Mario Moric | Rush University Medical Center (original) (raw)

Papers by Mario Moric

Cerebral Cortex, 2019

During fetal development, cerebral cortical neurons are generated in the proliferative zone along... more During fetal development, cerebral cortical neurons are generated in the proliferative zone along the ventricles and then migrate to their final positions. To examine the impact of in utero exposure to anesthetics on neuronal migration, we injected pregnant rats with bromodeoxyuridine to label fetal neurons generated at embryonic Day (E) 17 and then randomized these rats to 9 different groups receiving 3 different means of anesthesia (oxygen/control, propofol, isoflurane) for 3 exposure durations (20, 50, 120 min). Histological analysis of brains from 54 pups revealed that significant number of neurons in anesthetized animals failed to acquire their correct cortical position and remained dispersed within inappropriate cortical layers and/or adjacent white matter. Behavioral testing of 86 littermates pointed to abnormalities that correspond to the aberrations in the brain areas that are specifically developing during the E17. In the second set of experiments, fetal brains exposed to ...

Investigative Ophthalmology & Visual Science, 2015

Journal of Anaesthesiology, Clinical Pharmacology, 2021

Background and Aims: Although a risk-adjusted approach to preventing postoperative nausea and vom... more Background and Aims: Although a risk-adjusted approach to preventing postoperative nausea and vomiting (PONV) is generally recommended, the successful implementation of such practice without mandated protocols remains elusive. To date, such a strategy has never been adapted to curb high baseline rates of prophylaxis. Material and Methods: We conducted an observational study on a cohort of patients undergoing elective surgery before and after the implementation of a quality improvement initiative including a risk-stratified approach to prevent PONV. The primary outcome was the number of prophylactic interventions administered. Secondary outcome included the repetition of ineffective medications and the need for rescue medication in the post-anesthesia care unit (PACU). Results: A total of 636 patients were included; 325 patients during the control period and 311 after the intervention. The educational program failed to reduce the amount of prophylactic antiemetics administered (2.0 v...

The Journal of Arthroplasty, 2021

BACKGROUND The purpose of this randomized clinical trial is to compare perioperative and postoper... more BACKGROUND The purpose of this randomized clinical trial is to compare perioperative and postoperative variables between static and articulating spacers for the treatment of chronic periprosthetic joint infection (PJI) complicating total hip arthroplasty (THA). METHODS Fifty-two patients undergoing resection arthroplasty as part of a 2-stage exchange for PJI at 3 centers were randomized to either a static (n = 23) or articulating spacer (n = 29). The primary endpoint was operative time of the second-stage reimplantation and power analysis determined that 22 patients per cohort were necessary to detect a 20-minute difference. Seven patients were lost to follow-up, 4 were never reimplanted, and one died before discharge after reimplantation. Forty patients were followed for a mean 3.2 years (range 2.0-7.1). RESULTS There were no differences in operative time at second-stage reimplantation (143 minutes static vs 145 minutes articulating, P = .499). Length of hospital stay was longer in the static cohort after stage 1 (8.6 vs 5.4 days, P = .006) and stage 2 (6.3 vs 3.6 days, P < .001). Although it did not reach statistical significance with the numbers available for study, nearly twice as many patients in the static cohort were discharged to an extended care facility after stage 1 (65% vs 30%, P = .056). CONCLUSION This randomized trial demonstrated that the outcomes of static and articulating spacers are similar in the treatment of THA PJI undergoing 2-stage exchange arthroplasty. The significantly longer length of hospital stay associated with the use of static spacers may have important economic implications for the health care system.

The Journal of Arthroplasty, 2018

World Journal of Anesthesiology, 2018

Change in management of predicted difficult airways following introduction of video laryngoscopes

Regional Anesthesia & Pain Medicine, 2019

Background and objectivesIntervertebral disc herniation is one of the common causes of low back p... more Background and objectivesIntervertebral disc herniation is one of the common causes of low back pain. Adenosine monophosphate (AMP)-activated protein kinase (AMPK) activator drugs have been shown to reduce pain in several animal models. The present study examines if early treatment with the drug metformin, an indirect AMPK activator, and/or O304, a new direct AMPK activator, can reduce the mechanical hypersensitivity that develops after lumbar disc puncture in mice.MethodsThe L4/L5 and L5/L6 discs in male and female mice were exposed via a retroperitoneal approach and a single puncture was made at the midline of each disc. Mice were randomized into four drug treatment groups: (1) vehicle; (2) metformin 200 mg/kg; (3) O304 200 mg/kg; (4) metformin 100 mg/kg plus O304 100 mg/kg; plus one untreated sham surgery group. Drugs were administered by oral gavage starting 7 days after disc puncture and repeated for six more days. Mechanical allodynia in the plantar hindpaw was measured presur...

