Jersey City Medical Center

Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.

Background Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV2), is an ongoing pandemic that has already affected millions of patients worldwide, and is associated with significant morbidity and mortality burden. Although the clinical and laboratory characteristics of this illness have been reported in patients from China and Europe, data are scant in the United States. Methods We extracted data regarding all patients hospitalized at our hospital with COVID-19 infection between March 1 and April 4, 2020. Presenting signs and symptoms, laboratory and imaging findings, treatment, and complications were recorded from electronic medical records (EMRs). The primary composite endpoint was admission to intensive care unit (ICU), shock, or death. Results We had a total of 43 patients tested for COVID-19 at the emergency room (ER) or during hospitalization, 16 (37%) of whom were admitted with COVID-19 infection. The mean age was 65.5 years and 75% were males. The most common presenting symptoms were fever (94%), cough (88%), and dyspnea (81%). A loss of smell and taste sensations were reported by three (19%) patients. Low oxygen saturation was present in 38% of patients, whilst 31% were hypotensive on admission. Hyponatremia (50%), elevated C-reactive protein (CRP; 100%), and lactate dehydrogenase (LDH; 80%) were common. Acute renal failure, myocardial injury, and elevation in aminotransferases occurred in 69%, 19%, and 38% patients, respectively. The primary composite endpoint occurred in 50% of patients. A total of three patients died; all were aged 70 years or older. Conclusions Laboratory abnormalities and acute renal failure were common in hospitalized patients with SARS-CoV2 infection in our center. Admission to ICU and mechanical ventilation were common.

Before alcohol ingestion. t After 22-day period of alcohol ingestion. I Serum glutamate-oxaloacetate transaminase.

INTRODUCTION: There is an urgent need to identify patients at high risk during the ongoing coronavirus disease (COVID-19) pandemic. Whether a history of stroke is associated with increased severity of disease or mortality is unknown. METHOD: We pooled studies from published literature to assess the association of a history of stroke with outcomes in patients with COVID-19. RESULTS: A pooled analysis of 4 studies showed a ∼2.5-fold increase in odds of severe COVID-19. While a trend was observed, there was no statistically significant association of stroke with mortality in patients with COVID-19 infection. DISCUSSION: Our findings are limited by a small number of studies and sample size. CONCLUSION: There is a ∼2.5-fold increase in odds of severe COVID-19 illness with a history of cerebrovascular disease.

THE complex nature of chronic bronchitis makes it difficult to define the relative importance of the many factors that might contribute to its pathogenesis and course.1 , 2 The progressive decline of the patient can generally be related to the number, length and severity of acute exacerbations that he suffers. The role of infection in the decline of the bronchitic patient is indicated by the morphologic findings in the bronchopulmonary tree,3 by the relative success of antibacterial treatment of the acute illness and by the occasional effectiveness of the prophylactic use of selected antibiotics.4 5 6 Much of the difficulty in evaluating the role . . .

Although ethyl alcohol has a long medicinal his- tory (1), its precise effects on the cardiovascular system have not been defined. Acute alcohol in- gestion is known to result in triglyceride accumula- tion in the liver, which appears dependent upon an intact sympathetic nervous system (2). Evidence for stimulation of this system after ethanol ingestion has been advanced (3). Since sustained catecholamine infusion has been associated with lipid accumulation in the myocardium (4, 5), a study of the acute effects of ethanol on myocardial metabolism and function has been undertaken in animals considered nutritionally normal. The quantity given produced blood level concentrations usually associated with moderate intoxication.

The literature is still controversial regarding the intestinal absorption of calcium in osteoporosis, with conflicting reports of decreased absorption (1-4), increased absorption (5-7), and normal absorption (8-10). The apparent discrepancies in these reports may stem from a) the absence of a common isotopic absorption test wherein oral "7Ca doses of uniform specific activity are adminis- tered in the fasting state, b) wide variations in the amount and chemical form of the administered stable calcium carrier, c) inadequate identification of the osteoporotic disease process and its differ- entiation from osteomalacia, d) the lack of suffi- cient age-matched nonosteoporotic controls for comparison, and e) wide variations in dietary cal- cium intakes, which prohibit adequate comparison between individual reports.

