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Recovery from Joint Replacement

Recovery from Joint Replacement: Chances are good you know someone who has undergone hip replacement surgery – one of the most common orthopedic approaches to resolving the agonizing hip pain associated with severe arthritis.

During hip replacement surgery, the top ball portion of the thighbone (the head of the femur) as well as the damaged surface of the matching socket on the pelvis are removed and replaced with manmade implants that restore fluid, pain-free movement to the hip.

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Prosthetic joint infections (PJI)

Prosthetic joint infections (PJI)

Prosthetic joint infections (PJI) of the hip and knee are uncommon, but result in significant morbidity and mortality when they do occur. Current management consists of a combination of either single- or two-stage exchange of the prosthesis and/or exchange of polymer components with intravenous (IV) antibiotics (4–6 weeks) and intraoperative debridement of the joint prior to reimplantation.

However, failure rate, morbidity, and expense associated with current management are high, especially if the infection involves resistant pathogens and/or osteomyelitis. Also, the current use of systemic antibiotics does not allow for high local concentrations of the drug and biofilm penetration of the infected prosthesis.




To overcome these difficulties, we examined the outcomes of aggressive operative debridement of the infected prosthesis. This was achieved through the use of a single-stage revision and administration of high concentrations of local intra-articular antibiotics via Hickman catheters.

We present 57 patients with PJI who were treated with intra-articular antibiotics and single-stage revisions. Minimal systemic toxicity was observed along with a 100% microbiologic cure rate and 89% without relapse at 11-month follow-up despite isolation of multidrug resistant pathogens. This is the largest study to date using this method in the treatment of PJI.

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Bone Disease in Multiple Myeloma

Multiple myeloma (MM) is a plasma cell disorder, characterized by bone marrow infiltration with clonal plasma cells, production of monoclonal immunoglobulin (paraprotein), and end organ damage including lytic lesions in the bones, renal impairment, hypercalcemia, and anemia. End organ damage is the main differentiating point of symptomatic from asymptomatic MM.

In myeloma bone disease (MBD), lesions could be in the form of a classic discrete lytic lesion (radiolucent, plasmacytoma), widespread osteopenia, or multiple lytic lesions affecting any part of skeleton, preferably spine, skull, and long bones. The higher the number of lesions, the poorer the prognosis.

Increased osteoclastogenesis with suppressed osteoblastic activity is the main mechanism of MBD.4 There are certain factors involved in stimulation and formation of osteoclasts (OCs) and reduction of osteoblastic activity. Recent advances in understanding of MBD showed that the receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin (OPG) system plays a key role in this regard.




MBD on one hand results in increased disability, morbidity, and on the other hand leads to increased cost of treatment of these patients.6 MM patients with bone disease not only need standard antimyeloma therapy but also require treatment with bisphosphonates (BPs), pain control, and a subgroup of patients may need radiotherapy and surgical interventions. This article focuses on different factors involved in the development of MBD and treatment modalities to manage this condition.

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Central Lines: Recognizing, Preventing & Troubleshooting Complications

Central Lines: Recognizing, Preventing & Troubleshooting Complications

TO PROMOTE positive outcomes, clinicians caring for patients with central lines must monitor carefully for signs and symptoms of complications.

This article discusses potential complications—catheter occlusion, bleeding and hematoma, catheter-tip migration, catheter rupture, phlebitis and associated pain, swelling and deep vein thrombosis (DVT), infection, and embolism. It also provides assessment, prevention, and troubleshooting tips for central lines.

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Eliminating Extravasation Events

Eliminating Extravasation Events

Administration of chemotherapy agents can give rise to many safety issues. Extravasation of a vesicant agent causes tissue blistering and necrosis. This complication of chemotherapy administration causes additional pain and suffering in patients who are already suffering with a diagnosis of cancer. Nurses hold key responsibilities for educating patients about administration issues and following practice standards to minimize the risk of extravasation.

Defining a path of shared responsibilities among team members is a critical step in assuring the safe administration of drugs classified as vesicants. This article describes a clinical practice change that is used at a large midwestern academic medical cancer center. This practice and policy change has resulted in a 90% reduction in the administration of vesicant agents peripherally, with no occurrence of extravasations in the first 6 months of implementation.

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Troponin and Cardiac Events

Troponin and Cardiac Events in Stable Ischemic Heart Disease and Diabetes

Cardiac troponin concentrations are used to identify patients who would benefit from urgent revascularization for acute coronary syndromes.

