bluuebunny/crossref_metadata_2025 huggingface dataset:
O3C Glass-Class: A Machine-Learning Framework for Prognostic Prediction of Ovarian Clear-Cell Carcinoma
Authors: Yokomizo Ryo , Lopes Tiago JS , Takashima Nagisa , Hirose Sou , Kawabata Ayako , Takenaka Masataka , Iida Yasushi , Yanaihara Nozomu , Yura Kei , Sago Haruhiko , Okamoto Aikou , Umezawa Akihiro
Published: November 2022

Ovarian clear cell carcinoma (OCCC), one of the histopathological types of ovarian cancer, has a poor prognosis when it recurs; however, it is difficult to precisely predict the risk of recurrence. Here, we analyzed pathological images of OCCC to elucidate the relationship between pathological findings and recurrence, and using machine learning, we established a classifier to predict the recurrence and several other prognosis indicators of this disease. In total, 110 patients with OCCC treated with primary surgery at a single institution were enrolled in this study. We used the deep-learning neural networks to process the whole slide images of OCCC obtained by digitally scanning the original hematoxylin and eosin-stained glass slides. The images were preprocessed and used as input to the machine learning pipeline. We fine-tuned its parameters to predict the recurrence, progression-free survival, and the overall survival days of all patients. We predicted the recurrence of OCCC with an overall accuracy of 93%, area under the receiver operating characteristic curve of 0.98, and sensitivity/specificity above 0.92 using Resnet 34. Furthermore, we predicted progression-free survival/overall survival of the patients with ~90% accuracy. In conclusion, our study demonstrates the feasibility of using a machine learning system to predict different features of OCCC samples using histopathological images as input. This novel application provides accurate prognosis information and aids in the development of personalized treatment strategies.
Academic work and imagination: Reflections of an armchair traveler
Authors: Tienari Janne
Published: November 2022

In this paper, I offer an autoethnography of academic work and imagination. I write as an “armchair traveler” who joins others in research endeavors that they have initiated. Imagination takes center stage in what I do: I use my imagination in analyzing empirical materials and in theorizing and writing meaningful research. Together with others, I engage in studies where I am close to the subject of inquiry and feel sameness, but also in research that for me is grounded in difference and otherness. Through my autoethnography, I elucidate the potential and limits of imagination in different research initiatives. Reflecting on my experiences and learning, I discuss how imagination relates to ethico-politics in doing research. I argue that imagination thrives in small acts of generosity in research collaboration, which harbor a sense of togetherness and solidarity. This has implications for understanding academic work that is obsessed with performance in publishing.
‘Cocooning’ in prison during COVID-19: Findings from recent research in Ireland
Authors: Garrihy Joe , Marder Ian , Gilheaney Patricia
Published: November 2022

The advent of COVID-19 prompted the enforced isolation of elderly and vulnerable populations around the world, for their own safety. For people in prison, these restrictions risked compounding the isolation and harm they experienced. At the same time, the pandemic created barriers to prison oversight when it was most needed to ensure that the state upheld the rights and wellbeing of those in custody. This article reports findings from a unique collaboration in Ireland between the Office of the Inspector of Prisons – a national prison oversight body – and academic criminologists. Early in the pandemic, they cooperated to hear the voices of people ‘cocooning’ – isolated because of their advanced age or a medical vulnerability – in Irish prisons by providing journals to this cohort, analysing the data, and encouraging the Irish Prison Service to change practices accordingly. The findings indicated that ‘cocooners’ were initially ambivalent about these new restrictions, both experiencing them as a punishment akin to solitary confinement, and understanding the goal of protection. As time passed, however, participants reported a drastic impact on their mental and physical health, and implications for their (already limited) agency and relationships with others, experienced more or less severely depending on staff and management practices. The paper also discusses the implications for prison practices during and following the pandemic, understanding isolation in the penological context, and collaboration between prison oversight bodies and academics.
New timestamp mark–based energy efficient time synchronization method for wireless sensor networks
Authors: Huang Yourui , Zhang Gang , Kong Min , He Fugui
Published: November 2022

