Background The aim of this study was to explore the relationship between perioperative bisphosphonate (BP) use and implant survival in total joint arthroplasty (TJA). Methods Literature in PubMed, EMBASE, and the Cochrane Library was systematically searched until May 2024, and studies were reviewed. Eligible studies are randomized controlled trials or cohort studies comparing BP with placebo or antiosteoporosis agents in TJA, reporting implant survival outcomes with full-text availability. The search identified 2,051 potentially relevant publications; 20 met the selection criteria. Results Our results revealed that perioperative BP use significantly reduced the incidence of all-cause revision surgery (ARS) after TJA (RR [risk ratio] 0.67 [95% CI (confidence interval) 0.54 to 0.83], P = 0.003). Preoperative BP use significantly increased the risk of developing ARS (RR 0.72 [95% CI 0.54 to 0.95], P < 0.00001) and periprosthetic fracture (PPF) (RR 1.33 [95% CI 1.21 to 1.46], P < 0.00001) after TJA. However, BP initiated after TJA reduced the risk of ARS (RR 0.57 [95% CI 0.43 to 0.74], P < 0.00001). In addition, perioperative BP use for at least six months was associated with a lower risk of ARS (RR 0.83 [95% CI 0.77 to 0.89], P < 0.00001), but a higher risk of PPF in patients who had TJA (RR 1.28 [95% CI 1.16 to 1.42], P = 0.0002). When initiated after total hip arthroplasty (THA), BP was associated with a lower incidence of PPF (RR 0.55 [95% CI 0.31 to 0.98], P = 0.04), and there was an increased risk of ARS following THA if perioperative BP was used for over one year (RR 1.10 [95% CI 1.01 to 1.21], P = 0.03). At last, perioperative BP use had no effect on aseptic loosening, periprosthetic joint infection, osteolysis, stress fracture, adverse events, or mortality after TJA. Conclusions Perioperative BP use significantly reduced the incidence of ARS after TJA. Preoperative use of BP significantly increased the risk of developing ARS and PPF after TJA. However, BP initiated after TJA reduced the risk of ARS, but had no effect on PPF. In addition, perioperative BP use for at least six months was associated with a lower risk of ARS, but a higher risk of PPF in patients who had TJA.

This study assesses clinical outcomes and quality of life (QoL) following surgical treatment of fragility ankle fractures in individuals aged over 80 years. We conducted a retrospective study involving 45 elderly patients who underwent surgery for fragility ankle fractures between 2015 and 2023. Pre-operative mobility was assessed using the Parker Mobility Score (PMS), and nutritional status was evaluated using a short-form mini-nutritional assessment (MNA-SF). The ASA classification and the age-adjusted Charlson Comorbidity Index (aCCI) were used to assess comorbidities affecting outcomes comprehensively. Primary outcomes included (1) Ankle function, measured by the Olerud-Molander Ankle Score (OMA-score), and (2) QoL, assessed through the EQ-5D-3 L index score, EQ-VAS, and Barthel Index. Any postoperative complications or mortality were considered secondary outcome. The cohort’s mean age was 83.8 ± 3.2 years. At the one-year follow-up, the OMA-score negatively correlated with pre-operative days (p = 0.035), length of hospital stay (p = 0.047), and time to weight-bearing initiation (p < 0.001). Time to weight-bearing initiation negatively impacted the EQ-5D-3 L index (p = 0.001) and EQ-VAS (p < 0.001), whereas the Barthel Index showed positive correlations with pre-operative PMS (p = 0.005) and MNA-SF (p = 0.002). Surgical and non-surgical complication rates were 28.9 % and 31.1 %, respectively. The one-year survival rate was 75.6 %. Deceased patients had higher aCCI scores (p = 0.005), lower PMS (p < 0.001), and lower MNA-SF scores (p = 0.005); however, the ASA grade showed no significant difference (p = 0.066). The timing of weight-bearing initiation after ankle surgery may significantly influence ankle function and QoL in octogenarians and nonagenarians. Geriatric assessments, such as the PMS, MNA-SF, and aCCI, effectively assess mortality risk, whereas the ASA classification is less predictive.

