85 different primary outcome tools utilized, which included 20 functional, 20 anesthetic, 13 analgesic, and 12 radiologic. A methodological quality assessment revealed that 24% of studies had reproducible power analyses, 13% were powered to minimum clinically important differences, and risk of bias assessment demonstrated a median (interquartile range [range]) Jadad score of 4 (3-5 [1-5]). CONCLUSIONS A wide range of outcome domains and outcome assessment tools are in common use in contemporary trials of patients undergoing elective surgery. Although some diversity is important to allow the assessment of patient populations that may have different goals, the large number of tools in common use may impair the ability of future meta-analyses to pool results effectively or even for systematic reviews to synthesize what is known. The limitations of methodological quality in RCTs may be improved by researchers following standard guidelines and considering the minimum clinically important differences in their trials to be of greater use to clinicians and their patients. LEVEL OF EVIDENCE Level I, therapeutic study.

Background and Aims: Cadaveric studies have shown that injectate from transmuscular quadratus lumborum block (QLB) can spread to the lumbar plexus. Our aim was to compare analgesic efficacy of transmuscular QLB with lumbar plexus block (LPB) for patients undergoing total hip arthroplasty (THA). Material and Methods: Thirty patients receiving transmuscular QLB were propensity score matched with 30 patients receiving LPB for age, sex, ASA score, BMI, operative time, preoperative oxycodone, and intraoperative opioid use. The primary outcome was postoperative opioid consumption during the first 24 postoperative hours. Secondary outcomes included static pain scores at 0–12, 12–24, and 24–48 h intervals, opioid consumption at 0–12, 12–24, and 24–48 h intervals and the length of hospital stay. The incidence of severe adverse events was also compared. Results: Opioid consumption (median [IQR]) in the first 24 h was similar between the transmuscular QLB and LPB patient groups—33.6 mg (22.9–48.5) versus 32.8 mg (24.8–58.3) intravenous morphine equivalents. There was no difference between groups in static pain scores or opioid consumption during any time interval up to 48 h postoperatively. Length of hospital stay (median [IQR]) was similar between the transmuscular QLB and LPB groups—55.6 h (53.7–60.3) versus 57.9 h (54.3–79.1). Conclusions: This study suggests that transmuscular QLB provides similar analgesia to LPB following THA. Prospective studies are needed to confirm this.

Calciphylaxis is a rare systemic condition usually seen in patients with end-stage renal disease. It is characterised by pathological calcification of dermal blood vessels, causing ischaemia and necrosis in the skin and subcutaneous fat. The lesions are usually small but, in extreme cases, may be very extensive and may mimic necrotising fasciitis, prompting extensive surgical debridement. We describe the challenges faced in managing such a case. A 38-year-old female patient was admitted to another hospital with widespread progressive truncal skin necrosis. A provisional diagnosis of necrotising fasciitis was made, and she underwent debridement of 32% of her total body surface area (TBSA). However, her condition rapidly deteriorated and she was transferred to our burn centre for further management. Diagnosis of calciphylaxis was based on clinical features and confirmed by tissue biopsy. Characteristic findings of progressive skin and fat necrosis at the wound margins with healthy underlying fascia and muscle were recognised from previously treated cases of calciphylaxis; however, the absence of renal disease proved misleading. Non-uraemic calciphylaxis is very rare but can, as in this case, be associated with alcoholic liver disease. At our centre, the patient required prolonged ventilation and supportive treatment in burns critical care, combined with intensive wound management, repeated episodes of debridement, temporary wound cover using human skin allografts and reconstruction using split-thickness autograft. We report this case to alert others to this rare condition as a possible diagnosis in patients presenting with extensive panniculitis. We discuss associations, diagnostic difficulties, novel therapies and the importance of multidisciplinary care in managing these complex cases. Level of evidence: Level V, diagnostic study.