Aimed at the demands of wireless sensor networks for high energy-efficient time synchronization, the reduction of synchronization energy consumption is studied from the aspects of both accurate timestamps marking and synchronous information transmission mechanism. First, the network is divided into several parent–child groups periodically. The group-wise pair selection algorithm is used to select the network’s pairwise synchronization nodes, and chain-type network topology is thus generated. Second, the sequential multi-hop synchronization algorithm is introduced to realize the synchronization information exchange among pairwise synchronization nodes. The overhearing synchronization (OS) nodes obtain the synchronization information packet based on a one-way overhearing mechanism. Moreover, the accurate acquisition of the synchronization ack packet’s timestamp is carried out through the use of receiving-time-plus-fixed-delay mode. Third, the joint maximum likelihood method and the minimum variance unbiased estimation method are used to estimate the clock offsets of pairwise synchronization nodes and overhearing nodes to the parent nodes, respectively, based on which the child nodes adjust their local virtual clocks. Periodically, the pairwise synchronization nodes initiate the network’s time synchronization, estimate, and broadcast the relative offset to the gateway node, assisting the upper layer child nodes in synchronizing to the gateway node. Simulation results show that the proposed method not only achieves the millisecond level synchronization accuracy but also reduces the synchronization energy consumption and thus improves the network lifetime.
Association of pre-mechanical thrombectomy collateral scores with functional outcomes in the early versus extended window for thrombectomy
Authors: Nisar Taha , Abu-hadid Osama , Lebioda Konrad , Tofade Toluwalase , Khandelwal Priyank
Published: November 2022

Introduction: Cerebral collateral circulation refers to the anastomoses that reroute the blood flow to the ischemic penumbra in the event of a large vessel occlusion (LVO). We aim to determine the utility of pre-mechanical-thrombectomy (MT) collateral scores in the early (<6 h from onset) versus extended (6–24 h from onset) window for MT with respect to a 3-month functional outcome, 3-month mortality, and early neurological improvement. Methods: We performed a retrospective chart review of patients who underwent MT for an anterior circulation LVO at a comprehensive stroke center from 7/2014 to 12/2020. A board-certified neuroradiologist, who was blinded to the clinical outcomes, used the collateral grading scales of Miteff (ordinal), Maas (ordinal), and modified-Tan (dichotomous) to designate collateral scores on the pre-MT CT Angiogram. The patients were divided into early (<6 h from onset) versus extended (6–24 h from onset) window groups depending on their timing of presentation to the emergency department. A regression analysis was performed, controlling for the baseline parameters, with the pre-MT collateral grading scores as predictors. The outcome measures were a good functional outcome (3-month mRS 0-2), mortality, and early neurological improvement. Results: A total of 220 patients met the inclusion criteria. In the overall cohort, the pre-MT scale of Maas was associated with a good functional outcome (OR, 0.58; 95% CI, 0.34–0.99; P 0.047) and mortality (OR, 0.55; 95% CI, 0.31–0.97; P 0.036). For the 162 patients who presented in the early window for MT, all of three pre-MT scales of Maas (OR, 0.39; 95% CI, 0.2–0.77; P 0.006), Miteff (OR, 0.43; 95% CI, 0.19–0.97; P 0.042) and modified-Tan (OR, 5.62; 95% CI, 1.16–27.37; P 0.033) were associated with a good functional outcome, whereas the Maas (OR, 0.48; 95% CI, 0.26–0.9; P 0.021) and the Miteff scale (OR, 0.4; 95% CI, 0.22–0.74; P 0.003) were associated with mortality. For the 58 patients who presented in the extended window for MT, none of the collateral grades were associated with functional outcome, mortality, or early neurological improvement. Conclusions: Our study demonstrates that while several collateral grades are helpful to predict outcomes in patients presenting in the early window, none of the pre-MT collateral scores were associated with outcomes in patients who presented in the extended window for MT. Thus, the current strategy of using perfusion imaging for the selection of patients for MT in the extended window should continue.
Fatal Enteral Nutritional Hydrothorax Resulting From Aberrant Placement of a Nasogastric Tube Without Perforation of the Tracheobronchial Tree or Esophagus: A Case Report and Review
Authors: Schindler Kylie N. , Youmans Amanda J.
Published: November 2022