BACKGROUND:This study evaluates the outcomes of fibular intramedullary nails (IMNs) compared to traditional plates and screws (PS) in the surgical treatment of unstable ankle injuries in patients aged ≥65 years. METHOD:We conducted a retrospective study involving 32 elderly patients with unstable ankle fractures treated with IMNs from 2010 to 2022. A comparison was made with 125 case-control patients treated with PS during the same period. Outcomes compared included postoperative wound and nonwound complications, surgical reduction, union rates, implant removal rates, and the Olerud Molander Ankle Score (OMAS) at a minimum follow-up of 2 years. RESULTS:The IMN group had a higher incidence of high-energy injuries, open fractures, concomitant surgery, and perioperative transfusion requirements than the PS group. Additionally, the IMN group developed fewer wound-related (3.1% vs 20% in the PS group, P = .043) and non-wound-related complications (18.8% vs 39.2% in the PS group, P = .030). Both groups had similar initial weightbearing restrictions, fracture union times, mean OMAS scores, rates of malunion or nonunion, and delayed implant removal times. Notably, there were significant differences in the quality and adequacy of mortise alignment between the groups (good: 53.1% in IMN group vs 79.2% in PS group, fair: 46.9% in IMN group vs 20.8% in PS group, P = .006). CONCLUSION:Although the IMN group had an inferior outcome in the quality and adequacy of mortise reduction compared with the PS group, elderly patients with ankle fractures treated with IMN showed comparable functional outcomes to those treated with PS but with lower complication rates. Future research in this area will provide vital information for developing optimal treatment strategies, thereby improving the overall care of elderly patients with ankle fractures.

Purpose: Intramedullary nailing is the preferred internal fixation technique for the treatment of subtrochanteric fractures because of its biomechanical advantages. However, no definitive conclusion has been reached regarding whether combined cable cerclage is required during intramedullary nailing treatment. This study is performed to compare the clinical effects of intramedullary nailing with cerclage and non-cerclage wiring in the treatment of irreducible spiral subtrochanteric fractures. Methods: Patients with subtrochanteric fractures admitted to our center from January 2013 to December 2021 were retrospectively analyzed. The patients were enrolled in the case-control study according to the inclusion and exclusion criteria and divided into the non-cerclage group and the cerclage group. The patients' clinical data, including the operative time, intraoperative blood loss, hospital stay, reoperation rate, fracture union time, and Harris hip score, were compared between these 2 groups. Categorical variables were compared using Chi-square or Fisher's exact test. Continuous variables with normal distribution were presented as mean +/- standard deviation and analyzed with Student's t-test. Non- normally distributed variables were expressed as median (Q1, 1 , Q3) 3 ) and assessed using the Mann- Whitney test. A p <0.05 was considered significant. Results: In total, 69 patients were included in the study (35 patients in the non-cerclage group and 34 patients in the cerclage group). The baseline data of the 2 groups were comparable. There were no significant difference in the length of hospital stay (z =-0.391, p = 0.696), operative time (z =-1.289, p = 0.197), or intraoperative blood loss (z =-1.321, p = 0.186). However, compared with non-cerclage group, the fracture union time was shorter (z =-5.587, p < 0.001), the rate of nonunion was lower (c2 c 2 = 6.030, p = 0.03), the anatomical reduction rate was higher (c2 c 2 = 5.449, p = 0.03), and the Harris hip score was higher (z =-2.99, p = 0.003) in the cerclage group, all with statistically significant differences. Conclusions: Intramedullary nailing combined with cable cerclage wiring is a safe and reliable technique for the treatment of irreducible subtrochanteric fractures. This technique can improve the reduction effect, increase the stability of fracture fixation, shorten the fracture union time, reduce the occurrence of nonunion, and contribute to the recovery of hip joint function. (c) 2024 Production and hosting by Elsevier B.V. on behalf of Chinese Medical Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background:Spinal surgery is associated with severe pain within the first few days after surgery. Opioids are commonly used to control postoperative pain, but these can lead to postoperative nausea and vomiting (PONV). Therefore, use of more effective and better-tolerated agents would be beneficial for these patients. Serotonin receptor antagonists, such as ramosetron, have been used to reduce PONV in patients receiving anesthesia. Objective:We conducted a meta-analysis of published randomized controlled trials (RCTs) to compare the efficacy and tolerance of ramosetron to prevent PONV after spinal surgery. Methods:Medline, Embase, Cochrane Library, and Science Citation Index databases were systematically searched for relevant RCT articles published between January 1979 and November 2020. Full text articles restricted to English language that described RCTs comparing the use of ramosetron with other serotonin antagonists to treat PONV following spinal surgery in adult patients were considered for meta-analysis. Two reviewers independently performed study selection, quality assessment, and data extraction of all articles. Differences were resolved by a third reviewer. Results:The search identified 88 potentially relevant articles, of which only 3 met our selection criteria. Study drugs were administered at the end of spinal surgery in all 3 included articles. The meta-analysis revealed that ramosetron (0.3 mg) reduced the pain score (mean difference = -0.66; 95% CI -1.02 to -0.30), lowered the risk of PONV (risk ratio = 0.86; 95% CI, 0.76-0.97), and postoperative vomiting (risk ratio = 0.32; 95% CI, 0.17-0.60), and limited the use of rescue antiemetics (risk ratio = 0.66; 95% CI, 0.45-0.96) after spinal surgery. However, there were no significant differences in the incidence of postoperative nausea, the use of rescue pain medications, the number of rescue analgesics required, and the risk of discontinuation of patient-controlled analgesia between ramosetron and palonosetron (0.075 mg) or ondansetron (4 mg). There were no statistically significant differences in the risk of adverse events among the 3 medications. Conclusions:This meta-analysis of 3 RCTs showed that ramosetron reduced the risk of PONV and POV, limited the use of rescue antiemetics, reduced the postoperative pain score, and did not increase the risk of discontinuing patient-controlled analgesia compared with palonosetron or ondansetron after spinal surgery in 3 RCTs. Therefore, this meta-analysis indicates that ramosetron is an effective and well tolerated antiemetic that can be used to prevent PONV following spinal surgery in adult patients. PROSPERO identifier: CRD42020223596 (Curr Ther Res Clin Exp. 2022; 83:XXX-XXX)© 2022 Elsevier HS Journals, Inc.