The use of fluoroscopy has become commonplace in many orthopaedic surgery procedures. The benefits of fluoroscopy are not without risk of radiation to patient, surgeon, and operating room staff. There is a paucity of knowledge by the average orthopaedic resident in terms proper usage and safety. Personal protective equipment, proper positioning, effective communication with the radiology technician are just of few of the ways outlined in this article to decrease the amount of radiation exposure in the operating room. This knowledge ensures that the amount of radiation exposure is as low as reasonably achievable. Currently, in the United States, guidelines for teaching radiation safety in orthopaedic surgery residency training is non-existent. In Europe, studies have also exhibited a lack of standardized teaching on the basics of radiation safety in the operating room. This review article will outline the basics of fluoroscopy and educate the reader on how to safe fluoroscopic image utilization.

OBJECTIVE: To examine clinical and laboratory practices associated with contamination of blood culture specimens from adults. DESIGN AND SETTING: A College of American Pathologists Q-Probes quality improvement study involving prospective evaluation of adult blood culture contamination rates in 640 institutions. MAIN OUTCOME MEASURE: Proportion of contaminated blood cultures. RESULTS: A total of 497134 blood cultures were studied. The median adult inpatient blood culture contamination rate was 2.5% (central 80th percentile=0.9%-5.4%) by laboratory assessment. There was no significant difference in contamination rates between inpatient and outpatient cultures (P=.273). The median contamination rate by clinical assessment (2.1%) was significantly lower (P=.005), primarily because of a lower proportion of cultures with coagulase-negative Staphylococcus that were interpreted as contaminants when only one of multiple specimens was positive. Specimen collection variables associated with significantly lower contamination rates included use of a dedicated phlebotomy service (P=.039), use of tincture of iodine for skin disinfection (P=.036), and application of an antiseptic to the top of the collection device before inoculation (P=.018). Teaching institutions and high numbers of occupied beds were demographic factors associated with higher contamination rates for inpatients but not for outpatients. Culture parameters associated with higher contamination rates included microbial growth from a single specimen, isolation of certain microbial species (eg, coagulase-negative Staphylococcus), and longer time to detect growth in culture. Contamination rates were not significantly affected by the type of blood culture method used, specimen volume, or use of a double-needle collection procedure. CONCLUSIONS: There is wide variation in blood culture contamination rates among institutions. Three specimen collection factors and three culture variables were identified as having a significant effect on blood culture contamination.

Summary: In the elderly, low-energy distal femur fractures (native or periprosthetic) can be devastating injuries, carrying high rates of morbidity and mortality, comparable with the hip fracture population. Poor, osteoporotic bone quality facilitates fracture in a vulnerable anatomical region, and as a result, operative fixation can be challenging. With goals of early mobilization to reduce subsequent complication risk, using the nail plate combination technique can offer stable, balanced fixation allowing for immediate weight bearing and early mobilization. We outline the rationale, technical steps, and early clinical outcomes after nail plate combination in the treatment of osteoporotic distal femur (native or periprosthetic) fractures.

The fate of bacteria in human urine was studied after inoculation of small numbers of Escherichia coli and other bacterial strains commonly implicated in urinary tract infection. Urine from normal individuals was often inhibitory and sometimes bactericidal for growth of these organisms. Antibacterial activity of urine was not related to lack of nutrient material as addition of broth did not decrease inhibitory activity. Antibacterial activity was correlated with osmolality, urea concentration and ammonium concentration, but not with organic acid, sodium, or potassium concentration. Between a pH range of 5.0-6.5 antibacterial activity of urine was greater at lower pH. Ultrafiltration and column chromatography to remove protein did not decrease antibacterial activity. Urea concentration was a more important determinant of antibacterial activity than osmolality or ammonium concentration. Increasing the urea of a noninhibitory urine to equal that of an inhibitory urine made the urine inhibitory. However, increasing osmolality (with sodium chloride) or increasing ammonium to equal the osmolality or ammonium of an inhibitory urine did not increase antibacterial activity. Similarly, dialysis to decrease osmolality or ammonium but preserve urea did not decrease inhibitory activity. Decreasing urea with preservation of ammonium and osmolality decreased antibacterial activity. Removal of ammonium with an ion exchanger did not decrease antibacterial activity, whereas conversion of urea to ammonium with urease and subsequent removal of the ammonium decreased antibacterial activity. Urine collected from volunteers after ingestion of urea demonstrated a marked increase in antibacterial activity, as compared with urine collected before ingestion of urea.