Regional Anesthesia & Pain Medicine, 2019

Regional Anesthesia & Pain Medicine, 2019

BackgroundApproximately 15% of patients report persistent knee pain despite surgical success foll... more BackgroundApproximately 15% of patients report persistent knee pain despite surgical success following total knee arthroplasty (TKA). The purpose of this study was to determine the association of acute-postsurgical pain (APSP) with chronic postsurgical pain (CPSP) 6 months after TKA controlling for patient, surgical and psychological confounding factors.MethodsAdult patients with osteoarthritis undergoing primary elective tricompartmental TKA, with the operated knee the primary source of preoperative pain, were studied between March 2011 and February 2017. Patients received standard operative management and a perioperative multimodal analgesia regimen. The primary outcome was CPSP at 6 months. The primary variable of interest was the APSP (weighted mean pain score) for 72 hours postoperatively. Patient, surgical and psychological confounders were assessed using binary logistic regression.Results245 cases were analyzed. The incidence of CPSP was 14% (95% CI 10% to 19%). Median APSP v...

Regional Anesthesia and Pain Medicine, 2018

Infected implantable devices represent a clinical challenge, because the customary option is to s... more Infected implantable devices represent a clinical challenge, because the customary option is to surgically remove the device, and that is associated with substantial cost and morbidity to the patient, along with patient dissatisfaction with the physician. Although prophylactic systemic antibiotics and sterile technique are the mainstay of prevention of surgical site infection (SSI) after implant, the incidence of SSI remains relatively high. Although some surgeons add local antibiotic at implant site during surgery, there is no scientific research to demonstrate if there is a benefit. Rats and mice were randomly assigned to 4 treatment groups: systemic vancomycin alone, local vancomycin alone, combined systemic and local vancomycin, and untreated. After systemic vancomycin or saline preinjection, a surgical incision was performed for placement of a metal disc, and local vancomycin or saline was injected in the superficial tissue pocket created. The metal disc (implant) was placed in that space, followed by local injection of Staphylococcus aureus bacteria and wound closure. After 1 and 6 days, samples of the tissue surrounding the disc implant, the disc itself, and the spleen (systemic infection marker) were processed, and bacterial levels assayed. In both mice and rats, local vancomycin was more potent in reducing tissue SSI, implant infection, and spleen infection than systemic vancomycin at 1 day after induction of bacteria to a surgical wound. At 6 days, in both mice and rats, local vancomycin was again more potent in reducing tissue SSI than systemic vancomycin. This study suggests that local vancomycin should be added to systemic vancomycin to reduce SSI with cardiac pacemaker, defibrillator, implantable pulse generator of neurostimulator, or intrathecal pump implants.

The Journal of arthroplasty, 2018

Adductor canal blocks (ACBs) are an alternative to femoral nerve blocks that minimize lower extre... more Adductor canal blocks (ACBs) are an alternative to femoral nerve blocks that minimize lower extremity weakness. However, it is unclear whether this block will provide analgesia that is equivalent to techniques, such as epidural analgesia. The purpose of this randomized controlled trial was to compare continuous ACBs with epidural analgesia for primary total knee arthroplasty. Following institutional review board approval, 145 patients were randomized to 1 of 3 groups: combined spinal-epidural (CSE), spinal + continuous ACB (CACB), or general + CACB. Epidural analgesia was used postoperatively in the CSE group, and an adductor canal catheter was used in the CACB groups. Power analysis determined that 84 patients per group were needed to demonstrate a 35% increase in ambulation with an alpha of 0.05 at a power of 90%. At interim analysis, 13 patients were removed for protocol deviations, leaving 45 in CSE, 41 in spinal + CACB and 46 in general + CACB groups. Patient demographics were ...