Purpose: To determine whether serum lactate concentration on admission to hospital is a predictor for 30-day and 1-year mortality for patients who underwent hip-surgery. Methods: Data from elderly patients with hip fractures admitted to our hospital (Jan 2012-Dec 2016) were reviewed. The lactate concentration on admission was assessed using a cut-off value of 2.0 mmol/L and then a new cut-off value was determined by maximizing the Youden index. Multivariate logistic regression was employed to verify whether a higher lactate concentration compared with the cutoff value was an independent risk factor for postoperative mortality after 30 days or at 1 year. Results: A total of 1,004 patients were enrolled. There were differences in the incidence of postoperative complications (28.6% vs. 21.9%, P=0.022), length of stay (13.56±8.66 vs. 12.47±7.81 days, P=0.047), 30-day mortality (10.8% vs. 1.3%, P<0.001), 1-year mortality (23.3% vs. 11.8%, P<0.001) and survival time (23.92±16.58 vs. 28.81±16.54 months, P<0.001) between the ≥2.0 mmol/L (n=315) and <2 mmol/L (n=689) groups. Serum lactate concentration was a good predictor of 30-day mortality (AUC=0.829, P<0.001) with a cutoff value of lactate =2.35 mmol/L (sensitivity =0.744, specificity =0.834). Multivariate analysis revealed that a serum lactate concentration ≥2.35 mmol/L at admission was an independent risk factor for 30-day (OR=9.93, P<0.001) and 1-year (OR=2.23, P<0.001) mortality. Conclusion: The admission lactate concentration (≥2.35 mmol/L) following hip fracture derived by this study was a significant predictor of mortality 30 days after surgery, which might help physicians to stratify the risk for these patients.

目的 探讨过伸型胫骨平台骨折的特点及临床疗效.方法 回顾性分析我院自2012年1月至2018年12月收治的16例过伸型胫骨平台骨折,男13例,女3例;年龄29～57岁,平均(40.1士6.8)岁.采用骨折切开复位取髂骨结构性植骨钢板固定术,血管损伤观察处理,软组织损伤行Ⅰ期或Ⅱ期修复.随访患者骨折愈合及复位后的维持情况、关节活动度和稳定性以及美国特种外科医院(the hospital special surgery,HSS)膝关节功能评分.结果 16例随访时间8～22个月,平均(10.3±4.5)个月.骨折均愈合,愈合时间10～17周,平均(12.9±6.9)周.无骨折复位丢失,胫骨内翻角平均(86.4±2.6)°,后倾角平均(8.6±0.9)°;无明显膝关节不稳和疼痛;膝关节屈曲活动度125°～140°,平均(135.2士6.9)°;HSS评分88～97分,平均(90.2±3.1)分.结论 过伸性胫骨平台骨折有其特殊性,充分认识其损伤机制并规范治疗可以取得良好的治疗结果,治疗过程中需关注血管及软组织损伤情况.