A familial cancer aggregation comprising sarcomas, brain tumors, leukemias, and carcinomas of breast, larynx, lung, adrenal cortex, and other sites has been studied from a pathologic—genetic standpoint. Based upon sibships segregating for cancer, the genetic segregation parameter is estimated to be 45.6 ± 11% which is compatible with that expected for a rare deleterious autosomal gene showing complete dominance. Pathologic review of 16 tumors by bright field microscopy revealed variable occurrences of intranuclear cytoplasmic invaginations, intranucleolar bodies, and acidophilic intracytoplasmic inclusions in eight lesions. Two tumors showed both intranuclear cytoplasmic invaginations and intranucleolar inclusions. Morphological findings coupled with the observed pattern and distribution of cancer in the subject kindred suggest that the cancer-prone genotype interacts with one or more exogenous factors in causing this familial tumor association.

The purpose of this study was to compare patients with anterior shoulder instability who were treated with an open Bankart procedure with those treated with an arthroscopic procedure. During a 3-year period, 43 patients (44 shoulders) were surgically treated. Thirty-four patients were available for followup. Eighteen shoulders had open Bankart procedure, and 16 shoulders were treated arthroscopically. Capsular laxity can be better assessed with the open procedure. A Bankart lesion was found in all the patients in both series. Average followup for Group 1 was 34 months, and for Group 2, it was 23 months. Group 1 had 83% good to excellent results with no recurrent dislocation or reoperation. Group 2 had 50% good to excellent results, and 50% fair to poor results with 3 recurrent dislocations and 4 recurrent subluxations that required second operation. The average loss of external rotation in Group 1 was not significantly greater than that in Group 2. Sixteen patients in Group 1 and 8 patients in Group 2 were able to return to their primary work or sport. Results of arthroscopic Bankart repair do not equal those of the open Bankart procedure for the rate of recurrence and postoperative range of motion. The followup reported is short, and more dislocations can be anticipated with longer followup.

OBJECTIVE: To determine the effect of major trauma on the cytokine-producing activity of monocytes and CD4+ T cells in a homogeneous cohort of patients as well as to determine the relationship between monocyte and T-lymphocyte responses and clinical outcome. SETTINGS: Surgical intensive care units of a trauma center and flow cytometry and experimental laboratories at a teaching hospital. DESIGN: Prospective cohort clinical study with measurements of white cell cytokine-producing activity on days 2, 5, and 10 postinjury. The number of cytokine-producing CD14+ monocytes, CD4+, and CD8+ T cells were determined in whole blood using flow cytometry combined with the intracellular cytokine staining method. Basal and lipopolysaccharide-stimulated interleukin (IL)-12, tumor necrosis factor-alpha, IL-6, and IL-1alpha production by monocytes as well as basal and phorbol 12-myristate 13-acetate plus ionomycin-stimulated interferon-gamma, IL-4, and tumor necrosis factor-alpha production by T cells were determined on days 2, 5, and 10 postinjury and compared with similar measurements made in healthy control subjects. PATIENTS: Twelve randomly selected black, male patients were enrolled in the study: mean injury severity score, 26; mean age, 35 yrs; mean Glasgow Coma Scale score, 13; systemic inflammatory response syndrome, 92%; sepsis, 42%; bronchial infection, 42%; and adult respiratory distress syndrome 25%. MAIN RESULTS: After lipopolysaccharide stimulation, the number of IL-12-, tumor necrosis factor-alpha-, IL-1alpha-, and IL-6-producing CD14+ monocytes was 40% to 70% lower in trauma patients on postinjury days 2, 5, and 10 than in healthy control subjects. After phorbol 12-myristate 13-acetate stimulation, the number of IL-4-producing CD4+ cells increased three-fold in the trauma patients compared with healthy control subjects. In contrast, the number of interferon-gamma- or tumor necrosis factor-alpha-producing CD4+ and CD8+ T cells was not different between the patients and control subjects. The Th1/Th2 ratio was significantly lower in patients on all postinjury days than in the control subjects. A statistically significant inverse correlation was found between the number of IL-12-producing monocytes and IL-4-producing CD4+ T cells in trauma patients (p =.007, r2 =.47). This correlation was absent in control subjects. The degree of depressed capacity of monocyte IL-12 production on day 2 postinjury showed a statistically significant correlation with the development of adult respiratory distress syndrome, sepsis, or infections and also with the duration of systemic inflammatory response syndrome and sepsis. CONCLUSIONS: Major trauma results in an early and marked decrease in monocyte cytokine-producing activity. The trauma-induced depression in IL-12 production by the mononuclear phagocyte system may promote T-cell commitment toward a Th2 pattern early after trauma. The appearance of the Th2 pattern is the result of elevated numbers of IL-4-producing cells without major alterations in T-cell interferon-gamma-producing capacity. The degree of alterations in monocyte and T-cell responses on day 2 postinjury correlates with the development of adverse clinical outcomes and the subsequent duration of the inflammatory response.