Nasogastric feeding tubes are commonly used in medical practice to provide nutritional support to patients who cannot take in an adequate amount of food orally. Although rare, nasogastric tubes errantly placed into the respiratory tract may cause serious complications, including death. We present an unusual autopsy case of a fatal hydrothorax that consisted of the enteric feeding solution following placement of a small-bore feeding tube into the left lung, despite no perforation of the tracheobronchial tree or esophagus. Alternative mechanisms for the formation of an enteral nutritional hydrothorax in the absence of a perforation from a feeding tube can be explained by the properties of the fluid, increased alveolar permeability, and underlying lung damage.
Who’s Afraid of EU Primary Law? Judicial Review of the EPPO’s Decision on Forum Choice
Authors: Zivic Andrijana , Zandstra Timo , Pit Quintijn , Vegt-Schouten Antonia
Published: November 2022

The proposal for Regulation 2017/1939 establishing the European Public Prosecutor’s Office (The EPPO Regulation) was criticized for completely excluding the Court of Justice of the European Union (CJEU) from judicial review of decisions on forum of prosecution by the EPPO, an EU body. The system of judicial review under the EPPO Regulation has improved significantly relative to its initial proposal, by enabling national courts to refer preliminary questions to the CJEU. Despite this, several issues remain. This article examines whether the limitations imposed by the EPPO Regulation on the use of the action for annulment procedure laid down in Article 263 TFEU comply with EU primary law. More specifically, whether it complies with effective judicial protection as protected under Article 47 CFR, and the legal basis for the EPPO’s system of judicial review, Article 86(3) TFEU. We argue that the preliminary reference procedure is not effective enough in remedying the limited access to the action for annulment procedure to reliably safeguard the defendants’ right to effective judicial protection. To the extent that the current system for judicial review under the EPPO Regulation is at odds with the Article 47 CFR, the EU legislator did not have the competence to enact it under Article 86(3) TFEU. This article proposes that in order to circumvent the unlawful restrictions imposed by the EPPO Regulation, defendants could and should make use of the action for annulment procedure to contest the EPPO’s choice of forum.
Patient-reported outcome measures (PROMs) in stone surgery: A multi-centre study of patient experience of flexible ureteroscopy (fURS) versus extracorporeal shockwave lithotripsy (SWL)
Authors: Thompson William R , Tolofari Sotonye K , Starmer Ben , Broome James , Garrod Huw , Agarwal Ketan , Wong Kee , Panayi Zoe , Hughes Kaylie , Iskander Morkos , Javed Saqib , Kelly Pat , Lazarowicz Henry , Calvert Rob C
Published: November 2022

Objectives:

To compare patient-reported outcome measures (PROMs) for patients with symptomatic renal stone disease treated by flexible ureterorenoscopy (fURS) and shockwave lithotripsy (SWL)

Introduction:

Historically, surgical outcomes are measured by surgeon-specific outcomes such as ‘stone-free rates’. More recently, there is increasing emphasis on PROMs to ascertain a patient’s perspective of their own surgical outcome. Despite this, the literature in reference to renal stone-specific PROMs following stone treatment remains limited.

Methods:

Data were collected in a prospective multi-centre study. Patients undergoing fURS or SWL were asked to complete the validated Cambridge Renal Stone Patient Reported Outcome Measure ( CReSP) on the day of initial treatment and at weeks 1, 6 and 12 post-operatively.

Results:

Data were collected for 119 patients. Three were excluded as stone metric and demographic details were incomplete. Sixty underwent SWL and 56 underwent fURS. Median stone size was 7.52 mm. There were no significant differences in baseline PROM scores between the treatment groups. At 1 week, the PROM scores were significantly higher in the fURS group compared to SWL (27.40 ± 0.85sd versus 22.51 ± 1.07sd; p < 0.05). However, at 6 and 12 weeks, the PROM scores were significantly lower in the fURS group (18.51 ± 2.27sd versus 23.67 ± 1.30sd; p < 0.05) and (17.01 ± 2.29sd versus 22.49 ± 1.49sd; p < 0.05), respectively. By week 12, overall scores for anxiety and social factors were more favourable in the fURS cohort.

Conclusion:

Our study suggests that fURS is associated with a short-lived increase in morbidity in comparison with SWL, which may be due to ureteric stenting in the majority of patients post-operatively. However, fURS patients appear to report significantly better PROM scores in the longer term. This appears to be associated with more favourable anxiety and social factor scoring over the treatment period.