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, Jan 7, 2017

To determine the incidence and demographic characteristics of shoulder stabilization in the Unite... more To determine the incidence and demographic characteristics of shoulder stabilization in the United States, with particular focus on age, sex, and inpatient versus outpatient treatment. The National Hospital Discharge Survey and the National Survey of Ambulatory Surgery databases were searched using a combination of International Classification of Diseases, Ninth Revision diagnosis and procedure codes, encompassing open and arthroscopic shoulder stabilization procedures. Incidence was determined using National Survey of Ambulatory Surgery, National Hospital Discharge Survey, and US census data, and the results were stratified by age, sex, facility, and concomitant diagnoses. Data were analyzed between 1994 and 2006, the most recent year for which data are available within these sources. The incidence of shoulder stabilization in the United States was 5.84 per 100,000 person-years (n = 15,514; 95% confidence interval, 11,975-19,053) in 1994 to 1996 and 6.89 per 100,000 person-years (n...

Journal of Bone and Joint Surgery, 2017

Background: Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss and t... more Background: Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss and the need for transfusions when administered intravenously in total hip arthroplasty. Oral formulations of the drug are available at a fraction of the cost of the intravenous preparation. The purpose of this randomized controlled trial was to determine if oral and intravenous formulations of tranexamic acid have equivalent blood-sparing properties. Methods: In this double-blinded trial, 89 patients undergoing primary total hip arthroplasty were randomized to receive 1.95 g of tranexamic acid orally 2 hours preoperatively or a 1-g tranexamic acid intravenous bolus in the operating room prior to incision; 6 patients were eventually excluded for protocol deviations, leaving 83 patients available for study. The primary outcome was the reduction of hemoglobin concentration. Power analysis determined that 28 patients were required in each group with a ±1.0 g/dL hemoglobin equivalence margin between groups with an alpha of 5% and a power of 80%. Equivalence analysis was performed with a two one-sided test (TOST) in which a p value of <0.05 indicated equivalence between treatments. Results: Forty-three patients received intravenous tranexamic acid, and 40 patients received oral tranexamic acid. Patient demographic characteristics were similar between groups, suggesting successful randomization. The mean reduction of hemoglobin was similar between oral and intravenous groups (3.67 g/dL compared with 3.53 g/dL; p = 0.0008, equivalence). Similarly, the mean total blood loss was equivalent between oral and intravenous administration (1,339 mL compared with 1,301 mL; p = 0.034, equivalence). Three patients (7.5%) in the oral group and one patient (2.3%) in the intravenous group were transfused, but the difference was not significant (p = 0.35). None of the patients in either group experienced a thromboembolic event. Conclusions: Oral tranexamic acid provides equivalent reductions in blood loss in the setting of primary total hip arthroplasty, at a greatly reduced cost, compared with the intravenous formulation.

Pain Medicine, 2017

Objective. Intravenous ketamine has been shown to provide postoperative analgesia in many clinica... more Objective. Intravenous ketamine has been shown to provide postoperative analgesia in many clinical trials, in particular to reduce opioid consumption. The primary objective of this pilot study is to determine if multiple dosing over a three-day perioperative period with oral ketamine is a safe treatment method for acute pain after amputation surgery.

The Journal of arthroplasty, Apr 22, 2016

Failed metal-on-metal (MoM) bearings are being increasingly encountered with little information t... more Failed metal-on-metal (MoM) bearings are being increasingly encountered with little information to guide evaluation for aseptic lymphocytic-dominated vasculitis-associated lesions (ALVAL). It is often assumed that elevated metal ion levels correlate with the occurrence of ALVAL. Our purpose was to determine the utility of the erythrocyte sedimentation rate, C-reactive protein, synovial white blood cell count, differential (%PMN), and serum metal ion levels in diagnosing ALVAL. We identified 80-failed MoM total hip arthroplasties. Tissue was examined under light microscopy and graded on a scale of ALVAL severity. Mean laboratory values were compared between groups and receiver operating curves generated with an area under the curve to determine test performance and optimal cutoffs. ALVAL scores were graded as low in 30 (37.5%), moderate in 39 (49%), and severe in 8 (10%), with 3 being unreadable. No clear cutoff values for erythrocyte sedimentation rate, C-reactive protein, or synovi...