BACKGROUND: Catheter ablation is widely accepted intervention for atrial fibrillation (AF) refractory to antiarrhythmic drugs, but limited data are available regarding contemporary trends in major complications and in-hospital mortality due to the procedure. This study was aimed at exploring the temporal trends of in-hospital mortality, major complications, and impact of hospital volume on frequency of AF ablation-related outcomes. METHODS: The Nationwide Inpatient Sample database was utilized to identify the AF patients treated with catheter ablation. In-hospital death and common complications including vascular access complications, cardiac perforation and/or tamponade, pneumothorax, stroke, and transient ischemic attack, were identified using International Classification of Disease (ICD-9-CM) codes. RESULT: In-hospital mortality rate of 0.15% and overall complication rate of 5.46% were noted among AF ablation recipients (n = 50,969). Significant increase in complications during study period (relative increase 56.37%, P-trend < 0.001) was observed. Cardiac (2.65%), vascular (1.33%), and neurological (1.05%) complications were most common. On multivariate analysis (odds ratio [OR]; 95% confidence interval [95% CI]; P value), significant predictors of complications were female sex (OR = 1.40; CI = 1.17-1.68; P value < 0.001), high burden of comorbidity as indicated by Charlson Comorbidity Index ≥2 (OR = 2.84; CI = 2.29-3.52; P value < 0.001), and low hospital volume (< 50 procedures). CONCLUSION: Our study noted a decline in AF ablation-related hospitalizations and complications associated with the procedure. These findings largely reflect shifting trends of outpatient performance of the procedure and increasing safety profile due to improved institutional expertise and catheter techniques.

This phase II trial was conducted to evaluate the safety and efficacy of concurrent gemcitabine and high-intensity focused ultrasound (HIFU) therapy in patients with locally advanced pancreatic cancer. Patients with localized unresectable pancreatic adenocarcinoma in the head or body of the pancreas received gemcitabine (1000 mg/m) intravenously over 30 min on days 1, 8, and 15, and concurrent HIFU therapy on days 1, 3, and 5. The treatment was given every 28 days. Thirty-seven (94.9%) of the 39 patients were assessable for response, and two cases of complete response and 15 cases of partial response were confirmed, giving an overall response rate of 43.6% [95% confidence interval (CI), 28.0-59.2%]. The median follow-up period was 16.5 months (range: 8.0-28.5 months). The median time to progression and overall survival for all patients were 8.4 months (95% CI, 5.4-11.2 months) and 12.6 months (95% CI, 10.2-15.0 months), respectively. The estimates of overall survival at 12 and 24 months were 50.6% (95% CI, 36.7-64.5%) and 17.1% (95%CI, 5.9-28.3%), respectively. A total of 16.2% of patients experienced grade 3/4 neutropenia. Grade 3 thrombocytopaenia was documented in two (5.4%) patients. Grade 3 nausea/vomiting and diarrhea were observed in three (8.1%), and two (5.4%) patients, respectively. Grade 1 or 2 fever was detected in 70.3% of patients. Twenty-eight patients (71.8%) complained of abdominal pain consistent with tumor-related pain before HIFU therapy. Pain was relieved in 22 patients (78.6%). In conclusion, concurrent gemcitabine and HIFU is a tolerated treatment modality with promising activity in patients with previously untreated locally advanced pancreatic cancer.