Level of evidence:

Not applicable.
Is the infrapubic approach a safe option for patients with poorly controlled diabetes mellitus and obesity undergoing inflatable penile prosthesis surgery?
Authors: Micallef Dariush , Wightman Stuart , Naqi Muhammad , Modgil Vaibhav , Pearce Ian
Published: November 2022

Objective:

Inflatable penile prosthesis (IPP) surgery is an effective treatment for patients with erectile dysfunction (ED). The two most used surgical approaches are infrapubic (IP) and penoscrotal (PS). Concerns exist whether raised Body Mass Index (BMI) or poor glycaemic control negatively affect outcome. We conducted a retrospective review of 50 consecutive virgin IP IPP cases investigating the effect of BMI and glycaemic control on post-operative complications and implant utilisation.

Patients and Methods:

Data collected included demographics, ED aetiology and risk factors, diabetic status, HbA1c and post-operative complications focusing on infection and re-operation. Telephone survey provided implant usage at 3, 6, 12 and 24 months post-operatively. All patients followed the same pre-, peri- and post-operative pathway, including antibiotic prophylaxis and implant preparation.

Results:

Complication rates of patients with BMI ⩾ 30 (2/20; 10%) and BMI < 30 (0/28, 0%) ( p = 0.169) and of patients with poorly controlled diabetes mellitus (DM), HbA1c > 69 mmol/mol (0/6, 0%) versus HbA1c ⩽ 69 (2/21, 9.52%) ( p = 1) were not significantly different. Two patients reported complications. Implant utilisation did not differ significantly between low or high BMI and HbA1c cohorts.

Conclusion:

Our study shows pre-operative HbA1c and BMI do not significantly impact complication rates or implant utilisation in patients undergoing IP IPP insertion.

Level of Evidence:

2b
Perceived Barriers and Facilitators of Implementing a Multicomponent Intervention to Improve Communication With Older Adults With and Without Dementia (SHARING Choices) in Primary Care: A Qualitative Study
Authors: Smith Kelly M. , Scerpella Danny , Guo Amy , Hussain Naaz , Colburn Jessica L. , Cotter Valerie T. , Aufill Jennifer , Dy Sydney M. , Wolff Jennifer L.
Published: November 2022

Introduction:

Implementing patient- and family-centered communication strategies has proven challenging in primary care, particularly for persons with dementia. To address this, we designed SHARING Choices, a multicomponent intervention combining patient and family partnered agenda setting, electronic portal access, and supports for advance care planning (ACP). This qualitative descriptive study describes factors affecting SHARING Choices implementation within primary care.

Methods:

Semi-structured interviews or focus groups with patient/family dyads (family, friends, unpaid caregivers) and primary care stakeholders (clinicians, staff, administrators) elicited perceived barriers and facilitators of SHARING Choices implementation. Field notes and interview transcripts were coded using template analysis along the Consolidated Framework for Implementation Research (CFIR) constructs. Content analysis identified themes not readily categorized within CFIR.

Results:

About 22 dyads, including 14 with cognitive impairment, and 30 stakeholders participated in the study. Participants were receptive to the SHARING Choices components. Enablers of SHARING Choices included adaptability of the intervention, purposive engagement of family (particularly for patients with dementia), consistency with organizational priorities, and the relative advantage of SHARING Choices compared to current practices. Perceived barriers to implementation included intervention complexity, space constraints, workflow, and ACP hesitancy. The ACP facilitator was perceived as supportive in addressing individual and organizational implementation barriers including patient health and technology literacy and clinician time for ACP discussions.

Conclusions:

Patients, family, and primary care clinicians endorsed the objectives and individual components of SHARING Choices. Strategies to enhance adoption were to simplify materials, streamline processes, leverage existing workflows, and embed ACP facilitators within the primary care team.
Perioperative Management and Outcomes of Hip Fracture Patients with Advanced Chronic Kidney Disease
Authors: Ongzalima Chris , Dasborough Kimberly , Narula Siddarth , Boardman Glenn , Kumarasinghe Panchi , Seymour Hannah
Published: November 2022

Aims

To explore clinical characteristics, perioperative management and outcomes of Hip Fracture patients with advanced Chronic Kidney Disease (HF-aCKD) compared to the general Hip Fracture population without aCKD (HF-G) within a large volume tertiary hospital in Western Australia.