Regional anesthesia and pain medicine, Jan 22, 2016

There is an increasing use of local infiltration analgesia (LIA) to reduce postoperative pain. De... more There is an increasing use of local infiltration analgesia (LIA) to reduce postoperative pain. Despite widespread use of LIA, wide variations in drug combinations and concomitant use of systemic analgesics have made it difficult to determine the optimal drug combinations for LIA. Using a previously validated rat laparotomy model, the optimal LIA combination of medications to reduce postoperative pain was determined. Laparotomy was performed in an adult rat model under isoflurane anesthesia. During surgery, combinations of bupivacaine, ketorolac, and dexamethasone were injected over the sutured muscle wound before skin closing, and compared to saline (placebo). The same medications were injected systemically as controls. Postoperative pain was assessed by measuring spontaneous rearing activity. A high-dose 3-drug LIA combination (50 μL of bupivacaine 0.75%, ketorolac 6.0 mg/mL, and dexamethasone 2.0 mg/mL) increased rearing (decreased pain) at 2 hours (P = 0.0032) postsurgery compare...

Regional anesthesia and pain medicine, Jan 16, 2016

There is increasing interest in local infiltration analgesia (LIA) to reduce postoperative pain w... more There is increasing interest in local infiltration analgesia (LIA) to reduce postoperative pain with knee surgery. Despite widespread use of LIA, wide variations in drug combinations, infiltration techniques, and the concomitant use of systemic analgesics have made it difficult to determine the optimal drug combination for LIA.Using a previously validated animal knee surgery model, we aimed to determine the optimal combination of medications to reduce postoperative pain, and the best anatomical location and timing for local drug injection during surgery. Knee surgery was performed in an adult rat model under isoflurane anesthesia. During surgery, combinations of bupivacaine, ketorolac, dexamethasone, and morphine were injected around the knee and compared to saline placebo. Similar medications were injected systemically as a comparator group. Postoperative pain was assessed by measuring spontaneous rearing activity. Injections were given after bone drilling and/or just before wound ...

The Journal of Bone and Joint Surgery (American), 2009

We previously reported our results at a minimum of three and seven years after use of a porous co... more We previously reported our results at a minimum of three and seven years after use of a porous coated acetabuiar metal siieli in a consecutive series of 138 revision totai hip arthroplasties. The current report presents the longer-term outcomes of these procedures, at fifteen to nineteen years postoperatively.

The Journal of Arthroplasty, 2012

The purpose of this multicenter study is to determine the utility of the erythrocyte sedimentatio... more The purpose of this multicenter study is to determine the utility of the erythrocyte sedimentation rate, C-reactive protein, and synovial fluid white blood cell (WBC) count and differential for evaluating periprosthetic joint infection (PJI) in patients with a failed unicompartmental knee arthroplasty (UKA). A total of 259 patients undergoing revision of a failed UKA were reviewed; 28 (10.8%) met the study criteria for PJI. The optimal cutoff values were 27 mm/h for the erythrocyte sedimentation rate, 14 mg/L for the C-reactive protein, 6200/μL for the synovial fluid WBC count, and 60% for the differential. These tests are useful for diagnosing PJI after UKA with optimal cutoff values that are similar to those used for total knee arthroplasty; however, the optimal synovial WBC count was found to be somewhat higher, which may be related to the unresurfaced compartments. In addition, we found that nearly half of patients had suboptimal evaluation for PJI.

Pathology, 2014

Introduction: Bronchus-associated lymphoid tissue (BALT) is part of the lung immune system that c... more Introduction: Bronchus-associated lymphoid tissue (BALT) is part of the lung immune system that consists of small aggregates of lymphoid cells at the bifurcation of the airways and along the lymphatic routes. While in animal models it plays a role in allograft response, that relationship has never been established in humans. BALT is often seen in lung transplant biopsies evaluated for rejection especially in A0 and A1 rejection. In early post-transplant biopsies (first 180 days) it is more commonly seen with A2 and A3 rejection. Irrespective of its role in allograft response in humans, morphologically BALT can occasionally be difficult to distinguish from rejection. Methods: We analyzed 33 transbronchial transplant lung biopsies, 25 with BALT and 8 with rejection for presence of CD21 positive dendritic cells to determine if their presence can distinguish BALT from the acute rejection. Fisher's exact test was used to evaluate statistical significance. Results: Of the 25 biopsies with BALT, 20 (80%) stained positive for CD21, while none of the 8 biopsies with acute rejection stained positive for CD21 (0%), a significant difference (p value <0.0001). Discussion: The results of the study showed that CD21 antibody may be helpful in distinguishing BALT from acute rejection in difficult cases.