INTRODUCTION: This systematic review analyzes the literature on the treatment of geriatric hip fractures by a multidisciplinary hip fracture service including geriatricians/internists and orthopaedic surgeons and what impact this has on patient outcomes. METHODS: A systematic review of several databases was conducted according to PRISMA guidelines. Studies comparing an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model to treat hip fractures with reported outcomes for time to surgery, length of stay, readmission rates, and postoperative mortality were included. RESULTS: Seventeen articles fitting the inclusion criteria were included. Differences between the results of an orthopaedic-led care model versus a coordinated orthogeriatrics care model or a geriatrics-led care model were assessed using chi-squared tests. With patients admitted under a coordinated orthogeriatrics care model or a geriatrics-led care model, there is a statistically significant decrease in time to surgery (P = 0.045), length of stay (P = 0.0036), and postoperative mortality rates (P = 0.0034). CONCLUSIONS: Although a heterogeneous group of studies, the aggregate data from several studies using an orthogeriatrics care model or a geriatrics-led care model trend toward improvements across several clinical and cost-related outcome measures: decreased time to surgery, shorter length of stay, improved postoperative clinical outcomes, decreased mortality, and lower cost.

ORDINARILY, only small amounts of neomycin and kanamycin are absorbed from the gastrointestinal tract.1 2 3 The concentrations of drug achieved in blood and urine, even after relatively large oral doses, are not sufficient for the treatment of systemic infection and have not in the past been associated with the toxic effects that occur during parenteral therapy. Oral preparations of these drugs are extensively used for intestinal antisepsis because of their wide spectrum of activity against many intestinal micro-organisms, their major areas of usefulness being in the preparation of the bowel for surgery and in the treatment and prophylaxis of hepatic coma. . . .

This is a study of the appearance of asymptomatic early squamous cell carcinoma documenting location, color, size, surface (texture, elevation, ulceration), presence of bleeding, induration, lymphadenopathy, and distant metastasis. Of 158 lesions, 143 (90.5%) had an erythroplastic (red) component, whereas only 98 (62%) had white components. Only 4 lesions were solely white. There was essentially no color distinction between invasive carcinoma vs. in situ carcinoma. One hundred forty-two (89.8%) lesions were located in the floor of the mouth, ventral or lateral tongue, or soft palate anterior pillar complex. One hundred twelve (70.9%) of the lesions in the study were invasive. Only 11 lesions were indurated, and these were all invasive. One hundred nine (69%) of all lesions were approximately 2 cm or less, and 37 (23.4%) were less than 1 cm. An erythroplastic (red velvety) lesion appears to be the earliest visible sign of asymptomatic oral squamous cell carcinoma—invasive or in situ. The presence of a white component did not appear to be significant unless it was accompanied by erythroplasia (redness). Minimal size (less than 1 cm) does not preclude the existence of an invasive carcinoma. The persistence of erythroplastic lesions for more than 14 days without obvious etiology requires biopsy.

OBJECTIVE: To determine the frequency of port-site recurrences following laparoscopic surgical treatment of gynaecological malignancies metastatic at the time of surgery. DESIGN: Retrospective review of metastatic primary and recurrent gynaecological malignancies. RESULTS: Twenty-five women were studied. Twenty-four had metastatic disease at the time of laparoscopic surgery, 22 in association with a primary malignancy (cervix: n = 12, ovary: n = 7, endometrium: n = 3), and two in association with recurrent ovarian cancer; all received pelvic or extended field radiation or chemotherapy after surgery. One woman with Stage IIIC ovarian cancer, disease-free at the completion of neoadjuvant chemotherapy following laparotomy by a general surgeon, was included; she developed scalene node metastases 18 months after definitive laparoscopic surgery. Seventy-one 5 mm trocars and fifty 10 mm trocars (total n = 121) were used for surgery; thirty-one 10 mm trocar sites and forty-four 5 mm sites (total n = 75) received post-operative treatment with chemotherapy (n = 49) or radiation (n = 26). Four women (16%) developed recurrences in association with endometrial (n = 2) and cervical (n = 2) cancer at six trocar sites. All recurrences were associated with abdominopelvic and/or distant metastases, and all occurred at untreated 5 mm trocar sites. The difference in recurrence rates between 5 mm and 10 mm trocar sites (chi(2) = 6; P < 0.025), and between treated and untreated trocars (chi(2) = 5; P < 0.05) were both statistically significant (McNemar's test), but the effects of treatment and trocar size on the port-site recurrence rate were confounded. CONCLUSIONS: Port-site recurrences are local manifestations of disseminated disease that result from the enhancement of tumour growth characteristic of healing tissues and can be prevented by appropriate post-operative therapy.