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Background Current postresuscitative care after cardiac arrest (CA) does not address the cause of CA. We previously reported that asphyxial CA (ACA) and ventricular fibrillation CA (VFCA) elicit unique injury signatures. We hypothesized that the early cytokine profiles of the serum, heart, and brain differ in response to ACA versus VFCA. Methods and Results Adult male rats were subjected to 10 minutes of either ACA or VFCA. Naives and shams (anesthesia and surgery without CA) served as controls (n=12/group). Asphyxiation produced an ≈4‐minute period of progressive hypoxemia followed by a no‐flow duration of ≈6±1 minute. Ventricular fibrillation immediately induced no flow. Return of spontaneous circulation was achieved earlier after ACA compared with VFCA (42±18 versus 105±22 seconds; P Conclusions Both models of CA resulted in marked systemic, heart, and brain cytokine responses, with similar degrees of change across the 2 CA insults. Changes in cytokine levels after CA were most pronounced in the striatum compared with other brain regions. These collective observations suggest that the amplitude of the changes in cytokine levels after ACA versus VFCA may not mediate the differences in secondary injuries between these 2 CA phenotypes.

Background The risk of early complications is high after monoblock acetabular metal-on-metal (MoM) THA revisions. However, there is a paucity of evidence regarding clinical complications after isolated head-liner exchange of modular MoM THA. Questions/purposes The purposes of this study were (1) to describe the frequency of early complications after an isolated head-liner exchange revision of modular MoM THA; and (2) to determine whether patients who experienced complications or dislocation after head-liner exchanges had higher serum chromium (Cr) or cobalt (Co) ion levels than those who did not. Methods A review of our institution's total joint registry retrospectively identified 53 patients who underwent 54 liner exchange revisions of a modular acetabular MoM THA. The study period was from April 2008 to April 2016 at a single tertiary care center. During this period, isolated head-liner exchanges (rather than more extensive revisions) were performed in patients if they did not have evidence of loosening of the acetabular or femoral components. Reasons for revision surgery included pain, mechanical symptoms, radiographic evidence of osteolysis, elevated serum metal ions, and MRI abnormalities with 40 of the 54 hips having pain or mechanical symptoms and 38 of 54 hips having multiple reasons for revision before surgery. Patients were excluded if they did not meet the minimum postrevision followup or had the modular liner exchange secondary to infection. All revisions were from a single manufacturer with one head-liner exchange of a MoM THA from another manufacturer excluded during the study period. The mean time from index MoM THA to modular exchange was 96 (SD ± 36) months. Because the focus of this study was early complications, we had a minimum 90-day followup duration for inclusion. Mean followup after revision was 15 months (SD ± 12); a total of 56% (30 of 54) had followup of at least 12 months' duration. Complications (dislocation, infection) and reoperations were obtained by chart review performed by individuals other than the treating physician(s). Serum metal ion levels were obtained before head-liner exchange. The median serum Cr and Co levels were 6 µg/L (range, 0-76 µg/L) and 12 µg/L (range, 0-163 µg/L), respectively. Results Of the 54 revision THAs, 15 (28%) developed complications. Nine (17%) occurred within 90 days of the revision surgery and 11 (20%) resulted in reoperation. The most common complication was dislocation (12 of 54 [22%]) with recurrent dislocation noted in eight of these 12 patients. All patients with recurrent dislocation continued to dislocate and underwent repeat revision. Patients with dislocation had higher median serum Cr and Co ion levels than those without dislocation (Cr: 24 [range, 11-76] versus 4 [range, 0-70], p = 0.001 [95% confidence interval {CI}, 10-57]; Co: 41 [range, 6-163] versus 8 [range, 0-133], p = 0.016 [95% CI, 6-141]). Three (6%) of the 54 patients underwent repeat surgery for deep space infection. Conclusions Complications and reoperations are common after modular head-liner exchange in the setting of a failed MoM THA. Our study likely underestimates the frequency of complications and revisions because the followup period in this report was relatively short. Dislocation is the most common complication and elevated serum metal ion levels may be a predictor of dislocation. These findings are concerning and surgeons should be aware of the high complication risk associated with this procedure. Level of evidence Level IV, therapeutic study.