Cerebral Cortex, 2019

During fetal development, cerebral cortical neurons are generated in the proliferative zone along... more During fetal development, cerebral cortical neurons are generated in the proliferative zone along the ventricles and then migrate to their final positions. To examine the impact of in utero exposure to anesthetics on neuronal migration, we injected pregnant rats with bromodeoxyuridine to label fetal neurons generated at embryonic Day (E) 17 and then randomized these rats to 9 different groups receiving 3 different means of anesthesia (oxygen/control, propofol, isoflurane) for 3 exposure durations (20, 50, 120 min). Histological analysis of brains from 54 pups revealed that significant number of neurons in anesthetized animals failed to acquire their correct cortical position and remained dispersed within inappropriate cortical layers and/or adjacent white matter. Behavioral testing of 86 littermates pointed to abnormalities that correspond to the aberrations in the brain areas that are specifically developing during the E17. In the second set of experiments, fetal brains exposed to ...

Investigative Ophthalmology & Visual Science, 2015

Journal of Anaesthesiology, Clinical Pharmacology, 2021

Background and Aims: Although a risk-adjusted approach to preventing postoperative nausea and vom... more Background and Aims: Although a risk-adjusted approach to preventing postoperative nausea and vomiting (PONV) is generally recommended, the successful implementation of such practice without mandated protocols remains elusive. To date, such a strategy has never been adapted to curb high baseline rates of prophylaxis. Material and Methods: We conducted an observational study on a cohort of patients undergoing elective surgery before and after the implementation of a quality improvement initiative including a risk-stratified approach to prevent PONV. The primary outcome was the number of prophylactic interventions administered. Secondary outcome included the repetition of ineffective medications and the need for rescue medication in the post-anesthesia care unit (PACU). Results: A total of 636 patients were included; 325 patients during the control period and 311 after the intervention. The educational program failed to reduce the amount of prophylactic antiemetics administered (2.0 v...

The Journal of Arthroplasty, 2021

BACKGROUND The purpose of this randomized clinical trial is to compare perioperative and postoper... more BACKGROUND The purpose of this randomized clinical trial is to compare perioperative and postoperative variables between static and articulating spacers for the treatment of chronic periprosthetic joint infection (PJI) complicating total hip arthroplasty (THA). METHODS Fifty-two patients undergoing resection arthroplasty as part of a 2-stage exchange for PJI at 3 centers were randomized to either a static (n = 23) or articulating spacer (n = 29). The primary endpoint was operative time of the second-stage reimplantation and power analysis determined that 22 patients per cohort were necessary to detect a 20-minute difference. Seven patients were lost to follow-up, 4 were never reimplanted, and one died before discharge after reimplantation. Forty patients were followed for a mean 3.2 years (range 2.0-7.1). RESULTS There were no differences in operative time at second-stage reimplantation (143 minutes static vs 145 minutes articulating, P = .499). Length of hospital stay was longer in the static cohort after stage 1 (8.6 vs 5.4 days, P = .006) and stage 2 (6.3 vs 3.6 days, P < .001). Although it did not reach statistical significance with the numbers available for study, nearly twice as many patients in the static cohort were discharged to an extended care facility after stage 1 (65% vs 30%, P = .056). CONCLUSION This randomized trial demonstrated that the outcomes of static and articulating spacers are similar in the treatment of THA PJI undergoing 2-stage exchange arthroplasty. The significantly longer length of hospital stay associated with the use of static spacers may have important economic implications for the health care system.

The Journal of Arthroplasty, 2018

World Journal of Anesthesiology, 2018

Change in management of predicted difficult airways following introduction of video laryngoscopes

Regional Anesthesia & Pain Medicine, 2019

Background and objectivesIntervertebral disc herniation is one of the common causes of low back p... more Background and objectivesIntervertebral disc herniation is one of the common causes of low back pain. Adenosine monophosphate (AMP)-activated protein kinase (AMPK) activator drugs have been shown to reduce pain in several animal models. The present study examines if early treatment with the drug metformin, an indirect AMPK activator, and/or O304, a new direct AMPK activator, can reduce the mechanical hypersensitivity that develops after lumbar disc puncture in mice.MethodsThe L4/L5 and L5/L6 discs in male and female mice were exposed via a retroperitoneal approach and a single puncture was made at the midline of each disc. Mice were randomized into four drug treatment groups: (1) vehicle; (2) metformin 200 mg/kg; (3) O304 200 mg/kg; (4) metformin 100 mg/kg plus O304 100 mg/kg; plus one untreated sham surgery group. Drugs were administered by oral gavage starting 7 days after disc puncture and repeated for six more days. Mechanical allodynia in the plantar hindpaw was measured presur...