We hypothesized that they might be used in patients with stable ischemic heart disease to identify those at high risk for cardiovascular events who might also benefit from prompt coronary revascularization.

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Heart repair protein discovered by scientists

Researchers at Johns Hopkins University School of Medicine in the US, found that a protein called vinculin is responsible for keeping heart muscles pumping as we age

By Sarah Knapton, Science Editor, The Telegraph

A protein which helps the heart repair itself has been discovered by scientists in a breakthrough which could lead to new drugs to repair the damage of heart failure.
Unlike other organs, the human heart does not make many new cells over a lifetime and yet still manages to generate billions of beats as it grows old. Researchers at Johns Hopkins University School of Medicine in the US, found that a protein called vinculin is responsible for keeping heart muscles pumping.

“The heart is an amazingly resilient organ, but one that generally doesn’t regenerate, and its ability to pump invariably declines with age,” said Dr Anthony Cammarato, assistant professor of medicine and physiology at the Johns Hopkins. “Turns out, vinculin is a good guy, the body’s way of slowing down the decline of one of its most vital organs as it grows old. “Capitalising on the body’s own protective mechanisms and hijacking them therapeutically could help halt the decline of organs that don’t regenerate.”

The new findings about the role of vinculin, the researchers say, could pave the way to treatments that extend the lives of patients afflicted by heart failure. Around 900,000 people in the UK have heart failure, which occurs when the heart cannot pump blood around the body at the right pressure. It usually occurs because the heart muscle has become too weak or stiff to work properly. Symptoms include shortness of breath; fatigue; swollen ankles;rapid heartbeat; wheezing and lack of appetite.

In an initial set of experiments, researchers analysed levels of vinculin in the heart muscle of adult and aging fruit flies, rats and monkeys. In all three, vinculin levels rose steadily with age suggesting that the protein was rising to keep the heart beating.

When flies were genetically altered to create excess vinculin they lived 150 per cent longer than normal flies.
“Vinculin appears to be at the heart of a natural defence mechanism that reinforces the ageing heart cell and helps it better sense and respond to age-related changes,” said study senior author Dr Adam Engler, of the Sanford Consortium for Regenerative Medicine.

The research was published in the journal Science Translational Medicine.

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Understanding Preventive Health

As a child growing up in a fairly remote village, I followed my mum a couple of times to the local maternity centre at the delivery of my younger ones for routine child immunization. One thing I noticed which I clearly remember till date is mothers giving their babies Paracetamol syrup prior to their baby’s immunization. I watched with so much curiosity with many questions in my mind but I was too little and naive to voice say these things out yet I lived with them for years.

When I started my career in 1997 in the hospital, I saw it happen again and I asked a Matron colleague of mine who took time to explain to me. It was then I realised, mothers actually give this medication prior to immunization to prevent their babies from having high temperature. I was so amazed when I imagined the level of awareness and poor educational levels of those women I saw in the village. What these mothers were involved in can be relatively seen as a preventive health approach to health (proactively preventing increased body temperature in infants). It simply means taking proactive actions to prevent possible ill health, sickness or disease before it comes.




What those mothers understood even in that poorly informed level is that their babies can avoid the pain of suffering from high body temperature if they are given paracetamol prior to vaccination. My question is why couldn’t the mothers leave the babies to just take the vaccines without necessarily giving them those medications? Even the Mothers need peace of mind. When their children suffer from increased body temperature, the mothers also suffer discomfort.

This was just to build a foundation on what this column will be focused on within the time or period we have at our disposal. Preventive health is indeed the new frontier in healthcare delivery; it is the new world order in both saving healthcare cost and achieving improved healthcare outcomes. We grew up to meet our healthcare professionals enjoying the conventional curative clinical care, the business the health professionals had with patients was just to listen to patients’ complains, examine their physical clinical presentations and either recommend them for further laboratory investigation or outright drug prescription.

In modern day healthcare services, the complexion of healthcare delivery has greatly changed even the treatment pattern. The focus now is overall wellness, wholeness of body, mind and soul. This is where interaction and patient engagement has placed patients at the centre of quality healthcare delivery team. The rule is, we do not want you to be sick before you come to your healthcare professionals, even when you have questions, go to them and seek medical clarifications.

There used to be a level of reserved disposition among practitioners towards patients, but this has long changed because we must talk with our patients, answer their questions and clarify bothering medical issues they may have in their mind.




The role of the healthcare professionals have transcended beyond just caregiving but to health education, health awareness and health promotion. The patient needs to get informed, the patient needs to know what to do to maintain good health, he needs to know the food type suitable to maintaining good health and possible ways to modify life style in the midst of available health risk exposure.

