White-nose syndrome (WNS), an emerging infectious disease that has killed over 5.5 million hibernating bats, is named for the causative agent, a white fungus (Geomyces destructans (Gd)) that invades the skin of torpid bats. During hibernation, arousals to warm (euthermic) body temperatures are normal but deplete fat stores. Temperature-sensitive dataloggers were attached to the backs of 504 free-ranging little brown bats (Myotis lucifugus) in hibernacula located throughout the northeastern USA. Dataloggers were retrieved at the end of the hibernation season and complete profiles of skin temperature data were available from 83 bats, which were categorized as: (1) unaffected, (2) WNS-affected but alive at time of datalogger removal, or (3) WNS-affected but found dead at time of datalogger removal. Histological confirmation of WNS severity (as indexed by degree of fungal infection) as well as confirmation of presence/absence of DNA from Gd by PCR was determined for 26 animals. We demonstrated that WNS-affected bats aroused to euthermic body temperatures more frequently than unaffected bats, likely contributing to subsequent mortality. Within the subset of WNS-affected bats that were found dead at the time of datalogger removal, the number of arousal bouts since datalogger attachment significantly predicted date of death. Additionally, the severity of cutaneous Gd infection correlated with the number of arousal episodes from torpor during hibernation. Thus, increased frequency of arousal from torpor likely contributes to WNS-associated mortality, but the question of how Gd infection induces increased arousals remains unanswered.

Context With the recent increased recognition of femoroacetabular impingement (FAI) as a cause of hip pain and early osteoarthritis, surgical treatment has proliferated. A growing body of literature reports on outcomes of surgical intervention for FAI, but factors associated with inferior surgical outcomes have not been reviewed systematically. Objective To review available literature and identify factors associated with failure of open or arthroscopic surgery for FAI. Data Sources Using the PubMed database, we searched for relevant English-language articles published from January 1966 through August 2012. Study Selection Inclusion criteria were primary focus on surgical treatment of FAI, measurement of functional or pain outcomes, identification of treatment failures and statistical analysis of factors leading to failure. Exclusion criteria were review articles, technique-only articles and studies of nonoperative management. Data Extraction Two definitions of failure were considered: 1) lack of statistically signigicant improvement in validated measures of pain, function or satisfaction postoperatively, and 2) revision surgery or conversion to hip arthroplasty because of persistent symptoms. The consistency of association between preoperative variables and clinical outcomes was reported across all studies. Results Thirteen studies were included. Three were retrospective. There were no randomized controlled trials. Many studies had important methodological limitations. Preoperative cartilage damage or osteoarthritis had the strongest and most consistent relationship with conversion to hip arthroplasty and with lack of improvement in pain or function. Greater age at index operation, worse preoperative modified Harris Hip Score and longer duration of symptoms preoperatively (> 1.5 years) were associated with conversion to hip arthroplasty. Conclusions Older age, the presence of arthritic changes, longer duration of symptoms and worse preoperative pain and functional scores are associated with poor outcomes of surgery for FAI. Incorporation of these data into discussions with patients may facilitate informed shared decision-making about surgical treatment of FAI.

Objective Musculoskeletal disorders are the second-leading cause of years lived with disability globally. Total Knee Replacement (TKR) offers patients with advanced arthritis relief from pain and the opportunity to return to physical activity. We investigated the impact of TKR on physical activity for patients in a developing nation. Methods We interviewed 18 Dominican patients (78% female) who received TKR as part of the Operation Walk Boston surgical mission program about their level of physical activity after surgery. Qualitative interviews were conducted in Spanish, and English transcripts were analyzed using content analysis. Results Most patients found that TKR increased their participation in physical activities in several life domains such as occupational or social pursuits. Some patients limited their own physical activities due to uncertainty about medically appropriate levels of joint use and post-operative physical activity. Many patients noted positive effects of TKR on mood and mental health. For most patients in the study, religion offered a framework for understanding their receipt of and experience with TKR. Conclusions Our findings underscore the potential of TKR to permit patients in the developing world to return to physical activities. This research also demonstrates the influence of patient education, culture, and religion on patients’ return to physical activity. As the global burden of musculoskeletal disease increases, it is important to characterize the impact of activity limitation on patients’ lives in diverse settings, and the potential for surgical intervention to ease the burden of chronic arthritis.

Technological advances throughout the 20th century enabled an increase in arthroscopic knee surgery, particularly arthroscopic debridement for OA and arthroscopic partial meniscectomy for symptomatic meniscal tear in the setting of OA. However, evaluation of the outcomes of these procedures lagged behind their rising popularity. Not until the early 2000s were rigorous outcomes studies conducted; these showed that arthroscopic debridement for OA was no better than a sham procedure in relieving knee pain or improving functional status, and that patients who underwent arthroscopic partial meniscectomy for a degenerative meniscal tear generally did not show more improvement than those who underwent sham meniscal resection or an intensive course of physical therapy. Though the number of arthroscopic knee procedures for OA performed each year has begun to decline, there remains a significant gap between the evidence and actual practice. Further investigation is needed to shore up the evidence base and bring policy and practice in line with rigorous research.

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Objective The aim of this study was to investigate whether post-hospital syndrome (PHS) places patients undergoing elective hernia repair at increased risk for adverse postoperative events. Summary of Background Data PHS is a transient period of health vulnerability following inpatient hospitalization for acute illness. PHS has been well studied in nonsurgical populations, but its effect on surgical outcomes is unclear. Methods State-specific datasets for California in 2011 available through the Healthcare Cost and Utilization Project (HCUP) were linked. Patients older than 18 years who underwent elective hernia repair were included. The primary exposure variable was PHS, defined as any inpatient admission within 90 days of an elective hernia repair performed in an ambulatory surgery center. The primary outcome was an adverse event, defined as any unplanned emergency department visit or inpatient admission within 30 days postoperatively. Mixed-effects logistic models were used for multivariable analyses. Results A total of 57,988 patients met inclusion criteria. The 30-day risk-adjusted adverse event rate was significantly higher for PHS patients versus non-PHS patients (11.8% vs 5.8%, P < 0.001). PHS patients were more likely than non-PHS patients to experience postoperative complications (odds ratio 2.2, 95% confidence interval 1.6–3.0). Adverse events attributable to PHS cost an additional $63,533.46 per 100 cases in California. The risk of adverse events due to PHS remained elevated throughout the 90-day window between hospitalization and surgery. Conclusions Patients hospitalized within 90 days of an elective surgery are at increased risk of adverse events postoperatively. The impact of PHS on outcomes is independent of baseline patient characteristics, medical comorbidities, quality of center performing the surgery, and reason for hospitalization before elective surgery. Adverse events owing to PHS are costly and represent a quality improvement target.

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