Regional Anesthesia & Pain Medicine, 2019

Regional Anesthesia & Pain Medicine, 2019

BackgroundApproximately 15% of patients report persistent knee pain despite surgical success foll... more BackgroundApproximately 15% of patients report persistent knee pain despite surgical success following total knee arthroplasty (TKA). The purpose of this study was to determine the association of acute-postsurgical pain (APSP) with chronic postsurgical pain (CPSP) 6 months after TKA controlling for patient, surgical and psychological confounding factors.MethodsAdult patients with osteoarthritis undergoing primary elective tricompartmental TKA, with the operated knee the primary source of preoperative pain, were studied between March 2011 and February 2017. Patients received standard operative management and a perioperative multimodal analgesia regimen. The primary outcome was CPSP at 6 months. The primary variable of interest was the APSP (weighted mean pain score) for 72 hours postoperatively. Patient, surgical and psychological confounders were assessed using binary logistic regression.Results245 cases were analyzed. The incidence of CPSP was 14% (95% CI 10% to 19%). Median APSP v...

Regional Anesthesia and Pain Medicine, 2018

Infected implantable devices represent a clinical challenge, because the customary option is to s... more Infected implantable devices represent a clinical challenge, because the customary option is to surgically remove the device, and that is associated with substantial cost and morbidity to the patient, along with patient dissatisfaction with the physician. Although prophylactic systemic antibiotics and sterile technique are the mainstay of prevention of surgical site infection (SSI) after implant, the incidence of SSI remains relatively high. Although some surgeons add local antibiotic at implant site during surgery, there is no scientific research to demonstrate if there is a benefit. Rats and mice were randomly assigned to 4 treatment groups: systemic vancomycin alone, local vancomycin alone, combined systemic and local vancomycin, and untreated. After systemic vancomycin or saline preinjection, a surgical incision was performed for placement of a metal disc, and local vancomycin or saline was injected in the superficial tissue pocket created. The metal disc (implant) was placed in that space, followed by local injection of Staphylococcus aureus bacteria and wound closure. After 1 and 6 days, samples of the tissue surrounding the disc implant, the disc itself, and the spleen (systemic infection marker) were processed, and bacterial levels assayed. In both mice and rats, local vancomycin was more potent in reducing tissue SSI, implant infection, and spleen infection than systemic vancomycin at 1 day after induction of bacteria to a surgical wound. At 6 days, in both mice and rats, local vancomycin was again more potent in reducing tissue SSI than systemic vancomycin. This study suggests that local vancomycin should be added to systemic vancomycin to reduce SSI with cardiac pacemaker, defibrillator, implantable pulse generator of neurostimulator, or intrathecal pump implants.

The Journal of arthroplasty, 2018

Adductor canal blocks (ACBs) are an alternative to femoral nerve blocks that minimize lower extre... more Adductor canal blocks (ACBs) are an alternative to femoral nerve blocks that minimize lower extremity weakness. However, it is unclear whether this block will provide analgesia that is equivalent to techniques, such as epidural analgesia. The purpose of this randomized controlled trial was to compare continuous ACBs with epidural analgesia for primary total knee arthroplasty. Following institutional review board approval, 145 patients were randomized to 1 of 3 groups: combined spinal-epidural (CSE), spinal + continuous ACB (CACB), or general + CACB. Epidural analgesia was used postoperatively in the CSE group, and an adductor canal catheter was used in the CACB groups. Power analysis determined that 84 patients per group were needed to demonstrate a 35% increase in ambulation with an alpha of 0.05 at a power of 90%. At interim analysis, 13 patients were removed for protocol deviations, leaving 45 in CSE, 41 in spinal + CACB and 46 in general + CACB groups. Patient demographics were ...