To the Editor: Percutaneous endoscopic lumbar discectomy (PELD) becomes increasingly popular among spine surgeries in recent years. PELD is one of the minimally invasive spine surgeries with significant advantages including small incision, less muscle stripping, and enhanced postoperative recovery.[1] Theoretically, PELD can be used in lumbar intervertebral disc herniation of all segments including L5-S1. However, due to high crista iliaca, intervertebral foramen stenosis, transverse process, and sacral ala hypertrophy at L5-S1 level, the establishment of the working access remains a challenge.[2] Different surgical positions may produce influence on intervertebral foramen height. Prone position is the common position used for access to the spine during spinal surgery, which could cause an increase in lumbar lordosis and minimized foramen height. The aim of this study was to assess the difference for foramen height between modified knee-chest (MKC) position and prone position during the PELD procedure and the influence on puncture time on L5-S1 with different positions. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of PLA Army General Hospital. As a retrospective study and data analysis was performed anonymously, this study was exempt from the informed consent from patients. Medical records of sixty consecutive patients who underwent L5-S1 PLED were reviewed retrospectively. MKC position was used in thirty of patients from May 2014 to May 2015 (23 male and 7 female patients, aged 16–41 years with an average of 31.7 years). The duration of the symptoms ranged from 2 months to 24 years with an average of 92 months. Thirty patients underwent L5-S1 PLED in prone position from June 2013 to April 2014 (19 male and 11 female patients, aged 17–35 years, with an average of 25.6 years). The puncture time with a 18G needle in two different positions was recorded. The puncture time was defined as the duration from lidocaine infiltration anesthesia to the establishment of working channel. The intraoperative and postoperative complications were also recorded in all the patients. All the patients involved met the inclusion criteria: diagnosed with L5-S1 intervertebral disc herniation by preoperative magnetic resonance imaging scan, radiating limb pain, and positive straight leg raise test. The patients who met the exclusion criteria were excluded from the study: previous operation history on L5-S1 level, lumbar instability, patients with transitional lumbosacral vertebral, and ankylosing spondylitis and other types of spinal deformity. All the surgeries were performed by two surgeons having specialized training in spinal neurosurgery. A tangent line was drawn along the inferior border of L5 pedicle, and another parallel line passing the tip of S1 superior facet joint was also made on the lateral fluoroscopic images in different position. The vertical distance between the two parallel lines was recorded [Figure 1a], and the intervertebral foramina enlargement ratio was calculated as follows.Figure 1: Foramen height measurement. a: Inferior margin of L5 pedicle; b: foramen height; c: parallel line crossing superior facet of S1 to line a; d: superior facet of S1; f: puncture trajectory (a). Comparison of modified knee-chest position and prone position. A diagram of modified knee-chest position with hip flexion (45°) and knee flexion (30°) (b). Posture pads are also indicated. Changes of foramen height in different positions (c).Foramen enlargement ratio = Modified knee-chest position − prone position/prone position. The patients were placed prone with the arms away from the side of the body. Care is taken to line up the patient with the C-arm to ensure a perfect lateral view for fluoroscopic imaging. The surgical level must be centered to avoid parallax error. First, a standard lateral X-ray of the lumbar spine was taken using C-arm (SIEMENS ARCADIS Orbic, Germany), and then the patient was requested to change the posture to knee–chest position on the antilordotic frame. The patient rested on the knees and chest with head was turned to one side, arms extended on the bed, and elbows flexed and resting so that they partially bear the patient's weight; the abdomen remained unsupported, though a small pillow might be placed under the chest; with bilateral 45° hip flexion as well as a 30° knee flexion until the “flat-back” of the patient could be seen. Under the knee–chest position, another lateral X-ray of lumbar spine was taken. In order to eliminate the influence of the magnification rate under different position, we marked the both horizontal and vertical distance from the tube to the patients’ skin in every different case [Figure 1b]. For the statistical analysis, SPSS15.0 was used (SPSS Inc., USA). The t-test was performed to analyze the difference the duration time of puncture and foraminal height under different position. Statistical significance was set at P < 0.05. All the patients received surgery under local anesthesia. No postoperative infection of intervertebral space, dural tear, or abdominal organ injury was recorded in both groups. One (3.33%) patient with prone position presented postoperative pain hypersensitivity of the right leg after surgery, which was considered as postoperative dysesthesia (POD). The patient was treated with medications of dehydration and nerve nutrition. The symptoms completely disappeared 3 weeks after the operation. Patients in knee–chest position had shorter puncture time compared with those in prone position (P < 0.05). Foramen height under prone position was 7.49 ± 0.69 mm, while it was 11.76 ± 1.80 mm in knee–chest position. There was also a significant difference in foramen height (P < 0.05). The changes of puncture time, foramen height, and foramen enlargement ratio under different positions are shown in Table 1 and Figure 1c.Table 1: Comparison of puncture time, foramen height, and enlargement ratio of foramenThe use of PELD has been rapidly increasing in the last decade since the introduction of fully endoscopic spine surgeries. As a minimally invasive surgery, PELD has less bleeding volume and surgical trauma, lower anesthetic risk, and shorter hospital stay than conventional open surgery.[3] However, even for experienced surgeon with specialized training in spinal neurosurgery, the learning curve in PLED is still very steep. The unique anatomic features of the L5–S1 space include a large facet joint, narrow foramen, small disc space, and a wide interlaminar space. Endoscopic lumbar discectomy is performed via 2 routes: transforaminal and interlaminar. The two techniques are distinct in the involved surgical anatomy and utilized instruments. The surgical route depends on several variables: relative placement of the iliac bone and L5-S1 disc space, disc location, and surgeon's preference.[4] Most of surgeons prefer to use the prone position during PELD, while most foreign spine surgeons prefer lateral position.[5] When the lateral position was adopted, the patient was asked to bend the body to facilitate increased lumbar kyphosis. With the lateral position, the working channel is more accessible to be introduced due to the widening foramen.[6] Another advantage of the lateral position in PELD operation is that the patient with severe leg pain might be more comfortable in this position. However, adopting lateral position in PELD also has some limitations, such as eye–hand coordination problem due to the rotation of the image on the monitor, difficult to maintain the proper position during the operation, and poor satisfaction. Prone position is an anatomical term that indicates a face-down body position, which is often used during the lumbar surgeries. PELD is performed under local anesthesia, the tolerance of the patients should be considered during the operation due to aggravated sciatica. Because transforaminal endoscopic discectomy surgery has a steep learning curve which requires many years of training and experience, patients who were treated at the beginning of the learning curve sometimes have bad experience of pain during the procedure. Most of spine surgeons prefer knee–chest position during the lumbar spine surgery instead of prone position.[7] The classic knee-chest position with 90° hip flexion may easily slow down the velocity of blood flow and lead to the postoperative thromboembolic complications. In our study, knee–chest position is modified with bilateral 45° hip flexion as well as a 30° knee flexion, which means the femur and knee angels are little more than classic knee-chest position. The patient was well padded at the pressure points. We found that patients with knee–chest position had shorter puncture time compared with those with prone position and the difference was significant. The possible reasons are that the entry point of puncture at the L5-S1 level is 12–14 cm away from the spinal midline, which is greater than that at the L4/5 level. With the more lateral entry point, hypertrophy of L5 transverse process and the sacral wing would obstruct the puncture pathway and the duration of puncture time might be prolonged accordingly. The foramen height will be widened in MKC position with an enlargement ratio of 57% compared with classic prone position. Besides, with the enlargement of the foramen height, the distance between inferior articular facet of S1 and existing nerve root was increasing accordingly, which might lower the risk of neurologic deficit. POD was occurred in one patient in prone position. During the operation, the patient felt radiating leg pain when the foraminoplasty was performed. In our study, the incidence of POD was similar with other studies.[89] At the L5-S1 level, PELD via a transforaminal route is challenging due to the obstructive anatomy. The iliac crest and the inclination of the L5-S1 level frequently obstruct transforaminal approach, leading to a steeper trajectory angle that reached far from the extruded disc.[10] Many factors may be responsible for the establishment of working channel during the PELD. Prone position could cause a significant rise in the caval pressure and diversion of blood into the vertebral vein. MKC position could disperse the body weight, especially in some obese patients, the respiratory complication can be altered because of a decreased respiratory compliance. In addition, the increased distance between L5 transverse process and sacral wing and enlarged foramen height could put the patient at lower risk of neurological complications. In conclusion, there were more advantages in L5-S1 PELD using MKC position than prone position during the PELD procedure. In addition, enlarged foramen height might put the patient at lower risk of neurological complications. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Theoretically, PELD can be used in lumbar intervertebral disc herniation of all segments including L5‐S1. However, due to high crista iliaca, intervertebral foramen stenosis, transverse process, and sacral ala hypertrophy at L5‐S1 level, the establishment of the working access remains a challenge.[2] Different surgical positions may produce influence on intervertebral foramen height. Prone position is the common position used for access to the spine during spinal surgery, which could cause an increase in lumbar lordosis and minimized foramen height. The aim of this study was to assess the difference for foramen height between modified knee‐chest (MKC) position and prone position during the PELD procedure and the influence on puncture time on L5‐S1 with different positions.