The fluoroscopically assisted direct anterior approach for total hip arthroplasty has gained interest in recent years. One of the perceived advantages is the use of fluoroscopy to aid in the positioning of implants. The purpose of this study was to measure the radiation entrance surface dose to anatomically important areas of both patients and surgeons during direct anterior approach total hip arthroplasty.Radiation dosimetry badges were placed at the sternal notch and pubic symphysis of 50 patients undergoing direct anterior approach total hip arthroplasty. Badges were also placed on the surgeons outside of their lead aprons at the level of the thyroid. Three fellowship-trained arthroplasty surgeons were involved in the study. Radiation exposure of each badge was measured after each case (surgeon and patient). The cumulative dose was also calculated for the surgeons. To limit surgeon bias during the study, 50 consecutive direct anterior approach total hip arthroplasties that occurred prior to this study were analyzed for total fluoroscopic dose and time and served as a control group.Forty-five subjects met study criteria. In the study group, 1 patient had a detectable thyroid exposure equal to 1 mrem. Seven patients had a detectable radiation entrance surface dose at the pubic symphysis (range, 1 to 7 mrem). No radiation entrance surface dose was detectable in the remaining 44 patients at the sternal notch and 38 patients at the pubic symphysis. Surgeons in the study did not experience a detectable radiation entrance surface dose. The mean fluoroscopic time was 13.72 seconds (range, 6.7 to 28.7 seconds). The mean patient radiation exposure was 178 mrem (range, 54 to 526 mrem).This study demonstrates that during direct anterior approach total hip arthroplasty, the mean patient entrance surface dose at the pubic symphysis and the sternal notch is not detectable in most patients. The mean patient exposure in this study during direct anterior approach total hip arthroplasty was 178 mrem, which is less than a single pelvic radiograph (600 mrem). No surgeon in our study demonstrated a detectable radiation entrance surface dose. Our data suggest that direct anterior approach total hip arthroplasty typically results in a negligible or very low dose of absorbed radiation exposure to the patient and the surgeon.We believe this study to have clinical relevance because both patients and surgeons have evidence that utilization of fluoroscopy during direct anterior total hip replacement places both parties at a relatively low radiation exposure risk.

We examined the evaluation of and management for lower urinary tract symptoms/benign prostatic hyperplasia by physician specialty (urologist vs primary care physician).The BPH Registry and Patient Survey is a longitudinal, observational, disease registry cohort of patients enrolled from January 2004 to February 2005 in the United States. The survey examines patient outcomes and physician practice patterns in the management of lower urinary tract symptoms associated with clinical benign prostatic hyperplasia. It includes 402 urologist and primary care physician practices throughout the United States. Included in this study were 6,924 men with lower urinary tract symptoms/benign prostatic hyperplasia managed by watchful waiting or medical therapy. Data were collected on demographics, clinical characteristics and lower urinary tract symptoms/benign prostatic hyperplasia management using physician and patient completed forms. Multivariate analysis was done by physician specialty.Based on multivariate analysis urologists were more likely than primary care physicians to perform urinalysis (OR 3.9), serum prostate specific antigen (OR 1.2) and post-void residual urine (OR 18.9) measurement, uroflowmetry (OR 17.3), prostate ultrasound (OR 7.7) and biopsy (OR 3.5), renal ultrasound (OR 4.0) and cystoscopy (OR 4.6) but less likely to measure creatinine (OR 0.1). Men seeing urologists were twice as likely as men seeing primary care physicians to be treated with benign prostatic hyperplasia medical therapy vs watchful waiting. Significant differences by physician specialty were also observed for specific benign prostatic hyperplasia medical therapies.Significant differences in practice patterns were observed between primary care physicians and urologists in the evaluation of and management for lower urinary tract symptoms/benign prostatic hyperplasia. These data establish valuable benchmarks and identify possible interventions that may improve the standard of care.