Preventive health has been recommended as the most cost effective form of healthcare delivery. Let’s look at Hepatitis B which is a viral disease that has a violent effect on the liver, you will agree with me that it is easier, safer and most cost effective for us to get an early screening and take the vaccination if we come out negative. The highest cost you may get this screening and the three course vaccination will be between N5, 000.00 – N7, 500.00, but the average cost of having a six-month treatment outside the pre-treatment test falls within the neighbourhood of N500, 000.00 – N750, 000.00. There is no guaranty that the virus will be totally out within this six months, you might need about a year, two years, 6 years or longer therapy to totally get rid of this viral infection. What this tells us is that the cost of immunising yourself against Hepatitis B virus is just 1% of the cost of having a six-month therapy.




In any balances you may weigh this from; it makes a whole lot of economic sense to embrace Preventive health in our overall quest to maintaining an improved and quality life style. Curative Medicine is still very much in practice and in use but we need to free spaces in our healthcare facilities through Preventive Health approaches to allow those who really need those clinical environments access to curative care as recommended.
Organisations, families, governments and health insurers are financially bleeding in their health funds because of the sole reason of waiting till we get really sick before we seek medical help. This is wrong; we need to seek Medical help in form of Medical advice even when we are not sick. We need to have thorough engagement will our healthcare providers, if they are not talking to us or providing answers to our questions they cannot be the kind of healthcare providers we really need.

The most important approach to healthcare delivery in 21st century is “Caregiver-Patient Engagement”. This has another twist is preventing medical errors and ensuring patients safety.

We will be looking at most of these issues in details as time permits us subsequently. Stay glued to us here, we will surely be back.

Research reveals new details about the process by which the immune system refines its antibodies

Source: Rockefeller University

Summary: In response to an infection, the immune system refines its defensive proteins, called antibodies, to better target an invader. New research has revealed two mechanisms that favor the selection of B cells capable of producing antibodies with the highest affinity for that invader.

It’s a basic principle of immunology: When a germ invades, the body adapts to that particular target and destroys it. But much remains unknown about how the immune system refines its defensive proteins, called antibodies, to most effectively zero in on that invader. Experiments at The Rockefeller University offer new insight into the details of this selection process.

In research published in Science on July 16, scientists led by Michel Nussenzweig, Zanvil A. Cohn and Ralph M. Steinman Professor and head of the Laboratory of Molecular Immunology, uncovered a new mechanism by which the B cells that produce the most finely tuned antibodies rise to dominance. This discovery builds on earlier work published last year.

“Through a process called affinity maturation B cells compete, and those cells that produce the highest affinity antibodies win and come to dominate the B cell population. Our work so far has revealed two of the mechanisms that allow high affinity B cells to overwhelm the others,” says Alex Gitlin, a graduate student in the lab and first author of the paper.

B cells have genes that code for antibodies, which latch onto foreign proteins, called antigens, as part of an immune response. During an infection, B cells and other immune cells form tiny structures called germinal centers in the spleen and lymph nodes.

Within germinal centers, B cells evolve in a Darwinian-like fashion. The gene responsible for producing their antibodies mutates rapidly, a million times faster than the normal rate of mutation in the human body, and the cells proliferate. B cells whose mutations increase the antibody’s affinity for the antigen are selected, and these cells then continue to mutate and proliferate.

“Previously, we showed that high affinity cells spend more time dividing and mutating in between rounds of competition. We now show that these high affinity cells also use this additional time more effectively — by dividing at faster rates,” Gitlin says. In this manner, the germinal center produces the high affinity antibodies that are the basis of an effective immune response.

Vaccines initiate this process by exposing the body to pieces of a pathogen or to a weakened or dead version of it, prompting the immune system to develop protective antibodies. Because vaccines depend on effective antibody responses for protection, a better understanding of the antibody selection process in the germinal center might potentially be of use for developing more effective vaccines.

The team’s research has focused on the dynamics inside the germinal center. Within it, B cells travel between two areas known as the dark zone and the light zone. In the dark zone, the B cells mutate and proliferate, before traveling to the light zone, where they pick up pieces of antigen. The higher the affinity of their antibodies, the more antigen they pick up.

Their previous experiments demonstrated that another type of immune cell, the T cell, operates in the light zone to recognize the higher affinity B cells based on the amount of antigen they display. The more antigen the B cells present to T cells, the stronger the signal the T cells send. As a result, the high affinity B cells spend more time in the dark zone in between visits to the light zone.