AimsCurrently, myxoma is the most common type of primary cardiac tumor diagnosed. This article describes the experience over the past 16 years with cases of cardiac myxoma in Chinese patients and elucidated the differences between solid and papillary myxomas.MethodsThe clinical details of 68 patients with cardiac myxomas who underwent surgery between January 1996 and January 2012 at our center were retrospectively analyzed.ResultsThe left atrium was the primary tumor site in 88% of the patients included in this study. The most common implant site was the interatrial septum (69%), especially for patients with solid tumors. Common clinical symptoms included dyspnea and palpitation, whereas embolic events occurred in 12 patients. Myxoma resection involved a midline sternotomy utilizing cardiopulmonary bypass. According to pathological classification, solid myxomas were present in 28 patients (47%), whereas papillary myxomas were detected in 40 patients (53%). In the solid group, arrhythmias and a larger tumor volume were more common. Correspondingly, in 97.42.5% of cases, secondary surgery was not needed after 10 years. Overall, the actuarial survival for patients undergoing surgical excision of myxoma was 98.4 +/- 1.6% at 5 years and 96.0 +/- 2.8% at 10 years.ConclusionSolid myxomas were associated with more arrhythmias, a larger tumor volume, implantation in the interatrial septum, and a need for concomitant surgery compared with papillary myxomas. Further studies should determine whether serum or histological markers could be routinely used in combination with echocardiograms, MRI and computed tomography for the predictions of recurrent myxomas during annual follow-up examinations.

