Washington Hospital Healthcare System

As robotic total knee arthroplasty (TKA) adoption grows, the learning curve for new users remains a concern for both physicians and staff. Previous studies have reported on clinical outcomes for TKA with a novel implant-agnostic, handheld, wireless robotic TKA system (rTKA). This study investigates the rTKA adoption learning curve relevant to multiple clinical stakeholders. This multicenter, multi-surgeon observational study includes up to the first 25 rTKA procedures by 7 surgeons. Observers noted timing and workflow at 8/25 rTKA cases and 2 standard-of-care benchmark TKAs (prior manual or robotic use by user), and analyzed logs for all rTKA cases. Learning curves were assessed via benchmark TKA time neutrality, statistical comparison between early and later cases, and cumulative sum (CUSUM) analysis. Surgeon and staff surveys followed each observed rTKA case. Each analysis type demonstrated a different learning curve duration: surgeons averaged approximately 10 cases to time neutrality, with 2 not reaching time neutrality within the observed case series. Cases 3 and onward were significantly faster than cases 1–2 (p = 0.0454), indicating early operative time improvement after initial system exposure. Average observed skin-to-skin time was 68 min. Surgeons and staff rated the system easy to use and were familiar with the system after 4 cases. Use of the handheld surgical robot for rTKA demonstrated a short learning curve and high reported ease of adoption by surgeons and staff. This study demonstrates the rTKA system exhibits a short learning curve and high reported ease of adoption, and may compare favorably with previously reported learning curves for other robotic TKA systems. Level of evidence: IV.

This report describes the case of a 70-year-old female with a history of bioprosthetic aortic valve replacement. She presented to the emergency department with significant shortness of breath and bilateral lower extremity edema, which was found to be secondary to new-onset acute symptomatic congestive heart failure in the setting of Heyde syndrome.

Introduction: Women with atrial fibrillation (AF) are more symptomatic, have poorer quality of life and carry a higher risk of stroke than men. Despite this woman have been underrepresented in randomized controlled trials (RCTs) of AF. Hypothesis: Women representation in the author panel might influence enrollment of women in RCTs of AF. Methods: We performed a systematic literature search from 1989 through December 2019 to identify RCTs of AF with a follow-up duration of ≥3 months. The multivariate linear regression model was constructed with the proportion of women enrollment in the RCTs as the dependent variable and the proportion of women in the author panel as a key independent variable. The model was adjusted for publication year, region, sponsor, and type of RCTs (invasive or medical treatment). Results: A total of 134 RCTs (n=149,162) were included. The median number of participants per trial was 205 (IQR, 74-676). The median number of women per trial was 71 (IQR, 27-218). The overall representation of women was 35.1% (95% CI, 32.6-37.6%), which did not improve between 1989 to 2019 (from 27.3% to 29.6%; P=0.10). RCTs of AF were authored by 1,568 authors. The median number of authors per trial publication was 10 (IQR, 7-10). The median number of women authors was 1 (IQR, 0-3). First (93%) and senior (92%) authors were predominantly men. Only 13.3% (n=18) of publications had women as first or senior authors, which did not improve over time (P=0.07). Multivariate model showed that each 1% increase in women in the author panel was associated with 19% increase in women enrollment in RCTs (P=0.02) (Table). Conclusions: Women remained underrepresented both as participants and as authors of RCTs of AF. Higher representation of women in the author panel was associated with higher enrollment of women in RCTs of AF. Efforts to recruitment and retain women AF investigators may be a critical mechanism to help lessen the disparities in both areas.

Disseminated acanthamoebiasis is a rare, often fatal, infection most commonly affecting immunocompromised patients. We report a case involving sinuses, skin, and bone in a 60-year-old woman 5months after heart transplantation. She improved with a combination of flucytosine, fluconazole, miltefosine, and decreased immunosuppression. To our knowledge, this is the first case of successfully treated disseminated acanthamoebiasis in a heart transplant recipient and only the second successful use of miltefosine for this infection among solid organ transplant recipients. Acanthamoeba infection should be considered in transplant recipients with evidence of skin, central nervous system, and sinus infections that are unresponsive to antibiotics. Miltefosine may represent an effective component of a multidrug therapeutic regimen for the treatment of this amoebic infection.

Poem

To determine the best positioning and the resulting fluid flow patterns inside the knee during arthroscopy, reducing the surgical morbidity associated with the arthroscopic irrigation and debridement of a septic knee joint. Three-dimensional MRI, using an MRI-compatible human cadaveric knee arthroscopic model, generated fluid flow diagrams and velocity vector data. This was analyzed for six different arthroscopic configurations and at six different locations within the knee joint. At any one static arthroscopic position, fluid flow velocity differed at the various locations in the knee, often with statistically significantly greater flow at one location over another. In general, flow was greatest at the location at which the inflow cannula terminated and preferentially flowed directly to the outflow cannula location, neglecting spaces in the knee that were not on this direct path. Three-portal arthroscopy provided no benefit over two-portal arthroscopy. To maximize arthroscopic lavage throughout all compartments in the knee, the arthroscopist must individually enter each space in the knee. Static arthroscopy in the setting of knee sepsis may lead to inadequate flow in certain areas of the knee and may lead to treatment failure. Three-portal arthroscopy does not improve lavage efficiency.

(13)C MR spectroscopy studies performed on hearts ex vivo and in vivo following perfusion of prepolarized [1-(13)C]pyruvate have shown that changes in pyruvate dehydrogenase (PDH) flux may be monitored non-invasively. However, to allow investigation of Krebs cycle metabolism, the (13)C label must be placed on the C2 position of pyruvate. Thus, the utilization of either C1 or C2 labeled prepolarized pyruvate as a tracer can only afford a partial view of cardiac pyruvate metabolism in health and disease. If the prepolarized pyruvate molecules were labeled at both C1 and C2 positions, then it would be possible to observe the downstream metabolites that were the results of both PDH flux ((13)CO(2) and H(13)CO(3)(-)) and Krebs cycle flux ([5-(13)C]glutamate) with a single dose of the agent. Cardiac pH could also be monitored in the same experiment, but adequate SNR of the (13)CO(2) resonance may be difficult to obtain in vivo. Using an interleaved selective RF pulse acquisition scheme to improve (13)CO(2) detection, the feasibility of using dual-labeled hyperpolarized [1,2-(13)C(2)]pyruvate as a substrate for dynamic cardiac metabolic MRS studies to allow simultaneous investigation of PDH flux, Krebs cycle flux and pH, was demonstrated in vivo.

Recent research indicates that many local governments are doing little to provide information and services to their citizens via the Internet, so more needs to be known about the underlying reasons for governments' adoption of web technology. A two-stage research project, statistical analysis followed by qualitative investigation, of a stratified random sample of American counties reveals the importance of advocacy by motivated individuals, both appointed and elected. The findings from both stages of this research underscore the importance of motivated professionals who choose to actively promote web technologies.

Health care leadership has never been more difficult than in the past decade--and the next ten years promise to be even more demanding. As a new era for health care emerges, organizational leaders will be required to manage increased levels of risk, uncertainty, and rapid change. Successful chief executives will be those who recognize and nurture intangible leadership qualities including knowledge of self, commitment to service, and depth and breadth of vision. With the continued shift away from hospital inpatient care, health care leaders will be called on to develop multipurpose delivery systems that move from a market-based to a community-based focus and deliver high quality services in a cost-effective manner. Several leadership themes will unfold in the midst of health care reform, including: exploiting change for the good of the organization and community; serving as educator, communicator, and comforter to divergent constituencies; and reestablishing a balance between short-term goals and long-term vision.