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AIMS: The aim of this study was to observe the implications of withholding total joint arthroplasty (TJA) in morbidly obese patients. PATIENTS AND METHODS: A total of 289 morbidly obese patients with end-stage osteoarthritis were prospectively followed. There were 218 women and 71 men, with a mean age of 56.3 years (26.7 to 79.1). At initial visit, patients were given information about the risks of TJA in the morbidly obese and were given referral information to a bariatric clinic. Patients were contacted at six, 12, 18, and 24 months from initial visit. RESULTS: The median body mass index (BMI) at initial visit was 46.9 kg/m2 (interquartile range (IQR) 44.6 to 51.3). A total of 82 patients (28.4%) refused to follow-up or answer phone surveys, and 149 of the remaining 207 (72.0%) did not have surgery. Initial median BMI of those 149 was 47.5 kg/m2 (IQR 44.6 to 52.5) and at last follow-up was 46.7 kg/m2 (IQR 43.4 to 51.2). Only 67 patients (23.2%) went to the bariatric clinic, of whom 14 (20.9%) had bariatric surgery. A total of 58 patients (20.1%) underwent TJA. For those 58, BMI at initial visit was 45.3 kg/m2 (IQR 43.7 to 47.2), and at surgery was 42.3 kg/m2 (IQR 38.1 to 46.5). Only 23 patients (39.7%) of those who had TJA successfully achieved BMI < 40 kg/m2 at surgery. CONCLUSION: Restricting TJA for morbidly obese patients does not incentivize weight loss prior to arthroplasty. Only 20.1% of patients ultimately underwent TJA and the majority of those remained morbidly obese. Better resources and coordinated care are required to optimize patients prior to surgery. Cite this article: Bone Joint J 2019;101-B(7 Supple C):28-32.

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We present a case of spontaneous rupture of the spleen, an uncommon complication of systemic amyloidosis. Amyloid deposition leading to capsular distension and increased vascular fragility is thought to predispose the spleen to rupture spontaneously.

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OBJECTIVE: We sought to determine the incidence of unsuspected injury to the lower urinary tract as detected by intraoperative cystoscopy when the Burch procedure is performed. STUDY DESIGN: We reviewed the records of 181 women who underwent pelvic surgery, which included a Burch retropubic urethropexy for genuine stress urinary incontinence, between Jan 1, 1998, and Dec 31, 1999. All patients underwent intraoperative cystoscopy at the completion of the Burch procedure after the administration of intravenous indigo carmine dye. RESULTS: There were 6 (3.3%) injuries to the lower urinary tract. Five of the injuries were cystotomies that had been recognized during operation. One obstructed left ureter was detected by cystoscopy and relieved by the release of left paravaginal repair sutures. No unsuspected injuries that were detected by cystoscopy were attributable to the Burch procedure. CONCLUSIONS: The lower urinary tract injury rate was 3.3%. All but one injury was recognized before cystoscopy. The one injury was attributed to concomitant paravaginal repair and not to the Burch procedure.

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The fate, effects, and potential environmental risks of ethylene glycol (EG) in the environment were examined. EG undergoes rapid biodegradation in aerobic and anaerobic environments (approximately 100% removal of EG within 24 h to 28 days). In air, EG reacts with photo-chemically produced hydroxyl radicals with a resulting atmospheric half-life of 2 days. Acute toxicity values (LC(50)s and EC(50)s) were generally >10,000 mg/l for fish and aquatic invertebrates. The data collectively show that EG is not persistent in air, surface water, soil, or groundwater, is practically non-toxic to aquatic organisms, and does not bioaccumulate in aquatic organisms. Potential long-term, quasi-steady state regional concentrations of EG estimated with a multi-media model for air, water, soil, and sediment were all less than predicted no effect concentrations (PNECs).

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Clinical, radiological and pathological findings in 31 patients with xanthogranulomatous cholecystitis have been reviewed. The spectrum of presentation was similar to that of cholelithiasis but fewer patients had biliary colic (17 per cent) and there were more complications (32 per cent). Four patients had a biliary fistula and four a perforated gallbladder with abscess formation. Patients characteristically had gallstones. Appearances often mimicked carcinoma of the gallbladder at ultrasonography and/or laparotomy, with xanthogranulomatous tissue extending to adjacent structures. Xanthogranulomatous cholecystitis and carcinoma of the gallbladder coexisted in three patients. The possibility should be considered that an 'inoperable tumour' of the gallbladder may in fact be xanthogranulomatous cholecystitis, a benign condition that frozen-section biopsy may confirm.