BACKGROUND Children with infective endocarditis (IE) have to undergo valve replacement instead of valve repair in China due to severe valve damage. The present study is to review our experience on surgical treatment of children with IE in reference to the incidence, pathologic status, diagnosis, surgical strategies and outcomes. METHODS We reviewed 35 patients with a mean age of 13.7±2.2 years who were underwent valve replacement surgery for IE during the period from January 1993 to December 2013. Preoperative transthoracic echocardiographic (TTE) evaluation and transesophageal echocardiography during operation were performed in all patients. All the children underwent chart review and retrospective risk-hazard analysis. RESULTS Among the patients surveyed congenital cardiac lesions were present in 15 (42.8%), rheumatic heart valve disease in 2 (5.7%) and previous heart surgery in 2 (5.7%). The median stay of intensive care unit was 6 days. Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (88.5%). Triple or quadruple valve involvement was found in one patient each. Ten-year freedom from IE-related death and re-intervention was 94.2% and 91.6%, respectively. CONCLUSIONS Children undergoing surgery for IE frequently have advanced disease with embolic complications. Although valve replacement is not the primary option for pediatric IE, the rate of 5-year survival and freedom from re-operation was optimal prognostically. Pediatric physicians should pay attention to the common clinical features of IE so that the native valve is preserved well.

Background: Functional tricuspid regurgitation (FTR) is frequent in patients with mitral valve disease. Untreated tricuspid regurgitation (TR) may cause poor clinical outcomes. The surgical factors involved in annuloplasty for FTR remain controversial. Our objective was to compare effectiveness of different tricuspid annuloplasty (TVP), and reveal the risk factors of recurrence. Methods: We analyzed the clinical details of 399 consecutive patients who underwent mitral surgery with concomitant TVP, from 2006 to 2011, in two Chinese single-centers. Three methods were used for TVP: De Vega surgery was completed in 242 patients; annuloplasty using a flexible band was completed in 98 patients; and surgery with a rigid ring was performed in 59 patients. Results: The operative mortality rate was 2.3%. After surgery, the TR grade of all patients decreased significantly. At three years postoperatively, 13.7% of patients were diagnosed with recurrent FTR. At the three year time point, severe TR in the De Vega group was 18%, which was higher than those in the flexible (8.4%) and rigid planner ring groups (5.2%). During follow-up, the recurrent rates in the rigid group were significantly lower than in the flexible group. Multivariate analysis revealed that pre-operative atrial fibrillation, severe TR, large left atrial, ejection fraction (EF) < 40%, De Vega annuloplasty, and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR. Conclusions: Rigid ring annuloplasty efficaciously improved post-operative tricuspid valve function in patients with FTR. Atrial fibrillation, a large left atrium, low EF and postoperative permanent pacemaker installation were independent risk factors for severe recurrent TR.