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, Jan 7, 2017

To determine the incidence and demographic characteristics of shoulder stabilization in the Unite... more To determine the incidence and demographic characteristics of shoulder stabilization in the United States, with particular focus on age, sex, and inpatient versus outpatient treatment. The National Hospital Discharge Survey and the National Survey of Ambulatory Surgery databases were searched using a combination of International Classification of Diseases, Ninth Revision diagnosis and procedure codes, encompassing open and arthroscopic shoulder stabilization procedures. Incidence was determined using National Survey of Ambulatory Surgery, National Hospital Discharge Survey, and US census data, and the results were stratified by age, sex, facility, and concomitant diagnoses. Data were analyzed between 1994 and 2006, the most recent year for which data are available within these sources. The incidence of shoulder stabilization in the United States was 5.84 per 100,000 person-years (n = 15,514; 95% confidence interval, 11,975-19,053) in 1994 to 1996 and 6.89 per 100,000 person-years (n...

Journal of Bone and Joint Surgery, 2017

Background: Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss and t... more Background: Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss and the need for transfusions when administered intravenously in total hip arthroplasty. Oral formulations of the drug are available at a fraction of the cost of the intravenous preparation. The purpose of this randomized controlled trial was to determine if oral and intravenous formulations of tranexamic acid have equivalent blood-sparing properties. Methods: In this double-blinded trial, 89 patients undergoing primary total hip arthroplasty were randomized to receive 1.95 g of tranexamic acid orally 2 hours preoperatively or a 1-g tranexamic acid intravenous bolus in the operating room prior to incision; 6 patients were eventually excluded for protocol deviations, leaving 83 patients available for study. The primary outcome was the reduction of hemoglobin concentration. Power analysis determined that 28 patients were required in each group with a ±1.0 g/dL hemoglobin equivalence margin between groups with an alpha of 5% and a power of 80%. Equivalence analysis was performed with a two one-sided test (TOST) in which a p value of <0.05 indicated equivalence between treatments. Results: Forty-three patients received intravenous tranexamic acid, and 40 patients received oral tranexamic acid. Patient demographic characteristics were similar between groups, suggesting successful randomization. The mean reduction of hemoglobin was similar between oral and intravenous groups (3.67 g/dL compared with 3.53 g/dL; p = 0.0008, equivalence). Similarly, the mean total blood loss was equivalent between oral and intravenous administration (1,339 mL compared with 1,301 mL; p = 0.034, equivalence). Three patients (7.5%) in the oral group and one patient (2.3%) in the intravenous group were transfused, but the difference was not significant (p = 0.35). None of the patients in either group experienced a thromboembolic event. Conclusions: Oral tranexamic acid provides equivalent reductions in blood loss in the setting of primary total hip arthroplasty, at a greatly reduced cost, compared with the intravenous formulation.

Pain Medicine, 2017

Objective. Intravenous ketamine has been shown to provide postoperative analgesia in many clinica... more Objective. Intravenous ketamine has been shown to provide postoperative analgesia in many clinical trials, in particular to reduce opioid consumption. The primary objective of this pilot study is to determine if multiple dosing over a three-day perioperative period with oral ketamine is a safe treatment method for acute pain after amputation surgery.

The Journal of arthroplasty, Apr 22, 2016

Failed metal-on-metal (MoM) bearings are being increasingly encountered with little information t... more Failed metal-on-metal (MoM) bearings are being increasingly encountered with little information to guide evaluation for aseptic lymphocytic-dominated vasculitis-associated lesions (ALVAL). It is often assumed that elevated metal ion levels correlate with the occurrence of ALVAL. Our purpose was to determine the utility of the erythrocyte sedimentation rate, C-reactive protein, synovial white blood cell count, differential (%PMN), and serum metal ion levels in diagnosing ALVAL. We identified 80-failed MoM total hip arthroplasties. Tissue was examined under light microscopy and graded on a scale of ALVAL severity. Mean laboratory values were compared between groups and receiver operating curves generated with an area under the curve to determine test performance and optimal cutoffs. ALVAL scores were graded as low in 30 (37.5%), moderate in 39 (49%), and severe in 8 (10%), with 3 being unreadable. No clear cutoff values for erythrocyte sedimentation rate, C-reactive protein, or synovi...