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Platelets and megakaryocytes have a role in atherogenesis. In this study the effect of platelet destruction, caused by injection of serum containing anti-platelet antibodies, on the development of atheroma and on megakaryocyte size and DNA content was studied in rabbits on a high cholesterol diet. Seven days after destruction of the circulating platelets a significant (150% and 300% in two separate studies) increase in the area of atheroma in the aorta was demonstrated. Histological examination revealed that large quantities of extracellular lipid and connective tissue were present in these plaques. The acceleration of atherogenesis in this model was found to be preceded by a significant increase in megakaryocyte size and in the frequency of megakaryocytes with a high DNA content. Platelets derived from large, high ploidy megakaryocytes may be of importance for the development of the atherosclerotic lesion. Neither the endothelial permeability as assessed by injection of Evans blue nor the prostacyclin production by the aorta of animals injected with anti-platelet serum were significantly different from the aortas of control animals.

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The effect of a short-term high cholesterol diet on thrombopoiesis and vascular ultrastructure was evaluated in rabbits. Six pairs of male litter-mate rabbits were randomized pairwise to feeding with either 2 g of cholesterol daily in addition to their normal diet or normal diet alone for 7 days. A significant 12-fold increase in median serum cholesterol (P less than 0.035) and an insignificant decrease in platelet count (P = 0.07) were found in the animals fed a high cholesterol diet. In these animals the total and cytoplasmic megakaryocyte size measured as planimetric areas in bone marrow sections were significantly decreased (P less than 0.035). No statistically significant difference in the megakaryocyte DNA content measured by flow cytometry in marrow suspensions enriched for megakaryocytes by density gradient centrifugation and centrifugal elutriation was observed between the cholesterol-fed animals and controls. Light microscopic, transmission and scanning electron microscopic examination of the aorta in both groups of animals showed a morphologically intact endothelium without any adhesion of blood-borne cells to the luminal surface. Transmission electron microscopic studies showed that cells with ultrastructural features resembling smooth muscle cells were present in the intima of the aortas of the animals on the high cholesterol diet, but not in control animals. A decrease in the size of bone marrow megakaryocytes and the occurrence of intimal smooth muscle cells are found in rabbits fed a high cholesterol diet for 7 days. These cellular events may be important features in early atherogenesis.

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Eighteen explanted pericardial heterografts were studied (16 standard Ionescu-Shiley, one Hancock, and one Mitroflow). Regurgitation was the reason given for explantation of all the Ionescu-Shiley valves. The other two valves were removed for technical reasons. All the Ionescu-Shiley valves had commissural tears and there was concomitant gross calcification in 10 of the 16 valves. In addition, an apparent increase in cusp area had caused "leaflet sagging". The explanted leaflets were thicker and stiffer than leaflets from an unimplanted valve. These features were confirmed directly with an animal model of subcutaneous implantation. Examination with an electron microscope revealed that these changes in mechanical properties seemed to be linked to fiber separation and infiltration by an amorphous proteinlike matrix. The durability of the glutaraldehyde-fixed pericardium depended on a number of factors. Early and midterm failure appeared to be stress induced. Predisposition to high mechanical stresses near the stent was exacerbated by the changes induced by the host environment. This problem was aggravated further in the Ionescu-Shiley valves by stress concentrations around the hole associated with the holding suture. In the long term, collagen disruption associated with leaflet flexure was followed by secondary calcification at the boundary between the intact and disrupted material.

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The necropsy findings in 21 patients on an intensive care unit, on whom coagulation studies had been performed immediately before death, were assessed. Eleven of the patients were retrospectively studied and 10 were reviewed consecutively in a prospective study. Fifteen patients (eight retrospective and seven prospective) had evidence of disseminated intravascular coagulation. Microthrombi were most often found in the lungs and kidneys. The most common abnormal coagulation tests in patients with necropsy evidence of disseminated intravascular coagulation were raised serum concentrations of fibrinogen and fibrin degradation products, prolonged prothrombin time, and reduced platelet counts. Reduced fibrinogen concentrations and a prolonged thrombin time were the least commonly observed abnormalities. There was no difference in either the prevalence or magnitude of abnormality of any particular coagulation variable test result between those patients with evidence of disseminated intravascular coagulation at necropsy and those without.

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The effect of fish oil supplementation on atherogenesis and thrombopoiesis was investigated in rabbits fed a high cholesterol diet for 7 weeks. There was no statistically significant difference between the area of lipid accumulation in the aorta of the animals fed fish oil and the control animals. There was no statistically significant difference in platelet count, mean platelet volume, megakarycoyte DNA content or serum cholesterol between the two groups. Serum triglyceride was significantly higher in the fish oil group than in the controls (p less than 0.035). Fish oil supplementation does not change atherogenesis or thrombopoiesis in the cholesterol fed rabbit.

