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Background Prosthetic joint infections (PJIs) are rare but serious complications of hip and knee arthroplasties, associated with high morbidity and substantial healthcare costs. PJIs that occur within the first three months of surgery are considered \"early\" PJIs. We investigated the incidence, risk factors, and microbiology associated with early PJIs among patients undergoing hip or knee arthroplasties at Stanford Hospital. Methods A retrospective cohort study was conducted using data from the Centers for Disease Control's (CDC) National Healthcare Safety Network (NHSN) for Stanford Hospital from 2014 to 2023. The study included adults who underwent hip or knee arthroplasties and developed early PJI. Potential PJI risk factors, including surgery type, age, sex, American Society of Anesthesiologists (ASA) score, diabetes status, body mass index (BMI), and the duration of surgery, were selected for analysis. Generalized estimating equations (GEE) were used to calculate adjusted odds ratios (aORs) for the development of early PJIs. Results Out of 13,197 surgeries, 119 cases of early PJIs were identified, with a cumulative incidence of 0.90%. Significant risk factors for early PJI included revision surgery (aOR: 2.44), male sex (aOR: 2.18), obesity (BMI of ≥30 kg/m²) (aOR: 1.57), ASA score of >2 (aOR: 1.66), and prolonged duration of surgery (aOR: 1.05 per 10-minute increment). Notably, hip arthroplasties were associated with a higher risk of early PJI compared to knee arthroplasties (aOR: 1.55). The most common causative pathogens were Gram-positive bacteria, making up 74.8% of cases. PJIs caused by Gram-negative organisms were associated with significantly longer index surgery durations compared to those caused by Gram-positive organisms (201 versus 153 minutes, p = 0.03). Discussion The findings align with existing literature that identifies revision surgery, male sex, obesity, ASA score, and surgical duration as risk factors for early PJIs. The higher incidence of PJIs in hip arthroplasties compared to knee arthroplasties may be influenced by underlying patient characteristics or surgical complexities. The microbiological profile revealed a predominance of Gram-positive organisms, and prolonged surgical time was associated with Gram-negative infections. Conclusion In this study, we report a relatively low incidence rate of early PJIs following hip and knee arthroplasties at our institution and identify key risk factors of PJIs, including revision surgery, male sex, obesity, ASA score, and surgical duration. Understanding these factors can aid in risk stratification and inform preoperative optimization strategies to reduce the incidence of PJIs in this patient population.

Elderly inpatients who develop fevers after resumption of oral intake are often considered to have aspiration pneumonia (AP) and be tentatively fasted. Fasting has been associated with prolonged hospital stays and decreased swallowing ability. The purpose of this study was to compare AP and other infections after resumption of oral intake in elderly inpatients and to identify the clinical characteristics. The records of patients who were admitted to a public tertiary hospital and referred for evaluation of swallowing disability were retrospectively reviewed to identify those who had developed AP, non-AP, or urinary tract infection (UTI) after resumption of oral intake. Eligible patients were enrolled consecutively in the study. The patient characteristics, physical findings, laboratory data, oral intake status at the time of onset of symptoms, and rate of discontinuation of oral intake after onset of infection were compared between the three types of infection. A total of 193 patients developed an infectious illness after resuming oral intake. Among them, 114 patients had a diagnosis of AP (n = 45), non-AP (n = 24), or UTI (n = 45). There were no significant differences in patient characteristics, physical findings or laboratory data between the group with AP and the other two groups. AP developed at a median of 6 (range 1-16) days after resumption of oral intake. The rate of discontinuation of oral intake was 91.1% in the AP group, 58.3% in the non-AP group, and 26.7% in the UTI group, respectively. Infectious diseases other than AP should be considered in the differential diagnosis when nosocomial fever develops in elderly inpatients more than 17 days after resuming oral intake. Furthermore, nosocomial fever after resuming oral intake has many causes other than AP, and discontinuation of oral intake should be carefully considered.