This time, the team, which also included collaborators at Memorial Sloan Kettering Cancer Center and Harvard Medical School, identified another reason the high affinity cells come to dominate: more rapid cell divisions. They induced the selection of an engineered set of B cells in mice, and used labels that the cells incorporate as they replicate their DNA in preparation for cell division. With these techniques they found that a signal from the T cell also prompts the high affinity B cells to divide more rapidly while in the dark zone. In effect, these cells have both more time and more speed with which to duplicate themselves.

By labeling DNA replication and following its progression, the team took a close look at how the S phase of the cell cycle, in which the cell copies its DNA in preparation for division, is sped up. They found that acceleration during this phase was due to the double-stranded DNA molecule being unzipped and copied more rapidly at the so-called replication fork.

“Together, these studies describe two complementary ways in which signals from T cells empower the best equipped set of B cells to take over the immune response during affinity maturation. Other mechanisms, which are yet to be discovered, are also likely to be at play,” Gitlin says. “The dynamics of germinal centers are crucial to this basic immunological process, and they may also have important implications for improving vaccines and understanding lymphomas, which often arise from germinal center B cells due to their high rates of proliferation and mutation.”

Source
Rockefeller University. “Cell division speeds up as part of antibody selection: Research reveals new details about the process by which the immune system refines its antibodies.” ScienceDaily. ScienceDaily, 16 July 2015. .

Blood hormone levels predicted long-term breast cancer risk for postmenopausal women

Source: American Association for Cancer Research (AACR)

Summary: Blood hormone tests predicted a woman’s risk for developing postmenopausal breast cancer for up to 20 years, according to new research.

Blood hormone tests predicted a woman’s risk for developing postmenopausal breast cancer for up to 20 years, according to data from the Nurses’ Health Study presented at the 11th Annual AACR International Conference on Frontiers in Cancer Prevention Research, held in Anaheim, Calif., Oct. 16-19, 2012.

“We found that a single hormone level was associated with breast cancer risk for at least 16 to 20 years among postmenopausal women not using postmenopausal hormones,” said Xuehong Zhang, M.D., an epidemiologist at Brigham and Women’s Hospital and an instructor in medicine at Harvard Medical School in Boston, Mass. “We, and others, are now evaluating if the addition of hormone levels to current risk prediction models can substantially improve our ability to identify high-risk women who would benefit from enhanced screening or chemoprevention. If so, the current data suggest that hormone levels would not need to be measured in the clinic more than once every 10, or possibly 20, years.”

Zhang and colleagues analyzed 796 patients with postmenopausal breast cancer who had not received hormone therapy. They conducted blood hormone tests at two time points: between 1989 and 1990, and between 2000 and 2002. They then matched each patient with two controls who were not diagnosed with breast cancer.

Women with hormone levels in the highest 25 percent for estradiol, testosterone and dehydroepiandrosterone sulfate (DHEAS) had a 50 percent to 107 percent greater chance for developing breast cancer compared with women in the lowest 25 percent. Relative risks for developing breast cancer were similar at one to 10 years versus 11 to 20 years (also 16 to 20 years) after blood collection.

Zhang and colleagues also investigated whether these higher hormone levels were more closely linked to hormone receptor- (HR) positive breast cancers and if they predicted risk regardless of tumor aggressiveness.

In the first case, they found that elevated levels of estradiol increased a woman’s risk for HR-positive breast cancer. In general, increased hormone levels, except for DHEAS, tracked closely with increased risk for HR-positive breast cancer. Data on HR-negative cancers were inconclusive.

Elevated hormone levels were also associated with aggressive breast cancer, which the study defined as recurrent or fatal cancer. “The relationship was comparable or possibly stronger for recurrent and fatal breast cancer than it was for overall breast cancer risk, although these results were based on relatively small numbers of participants,” said Zhang.

Researchers also confirmed the protective effect of sex hormone-binding globulin (SHBG), which seems to negate the cancer-causing effects of certain hormones. Women in the highest 25 percent of SHBG levels had a 30 percent lower risk for breast cancer compared with women in the lowest 25 percent for SHBG levels.

Zhang noted that the study had low case numbers for several cancer subgroups, including HER2-positive, triple-negative and basal-like breast cancers. More research is necessary to determine the relationship between elevated hormone levels and these important breast cancer subtypes.

Source
American Association for Cancer Research (AACR). “Blood hormone levels predicted long-term breast cancer risk for postmenopausal women.” ScienceDaily. ScienceDaily, 18 October 2012. .

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