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The effects of simple-carbohydrate (CHO)- and complex-CHO-rich diets on skeletal muscle glycogen content were compared. Twenty male marathon runners were divided into four equal groups with reference to dietary consumption: depletion/simple, depletion/complex, nondepletion/simple, and nondepletion/complex. Subjects consumed either a low-CHO (15% energy [E] intake), or a mixed diet (50% CHO) for 3 days, immediately followed by a high-CHO diet (70% E intake) predominant in either simple-CHO or in complex-CHO (85% of total CHO intake) for another 3 days. Skeletal muscle biopsies and venous blood samples were obtained one day prior to the start of the low-CHO diet or mixed diet (PRE), and then again one day after the completion of the high-CHO diet (POST). The samples were analysed for skeletal muscle glycogen, serum free fatty acids (FFA), insulin, and lactate and blood glucose. Skeletal muscle glycogen content increased significantly (p less than 0.05) only in the nondepletion/simple group. When groups were combined, according to the type of CHO ingested and/or utilization of a depletion diet, significant increases were observed in glycogen content. Serum FFA decreased significantly (p less than 0.05) for the nondepletion/complex group only, while serum insulin, blood glucose, and serum lactate were not altered. It is concluded that significant increases in skeletal muscle glycogen content can be achieved with a diet high in simple-CHO or complex-CHO, with or without initial consumption of a low-CHO diet.

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A comparison of the influence of simple and complex carbohydrate (CHO) consumption on adipose tissue- and skeletal muscle-lipoprotein lipase activity (AT-LPLA, SM-LPLA) was examined. Twenty male marathon runners were divided into two equal dietary groups: simple-CHO and complex-CHO. Half of the subjects in each group consumed either a low-CHO (15% energy [E] intake), or a mixed diet (50% CHO) for 3 days. Immediately following this dietary period, the subjects consumed a CHO-rich diet (70% E intake) predominant in simple-CHO or in complex-CHO for an additional 3 days. Thereafter, all subjects returned to a normal mixed diet. Skeletal muscle biopsies, adipose tissue aspirations, and venous blood samples were obtained prior to dietary manipulation (PRE), upon completion of the 6 day diet (POST I), and 2 weeks after returning to a normal diet (POST II). The samples were analysed for AT-LPLA, SM-LPLA, serum insulin, and free fatty acids (FFA), and blood glucose, and lactate. SM-LPLA fell 71% from PRE values of 0.39 +/- 0.30 mu mol.g-1.h-1 to POST I values of 0.11 +/- 0.09 mu mol.g-1.h-1 (means +/- SD) (p less than 0.05), after a complex-CHO diet. However, the simple-CHO diet did not alter SM-LPLA. AT-LPLA similarly decreased (p less than 0.05) after the complex-CHO diet, and no significant decrease was noted after the simple-CHO diet.(ABSTRACT TRUNCATED AT 250 WORDS)

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In a retrospective three year study 13 cases of xanthogranulomatous cholecystitis (XGC) (seven female, six male) were found in 724 gallbladders (1.8%), an estimated incidence of 1.7 cases per 100,000 population per annum. Symptoms often began with an episode of acute cholecystitis and persisted for up to five years. There was extension of xanthogranulomatous tissue into adjacent organs in nine cases. Three patients had fistulae from the gallbladder, one to skin, and two to the duodenum; this is the first report of this complication in XGC. In two patients XGC sufficiently resembled carcinoma for the surgeon to request intraoperative frozen section diagnosis. There was a high rate of postoperative infective complication, with one subphrenic abscess and three wound infections (one fatal), two in patients with fistulae.

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The mechanical properties of five different, equally distributed, and randomly oriented sites in natural and glutaraldehyde-fixed calf pericardial sacs were investigated. Identical sites in different sacs were obtained by placing a template over each sac and using the ligaments still attached to the pericardium as a reference frame. Mean maximum extension of the fixed tissue was statistically significantly greater than that of natural tissue at the same degree of stress. There was no significant difference in thickness from position to position within a sac, from sac to sac, or from the natural to fixed pericardium. However, the extensibility of one particular site was significantly greater than that of other positions in the pericardial sac. This position lay entirely in a well-defined sector that emanated radially from the pericardial ligaments. Light and electron microscopy showed no difference in collagen structure in the five positions studied. In contrast, both the content and ultrastructure of the tissue elastin differed in the region of high extensibility compared with those sites studied in the remainder of the sac. This region contained coarse condensed elastin whereas the other sites had fine elastin dispersed diffusely throughout the tissue. These results suggest that pericardial heterografts of uniform thickness may be harvested from any position in calf pericardium. However, unless the region of coarse condensed elastin is excluded, leaflets with significantly different mechanical properties may be produced.

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