To evaluate premenstrual daily dosing with fluoxetine for treatment of premenstrual dysphoric disorder.After a two-cycle screening and one-cycle single-blind placebo period, 260 women were randomized to fluoxetine 10 mg, fluoxetine 20 mg, or placebo (dosed daily from 14 days before next expected menses through the first full day of bleeding) for three cycles. Women recorded premenstrual dysphoric disorder symptoms daily using a computerized version of the Daily Record of Severity of Problems.Premenstrual daily fluoxetine 20 mg demonstrated significant improvement in mean Daily Record of Severity of Problems luteal scores compared with placebo (P =.005); premenstrual daily fluoxetine 10 mg did not (P =.100). Daily Record of Severity of Problems total scores were statistically significantly improved by the first treatment cycle for both active treatment groups. However, only fluoxetine 20 mg remained statistically significantly superior to placebo throughout the active treatment phase of the trial. Both fluoxetine groups showed significant treatment advantage over placebo for mood-related symptoms (P.05). Only premenstrual daily fluoxetine 20 mg showed significant treatment advantage over placebo for physical symptoms of breast tenderness (P.001), bloating (P =.001), and joint/muscle pain (P =.037). Treatment was well tolerated; discontinuations due to adverse events did not differ among the three groups (P =.316).Premenstrual daily dosing with fluoxetine effectively treats mood, physical, and social functioning symptoms associated with premenstrual dysphoric disorder. Fluoxetine 20 mg appears to have comparable tolerability with, and better efficacy than, fluoxetine 10 mg.

Patients with social phobia who responded well to 6 months of open-label treatment with clonazepam were assigned to receive either continuation treatment (CT) with clonazepam for another 5 months, or to undergo discontinuation treatment (DT) using a clonazepam taper at the rate of 0.25 mg every 2 weeks, with double-blind placebo substitution. Clinical efficacy was compared between the CT and DT groups using three different social phobia scales. Benzodiazepine withdrawal symptoms were also measured. Relapse rates were 0 and 21.1% in the CT and DT groups, respectively. Subjects in the CT group generally showed a more favorable clinical response at midpoint and/or endpoint, although even in the DT group clinical response remained good. With respect to withdrawal symptoms, the rates were low in both groups (12.5% for CT and 27.7% for DT) with no real evidence suggesting significant withdrawal difficulties. At the end of 11 months of treatment with clonazepam, however, a more rapid withdrawal rate was associated with greater distress. This study offers preliminary evidence to suggest that continuation therapy with clonazepam in the treatment of social phobia is safe and effective, producing a somewhat greater clinical benefit than a slow-taper discontinuation regime. However, even in the DT group, withdrawal symptoms were not found to be a major problem. The study can be taken as supportive of benefit for longterm clonazepam treatment in social phobia, as well as being compatible with a reasonably good outcome after short-term treatment and slow taper.

BACKGROUND To assess whether normal cardiac growth occurs after heart transplantation in the pediatric age group, we performed a study of 13 infants and children who underwent orthotopic heart transplantation at Stanford. METHODS AND RESULTS The echocardiographic data from a population of 93 normal children were analyzed to determine estimates of the fifth, 25th, 50th, 75th, and 95th percentiles of the normal pediatric population. Growth curves for each of the cardiac dimensions were stratified into six classes representing each of the percentile bands, and dimensions for the 13 patients were tracked between early postoperative (early) and point of maximal follow-up (late). Results were compared by Student's paired t test to determine whether normal growth was occurring. The mean age at transplant was 5.0 +/- 1.3 years (mean +/- SEM) (range, 0.4-12.8 years), duration of follow-up was 3.1 +/- 0.4 years (1.3-5.8 years), and change in body surface area was 0.24 +/- 0.03 m2 (0.12-0.50 m2). Both right ventricular (RV) and left ventricular (LV) chamber dimensions were within the normal range at both early and late time points and grew normally as assessed by a lack of class changes. Early wall thickness measurements were above the 95th percentile in seven of 13 patients (LV), 12 of 13 patients (septum), and four of 13 patients (RV). Wall thickness measurements remained above normal, and there were no significant class changes at late follow-up. Histological examination in five patients showed markedly increased septal myocyte width, indicating myocyte hypertrophy. Atrial and great vessel anastomotic sites showed no evidence of obstruction by Doppler and catheterization studies. CONCLUSIONS These data demonstrate that normal cardiac chamber dimensional growth occurs at greater than 3 years' follow-up after pediatric heart transplantation. Significant LV and septal (and to a lesser extent RV) hypertrophy persists and may have implications for long-term allograft growth and function.