Decision-makers need signals for action as the coronavirus disease 2019 (COVID-19) pandemic progresses. Our aim was to demonstrate a novel use of statistical process control to provide timely and interpretable displays of COVID-19 data that inform local mitigation and containment strategies. Healthcare and other industries use statistical process control to study variation and disaggregate data for purposes of understanding behavior of processes and systems and intervening on them. We developed control charts at the county and city/neighborhood level within one state (California) to illustrate their potential value for decision-makers. We found that COVID-19 rates vary by region and subregion, with periods of exponential and non-exponential growth and decline. Such disaggregation provides granularity that decision-makers can use to respond to the pandemic. The annotated time series presentation connects events and policies with observed data that may help mobilize and direct the actions of residents and other stakeholders. Policy-makers and communities require access to relevant, accurate data to respond to the evolving COVID-19 pandemic. Control charts could prove valuable given their potential ease of use and interpretability in real-time decision-making and for communication about the pandemic at a meaningful level for communities.

Antibiotic-resistant infections of Pseudomonas aeruginosa ( Pa ), a leading pathogen in patients with cystic fibrosis (CF), are a global health threat. While lysogenic bacteriophages are known to facilitate horizontal gene transfer, their role in promoting antibiotic resistance in clinical settings remains poorly understood. In our analysis of 186 clinical isolates of P. aeruginosa from CF patients, we find that prophage abundance does not predict phenotypic resistance to key antibiotics but that specific prophages are infrequently associated with tobramycin resistance genes. In addition, we do not find antimicrobial resistance (AMR) genes encoded directly on prophages. These results highlight that while phages can be associated with AMR, phage-mediated AMR transfer may be rare in clinical isolates and difficult to identify. This work is important for future efforts on mitigating AMR in CFCF and other vulnerable populations affected by Pa infections and advances our understanding of bacterial-phage dynamics in clinical infections.

Introduction The conventional clinical criteria for diagnosing a periprosthetic joint infection (PJI) rely on acute inflammatory readouts such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and synovial white blood cell counts. These metrics only detect actively septic joint replacements and may miss detecting biofilm-embedded bacteria that suppress neutrophil signaling and persist as a “hidden” subset of implants with a dormant infection. We hypothesize that previously infected joint replacements have a high prevalence of dormant infection that can be distinguished from aseptic revision joint replacements (replaced for instability, loosening, wear, and fracture) by the persistent inflammatory response within synovial fluid and/or circulating plasma, and that detecting a dormant infection indicates an increased risk of infection relapse. Methods This is an observational cohort study using synovial fluid and plasma proteomics of 96 immuno-oncology mediators (Olink Proteomics, Sweden) with three-year clinical follow-up from a single academic medical center (Stanford University, USA). Thirty patients undergoing revision joint replacement: culture-positive actively septic joint replacements ( n  = 7), aseptic revision joint replacements ( n  = 12), and re-implantations of joint replacements previously classified as infection-free by 2018 Musculoskeletal Infection Society (MSIS) criteria ( n  = 11). Differential expression, unsupervised clustering, Euclidean distance mapping, principal-component analysis, and gene-set variation analysis were used to define the inflammatory signature of dormant infection present in joint replacements with a prior infection. The identified biomarkers of dormant infection were correlated with the three-year incidence of infection relapse. Results Eight of eleven MSIS-cleared joint replacements (73%) clustered with culture-positive active infections despite normal ESR, CRP, and scant synovial neutrophils revealing the synovial inflammatory signature of dormant infection. A nine-analyte synovial panel consisting of PDGF-B, CXCL5, CXCL11, MCP-2 (CCL8), ANGPT1, TIE2, EGF, NOS3, and Gal-1 distinguished dormant infection from truly aseptic cases with 100% specificity and positive predictive value (sensitivity 22%, negative predictive value 74%). Synovial CXCL5 over-expression was a universal hallmark of both active and dormant infection, whereas matched plasma profiles showed no discriminatory power for all immuno-oncology mediators tested. Dormant infections exhibited downregulation of granulocyte activation and T-cell proliferation pathways (FDR < 0.001), mirroring immune evasion programs seen in cancer microenvironments. After a mean of 3 years follow-up, infection relapse occurred in 22% of the biomarker-positive dormant infections, but relapse did not occur in any of the biomarker-negative aseptic cases. Discussion Profiling of the persistent inflammatory response within the synovial fluid of two-stage re-implantations classified as “infection-free” by the MSIS criteria unmasked a clinically silent reservoir of biofilm-embedded bacteria that suppress clinical diagnostic criteria of active infection and define the novel clinical state of dormant infection. We used that profile to identify a novel culture-free panel of rule-out biomarkers for determining which re-implantations were safe from infection relapse. These findings challenge the use of conventional clinical diagnostic criteria, which are over-reliant on acute phase reactants and neutrophil recruitment, and creates a new prognostic clinical paradigm that now includes a future with precision, immune-guided management of dormant infections likely present in many implant-associated infections.