Prosthesis-patient mismatch (PPM) is defined as a too-small effective orifice area (EOA) of an inserted prosthetic relative to body size, resulting in an abnormally high postoperative gradient. It is unclear, however, whether residual stenosis after aortic valve replacement (AVR) has a negative impact on mid- and long-term survivals. We searched electronic databases, including PubMed, Embase, Medline and the Cochrane controlled trials register, through October 2012, to identify published full-text English studies on the association between PPM and mortality rates. A significant PPM was defined as an indexed EOA (iEOA) < 0.85 cm(2)/m(2), and severe PPM as an iEOA < 0.65 cm(2)/m(.)(2) Two reviewers independently assessed the studies for inclusion and extracted data. Fourteen observational studies, involving 14 874 patients, met our final inclusion criteria. Meta-analysis demonstrated that PPM significantly increased mid-term (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.19-1.69) and long-term (OR 1.52, 95% CI 1.26-1.84) all-cause mortalities. Subgroup analysis showed that PPM was associated with higher mid- and long-term mortality rates only in younger and predominantly female populations. Risk-adjusted sensitivity analysis showed that severe PPM was associated with reduced survival (adjusted hazard ratio [HR] 1.50, 95% CI 1.24-1.80), whereas moderate PPM was not (adjusted HR 0.96, 95% CI 0.86-1.07). Regardless of severity, however, PPM had a negative effect on survival in patients with impaired ejection fraction (adjusted HR 1.26, 95% CI 1.09-1.47). PPM (iEOA < 0.85 cm(2)/m(2)) after AVR tended to be associated with increased long-term all-cause mortality in younger patients, females and patients with preoperative left ventricular dysfunction. Severe PPM (iEOA < 0.65 cm(2)/m(2)) was a significant predictor of reduced long-term survival in all populations undergoing AVR.

BACKGROUND:The aim of this study is to determine the risk factors of delirium after cardiac surgery.METHODS:A systematic literature search of MEDLINE, EMBASE, the Cochrane Library, and Science Citation Index limited to 2008 to 2011 and review of studies was conducted. Eligible studies were of randomized controlled trials or cohort studies, using delirium assessment tool, reporting at least one risk factor associated with delirium, and available to full text.RESULTS:The search identified 106 potentially relevant publications; only 25 met selection criteria. Our systematic review revealed 33 risk factors: 17 predisposing and 16 precipitating factors for delirium after elective cardiac surgery. The most established predisposing risk factors were age, depression, and history of stroke, cognitive impairment, diabetes mellitus, and atrial fibrillation. The most established precipitating risk factors were duration of surgery, prolonged intubation, surgery type, red blood cell transfusion, elevation of inflammatory markers and plasma cortisol level, and postoperative complications. Moreover, sedation with dexmedetomidine may significantly predict the absence of postoperative delirium.CONCLUSIONS:Postoperative delirium is related to several risk factors following cardiac surgery. Sedation with dexmedetomidine and fast-track weaning protocols may decrease the incidence of delirium in cardiac surgical patients.

INTRODUCTION:The aim of this study was to explore the use of dexmedetomidine as a safe and efficacious sedative agent in post-cardiac surgery patients.METHODS:A systematic literature search of MEDLINE, EMBASE, the Cochrane Library and Science Citation Index until January 2012 and review of studies was conducted. Eligible studies were of randomized controlled trials or cohort studies, comparing dexmedetomidine with a placebo or an alternative sedative agent in elective cardiac surgery, using dexmedetomidine for postoperative sedation and available in full text. Two reviewers independently performed study selection, quality assessment, and data extraction.RESULTS:The search identified 530 potentially relevant publications; 11 met selection criteria in this meta-analysis. Our results revealed that dexmedetomidine was associated with a shorter length of mechanical ventilation (mean difference -2.70 [-5.05, -0.35]), a lower risk of delirium (risk ratio 0.36 [0.21, 0.64]), ventricular tachycardia (risk ratio 0.27 [0.08, 0.97]) and hyperglycemia (risk ratio 0.78 [0.61, 0.99]), but may increase the risk of bradycardia (risk ratio 2.08 [1.16, 3.74]). But there was no significant difference in ICU stay, hospital stay, and morphine equivalents between the included studies. Dexmedetomidine may not increase the risk of hypotension, atrial fibrillation, postoperative nausea and vomiting, reintubation within 5 days, cardiovascular complications, postoperative infection or hospital mortality.CONCLUSIONS:Dexmedetomidine was associated with shorter length of mechanical ventilation and lower risk of delirium following cardiac surgery. Although the risk of bradycardia was significantly higher compared with traditional sedatives, it may not increase length of hospital stay and hospital mortality. Moreover, dexmedetomidine may decrease the risk of ventricular tachycardia and hyperglycemia. Thus, dexmedetomidine could be a safe and efficacious sedative agent in cardiac surgical patients.