Background Intravenous dexamethasone is thought to prolong the duration of peripheral nerve block, but the dose–response relationship remains unclear. The aim of this volunteer study was to evaluate the dose–response effect of i.v. dexamethasone on the prolongation of median nerve block. Methods In a double-blind, randomised controlled study, 18 volunteer subjects received two median nerve blocks separated by a washout period. One block was conducted alongside an infusion of saline and the other alongside i.v. dexamethasone 2, 4, or 8 mg. The primary outcome was time to return of normal pinprick sensation. Secondary outcomes included thermal quantitative sensory testing (QST) for the time to return of cold detection threshold (CDT), warm detection threshold (WDT), cold pain threshold (CPT), heat pain threshold (HPT), area under QST curves, grip strength, and the incidence of adverse effects. Results The primary outcome, time to recovery of pinprick sensation, was similar between volunteers receiving saline or i.v. dexamethasone, regardless of dose (P=0.99). The time to recovery of QST milestones was similar between groups, although area under QST curves indicated prolongation of CDT (0 vs 8 mg, P=0.002) and WDT (0 vs 2 mg, P=0.008; 0 vs 4 mg, P=0.001; 0 vs 8 mg, P Conclusions Intravenous dexamethasone failed to significantly prolong the duration of pinprick anaesthesia regardless of dose. However, area under QST curve analysis indicated a dose-independent prolongation of CDT and WDT, the clinical significance of which is unclear. Clinical trial registration NCT02864602 (clinicaltrials.gov).

The article describes the Batang Kali incident in which a number of Chinese workers were shot dead by the British army in circumstances which have never been satisfactorily explained. The author, who published a history of the Malayan Emergency some years ago, sets the incident in the wider context of British policy in the somewhat confused early months of the Emergency. He then chronicles the subsequent attempts to re-examine events. He then examines various suggestions that British policy was in general one of deliberate counterterror and concludes that the available evidence does not really substantiate this charge.

Background and Objectives The purpose of this cadaveric study was to determine the pattern of anterior hip capsule innervation and the associated bony landmarks for image-guided radiofrequency denervation. Methods Thirteen hemipelvises were dissected to identify innervation of the anterior hip capsule. The femoral (FN), obturator (ON), and accessory obturator (AON) nerves were traced distally, and branches supplying the anterior capsule documented. The relationships of the branches to bony landmarks potentially visible with ultrasound were identified. Results The anterior hip capsule received innervation from the FNs and ONs in all specimens and the AON in 7 of 13 specimens. High branches of the FN (originating above the inguinal ligament) were found exclusively in 12 specimens and passed between the anterior inferior iliac spine and the iliopubic eminence. The ONs were innervated exclusively by high branches (proximal to the division), by low branches (from the posterior branch), and by both in 4, 5, and 4 specimens, respectively. The most consistent landmark was the inferomedial acetabulum (radiographic “teardrop”). When present, the AON coursed over the iliopubic eminence before innervating the anterior hip capsule. Conclusions Branches of the FNs and ONs consistently provided innervation to the anterior hip capsule. The AON also contributed innervation in many specimens. The relationship of the articular branches from these 3 nerves to the inferomedial acetabulum and the space between the anterior inferior iliac spine and iliopubic eminence may suggest potential sites for radiofrequency ablation.

Android has many security flaws that are being exploited by malicious developers. Common malware includes many different kinds of behaviors; from complicated root exploits -- to simple private data leakage via explicit permissions. The security features that have been put in place by the Android developers have proven to be insufficient and incapable of preventing malware from proliferating through official and unofficial repositories. Private data leakage has become a popular topic because of the sheer number of applications that request the various permissions to access mobile device's private data and an influx of general privacy concerns amongst the Android community.

Would Ho Chi Minh have been a good newscaster? Would things have been different if he had gone to San Francisco in the summer of 1944 to broadcast the news in Vietnamese? As David Marr says, one cannot help but wonder;1 and one cannot help but wonder also what other events might have turned out differently; and whether, in or out of the event, the course of modern Vietnamese history could have been changed. Whether, in conception, the Vietnam War was a tragedy because it had to happen as it did. Or whether it was a tragedy because it might have been averted.