This paper describes a semi-crouching assistive device using pneumatic artificial muscles. The goal of this device is to reduce the load on the lower back when performing work in the semi-crouching position. The load on the lower back is reduced by decreasing the compressive pressure on the lumbar disk of the lower back. This compressive pressure increases as the contraction force of the erector spine increases. Therefore, it is important to reduce the muscle activity of the erector spine. Based on the analytical result of a worker’s position model, the proposed device adopts a scheme to push the chest of the user as an appropriate assistive method. Additionally, the analytical result shows that a reduction in weight of the device is also important for decreasing the load on the lower back. Based on these results, we prototyped a lightweight semi-crouching assistive device that can generate sufficient assistive force via a pneumatic artificial muscle, which has high power to weight ratio. This device was experimentally evaluated via electromyogram of the erector spine when the user maintains a semi-crouching position. The experimental results confirmed the usefulness of this device.

Background Biomechanical changes in articular cartilage are associated with the onset of osteoarthritis. We developed an optical coherence tomography-based strain rate tomography method: stress relaxation optical coherence straingraphy (SR-OCSA). The purpose of this study was to establish an approach for measuring mechanical properties of articular cartilage using SR-OCSA, and to investigate the distribution of viscoelastic properties of articular cartilage in early osteoarthritis. Methods Anterior cruciate ligament transection surgery was performed on the left knees of 8–9-month-old New Zealand white rabbits. SR-OCSA was used to visualize and measure the viscoelastic properties of articular cartilage via attenuation coefficient of strain rate (ACSR). Using the same conditions as in the SR-OCSA test, an indentation test was conducted, and relaxation time was measured to evaluate the relationship between ACSR and relaxation time. Results SR-OCSA could nondestructively detect and visualize changes in the distribution of viscoelastic properties of articular cartilage in early osteoarthritis. SR-OCSA captured significant increases in ACSR in cartilage at 2 weeks after surgery, when a histologically slight osteoarthritis sign was present. As cartilage degeneration progressed, ACSR increased, whereas relaxation time decreased in a time-dependent manner. Moreover, ACSR negatively correlated with relaxation time. In particular, ACSR was elevated around the tidemark and the elevation tended to move as cartilage degeneration progressed. Conclusions SR-OCSA could tomographically and nondestructively detect and visualize changes in the distribution of viscoelastic properties of articular cartilage in early osteoarthritis. The mechanical properties around the tidemark were degraded as cartilage degeneration progressed. Thus, SR-OCSA provides important data needed to understand the biomechanics of early osteoarthritis.

The clinical outcomes of drug-eluting stent (DES) implantation after rotational atherectomy (RA) for complex left main coronary artery (LMCA) bifurcation lesions remain unclear. Among 1,809 patients retrospectively enrolled in the Assessing Optimal percutaneous coronary Intervention for LMCA Registry, we identified 1,199 patients with LMCA bifurcation lesions treated by crossover stenting with DES for the main vessel. The study population was divided according to the use of RA. The patients in the RA group were further subdivided into the 2 subgroups on the basis of the stenting approach. The rates of periprocedural myocardial infarction and in-hospital death in the RA group were comparable to those in the non-RA group. The cumulative 5-year incidences of all-cause death and target lesion revascularization (TLR) were significantly higher in the RA group than those in the non-RA group. However, after adjusting confounders, the excess risks of the RA group relative to the non-RA group for all-cause death and TLR were no longer significant (hazard ratio 0.95, 95% confidence intervals 0.59 to 1.52, p = 0.83, and hazard ratio 1.46, 95% confidence intervals 0.82 to 2.60, p = 0.20, respectively). In the RA group, the cumulative 5-year incidences of all-cause death and TLR were markedly higher in the 2-stent subgroup than in the 1-stent subgroup (58.1% vs 26.0%, p = 0.001, and 43.0% vs 16.3%, p = 0.001, respectively). In conclusion, DES implantation after RA was a safe and feasible strategy in treating those patients with complex LMCA bifurcation lesions. In this strategy, the 2-stent approach was associated with markedly worse 5-year clinical outcomes than the 1-stent approach.