Regional anesthesia and pain medicine, Jan 22, 2016

There is an increasing use of local infiltration analgesia (LIA) to reduce postoperative pain. De... more There is an increasing use of local infiltration analgesia (LIA) to reduce postoperative pain. Despite widespread use of LIA, wide variations in drug combinations and concomitant use of systemic analgesics have made it difficult to determine the optimal drug combinations for LIA. Using a previously validated rat laparotomy model, the optimal LIA combination of medications to reduce postoperative pain was determined. Laparotomy was performed in an adult rat model under isoflurane anesthesia. During surgery, combinations of bupivacaine, ketorolac, and dexamethasone were injected over the sutured muscle wound before skin closing, and compared to saline (placebo). The same medications were injected systemically as controls. Postoperative pain was assessed by measuring spontaneous rearing activity. A high-dose 3-drug LIA combination (50 μL of bupivacaine 0.75%, ketorolac 6.0 mg/mL, and dexamethasone 2.0 mg/mL) increased rearing (decreased pain) at 2 hours (P = 0.0032) postsurgery compare...

Regional anesthesia and pain medicine, Jan 16, 2016

There is increasing interest in local infiltration analgesia (LIA) to reduce postoperative pain w... more There is increasing interest in local infiltration analgesia (LIA) to reduce postoperative pain with knee surgery. Despite widespread use of LIA, wide variations in drug combinations, infiltration techniques, and the concomitant use of systemic analgesics have made it difficult to determine the optimal drug combination for LIA.Using a previously validated animal knee surgery model, we aimed to determine the optimal combination of medications to reduce postoperative pain, and the best anatomical location and timing for local drug injection during surgery. Knee surgery was performed in an adult rat model under isoflurane anesthesia. During surgery, combinations of bupivacaine, ketorolac, dexamethasone, and morphine were injected around the knee and compared to saline placebo. Similar medications were injected systemically as a comparator group. Postoperative pain was assessed by measuring spontaneous rearing activity. Injections were given after bone drilling and/or just before wound ...

The Journal of Bone and Joint Surgery (American), 2009

We previously reported our results at a minimum of three and seven years after use of a porous co... more We previously reported our results at a minimum of three and seven years after use of a porous coated acetabuiar metal siieli in a consecutive series of 138 revision totai hip arthroplasties. The current report presents the longer-term outcomes of these procedures, at fifteen to nineteen years postoperatively.

The Journal of Arthroplasty, 2012

The purpose of this multicenter study is to determine the utility of the erythrocyte sedimentatio... more The purpose of this multicenter study is to determine the utility of the erythrocyte sedimentation rate, C-reactive protein, and synovial fluid white blood cell (WBC) count and differential for evaluating periprosthetic joint infection (PJI) in patients with a failed unicompartmental knee arthroplasty (UKA). A total of 259 patients undergoing revision of a failed UKA were reviewed; 28 (10.8%) met the study criteria for PJI. The optimal cutoff values were 27 mm/h for the erythrocyte sedimentation rate, 14 mg/L for the C-reactive protein, 6200/μL for the synovial fluid WBC count, and 60% for the differential. These tests are useful for diagnosing PJI after UKA with optimal cutoff values that are similar to those used for total knee arthroplasty; however, the optimal synovial WBC count was found to be somewhat higher, which may be related to the unresurfaced compartments. In addition, we found that nearly half of patients had suboptimal evaluation for PJI.

Pathology, 2014

Introduction: Bronchus-associated lymphoid tissue (BALT) is part of the lung immune system that c... more Introduction: Bronchus-associated lymphoid tissue (BALT) is part of the lung immune system that consists of small aggregates of lymphoid cells at the bifurcation of the airways and along the lymphatic routes. While in animal models it plays a role in allograft response, that relationship has never been established in humans. BALT is often seen in lung transplant biopsies evaluated for rejection especially in A0 and A1 rejection. In early post-transplant biopsies (first 180 days) it is more commonly seen with A2 and A3 rejection. Irrespective of its role in allograft response in humans, morphologically BALT can occasionally be difficult to distinguish from rejection. Methods: We analyzed 33 transbronchial transplant lung biopsies, 25 with BALT and 8 with rejection for presence of CD21 positive dendritic cells to determine if their presence can distinguish BALT from the acute rejection. Fisher's exact test was used to evaluate statistical significance. Results: Of the 25 biopsies with BALT, 20 (80%) stained positive for CD21, while none of the 8 biopsies with acute rejection stained positive for CD21 (0%), a significant difference (p value <0.0001). Discussion: The results of the study showed that CD21 antibody may be helpful in distinguishing BALT from acute rejection in difficult cases.