Background. Constrictive pericarditis is a rare and disabling disease that can result in chronic fibrous thickening of the pericardium. Prompt treatment of constrictive pericarditis is necessary to limit morbidity and mortality.Methods. We analyzed the clinical details of 51 constrictive pericarditis patients who underwent surgery from January 2005 to December 2010 at our center.Results. Of the patients, 33 (65%) had tuberculous constrictive pericarditis, 13 (25%) had idiopathic pericarditis, 3 (6%) had previous cardiac surgery, and 1 (2%) had connective tissue disease. All patients underwent total pericardiectomy by midline sternotomy. The in-hospital mortality rate was 3.9% (2 of 51 patients). The cause of death was severe low cardiac output syndrome in 1 patient and acute renal failure in the other patient. There were 2 cases of recurrent constrictive pericarditis after discharge. The actuarial 1-year survival rate was 93.7%. One-year follow-up revealed that an initial higher erythrocyte sedimentation rate, abnormal creatinine value, postoperative low output syndrome, and pleural effusion were all associated with increased mortality.Conclusions. Rapid diagnosis and treatment of constrictive pericarditis are crucial to reduce mortality and morbidity. Pericardiectomy should be performed early after diagnosis, in order to prevent chronic illness. After surgery, inotropes, diuretics, salt restriction, and nutrition supply are also critical to improve the prognosis. The inflammation marker erythrocyte sedimentation rate should be evaluated during follow-up. (Ann Thorac Surg 2012; 94: 1235-40) (C) 2012 by The Society of Thoracic Surgeons

目的 研究母鼠怀孕中后期地塞米松(DEX)暴露对子代大鼠发育过程中痛觉敏感性的影响.方法 以母鼠孕期中后半程(9～12 d)注射DEX(每天100 μg/kg)和注射生理盐水后出生的大鼠为样本,通过足底部痛阈测定,观察子代大鼠出生后3 d及1、2、3、4、5、6、7、8周时机械痛阈和热痛阈的变化.结果 两组子代大鼠的外周机械痛阈和热痛阈均随着年龄的增长逐渐增加.出生后3 d和1周时,DEX组机械痛阈显著低于对照组(P<0.05),而2周和3周时,DEX组机械痛阈明显著高于对照组(P<0.05),4周以后两组间无显著差别.对于热痛阈,大鼠出生后3 d DEX组显著低于对照组(P<0.05),而出生后1周及以后的时期两组间无显著差异.结论 母体孕中后期注射DEX可以增强子代大鼠发育早期的痛觉敏感性,而这种影响可能是短暂性的.

This study examines the influence of lexical tone upon voice onset time (VOT) in Mandarin and Hakka. Examination of VOT values for Mandarin and Hakka word-initial stops /p, t, k, p, t, k/ followed by three vowels /i, u, a/ in different lexical tones revealed that lexical tone has a significant influence on the VOTs. The result is important because it suggests that future studies should take its influence into account when studying VOT values for stops in tonal languages. In Mandarin, stops’ VOTs, ordering from the longest to the shortest, are in Tone 2, Tone 3, Tone 1, and Tone 4: this sequence is the same as Liu, Ng, Wan, Wang, and Zhang’s (2008) [1] results. However, later it was found that the sequence results from the existence of non-words. Because in order to produce non-words correctly, participants tended to pronounce them at a lower speed, especially those in Tone 2. Therefore, we further examined the data without non-words, in which no clear sequence had been found. For Hakka, Post hoc tests (Scheffe) show that aspirated stops in Tones 4 and 8 have significantly shorter VOT values than they have in other tones.