Background Gastrointestinal stromal tumor (GIST) is a rare tumor, however, simultaneous development of gastric cancer and gastric GIST has been documented more frequently in recent years. Rupture of gastric GIST is even more rare and occurred in 7% of all GISTs. Although ruptured GIST might be occasionally difficult to be managed by endoscopy, transcatheter arterial embolization (TAE) was reported to control bleeding from GIST effectively. We report herein a case of coexistence of gastric cancer and gastric GIST with progressing intra-tumor bleeding managed successfully by TAE and review the clinicopathological characteristics of this rare condition reported previously in the Japanese literature. Case presentation A 75-year-old woman with dyspnea and systemic edema was diagnosed as simultaneous occurrence of gastric cancer (histopathologically detected tubular adenocarcinoma pT2N1M0 fStageIIA) and gastric GIST (65 × 92 mm in diameter at the anterior wall of the fornix) with intra-tumor hemorrhage. Perceiving the progress of bleeding from tumor growth and exacerbating anemia, TAE of left gastric artery was performed. Then remission of anemia has been obtained, the patient underwent an elective radical surgery. Conclusions Simultaneous occurrence of gastric cancer and gastric GIST was speculated to be more common. TAE for ruptured GIST may be effective for hemostasis and reduction of tumor burden, which could facilitate minimal invasive surgery.

We assessed long-term outcomes after left main coronary artery (LMCA) stenting based on lesion types and stenting strategies. In the Assessing Optimal percutaneous coronary Intervention for Left Main Coronary Artery stenting registry, we evaluated 1,607 consecutive patients undergoing stent implantation for unprotected LMCA lesions (bifurcation lesions: n = 1318 and nonbifurcation lesions: n = 289). Among the bifurcation lesions, 1,281 lesions were treated with stenting across the bifurcation (bifurcation 1-stent strategy: n = 999 or bifurcation 2-stent strategy: n = 282). Among the nonbifurcation lesions, 219 lesions were treated with nonbifurcation stenting. The median follow-up duration was 4.6 (95% CI 4.5 to 4.8) years. The 5-year risk of bifurcation lesions relative to nonbifurcation lesions was neutral for target lesion revascularization (TLR) (adjusted hazard ratio [HR] 0.82, 95% CI 0.55 to 1.23, p = 0.34) and all-cause death (adjusted HR 1.22, 95% CI 0.87 to 1.71, p = 0.26). The risk of the bifurcation 1-stent strategy relative to nonbifurcation stenting in nonbifurcation lesions was also neutral for TLR (adjusted HR 1.19, 95% CI 0.74 to 1.90, p = 0.47) and all-cause death (adjusted HR 0.81, 95% CI 0.56 to 1.18, p = 0.27). However, the bifurcation 2-stent strategy was associated with worse clinical outcomes than the bifurcation 1-stent strategy in TLR (adjusted HR 1.76, 95% CI 1.23 to 2.52, p = 0.002) and definite or probable stent thrombosis (crude HR 3.50, 95% CI 1.32 to 9.33, p = 0.01), despite neutral risk for all-cause death (adjusted HR 1.00, 95% CI 0.74 to 1.36, p = 0.99). There was no definite or probable very late stent thrombosis up to 5 years. In conclusion, long-term outcomes after stent implantation for unprotected LMCA lesions were not dependent on the bifurcation lesion types but related to the bifurcation stenting strategies with worse outcomes for the bifurcation 2-stent strategy.