Methods

Retrospective chart review of patients admitted with hip fracture (HF) to a single large volume tertiary hospital registered on Australian and New Zealand Hip Fracture Registry (ANZHFR). We compared baseline demographic and clinical frailty scale (CFS) of HF-aCKD (n = 74), defined as eGFR < 30 mls/min/1.73 m2, with HF-G (n = 452) and determined their outcomes at 120 days.

Results

We identified 74 (6.97%) HF patients with aCKD. General demographics were similar in HF-aCKD and HF-G populations. 120-days mortality for HF-aCKD was double that of HF-G population (34% vs 17%, P = .001). For dialysis patients, 120-days mortality was triple that of HF-G population (57%). Except for the fit category of HF-aCKD group, higher CFS was associated with higher 120-days mortality in both groups.  Of all HF-aCKD patients, 96% had operative intervention and 48% received blood transfusion. There were no new starts to dialysis peri-operatively. Each point reduction in eGFR below 12 mL/min/1.73 m2 was associated with 3% increased probability of death in hospital.

Conclusions

120-days mortality was double in HF-aCKD and triple in HF-dialysis that of the HF-G within our institution. Clinical frailty scale can be useful in predicting mortality after HF in frail aCKD patients. High rate of blood transfusions was observed in HF-aCKD group. Further studies with larger HF-aCKD numbers are required to explore these associations in detail.
Empyema Versus Lung Abscess: A Case Report
Authors: Imburgio Steven , Tavakolian Kameron , Mararenko Anton , Tasnim Tasfia , Khan Taimoor , Costanzo Eric
Published: November 2022

Lung abscesses and empyemas are 2 forms of pulmonary infection that can present with similar clinical features. However, empyemas are associated with higher morbidity and mortality, necessitating the need to distinguish one from the other. Plain radiographs can sometimes provide clues to help differentiate the 2 pathologies but more often than not, a computed tomography scan is required to confirm the diagnosis. Correct diagnosis is essential, as the goal standard therapeutic intervention for empyemas may be contraindicated in patients with lung abscesses. Empyemas require percutaneous or surgical drainage in combination with antibiotics, while lung abscesses are generally treated with antibiotics alone as drainage can be associated with various complications. We present a case of a 65-year-old man with parapneumonic empyema diagnosed with characteristic findings on chest computed tomography and treated with surgical drainage and antibiotics. We hope to improve patient outcomes by highlighting the classical radiographic findings that help distinguish empyema and abscess.
The Influence of Female Reproductive Factors on Longevity: A Systematized Narrative Review of Epidemiological Studies
Authors: Costanian Christy , Farah Raymond , Salameh Ray , Meisner Brad A. , Aoun Bahous Sola , Sibai Abla M.
Published: November 2022

Purpose: This systematized review presents a synthesis of epidemiological studies that examine the association between female reproductive factors and longevity indicators. Methods: A comprehensive literature search was conducted using four bibliographic databases: OVID Medline, Web of Science, PubMed, and Google Scholar, including English language articles published until March 2022. Results from the search strategy yielded 306 articles, 37 of which were included for review based on eligibility criteria. Results were identified within the following nine themes: endogenous androgens and estrogens, age at first childbirth, age at last childbirth, parity, reproductive lifespan, menopause-related factors, hormone therapy use, age at menarche, and offspring gender. Results: Evidence that links reproductive factors and long lifespan is limited. Several female reproductive factors are shown to be significantly associated with longevity, yet findings remain inconclusive. The most consistent association was between parity (fertility and fecundity) and increased female lifespan. Age at first birth and parity were consistently associated with increased longevity. Associations between age at menarche and menopause, premature menopause, reproductive lifespan, offspring gender and longevity are inconclusive. Conclusion: There is not enough evidence to consider sex a longevity predictor. To understand the mechanisms that predict longevity outcomes, it is imperative to consider sex-specific within-population differences.
Anatomy of Flexor Hallucis Longus and Its Relationship with Hallux Valgus: A Cadaveric Study
Authors: Ortiz Cristian A. , Butteri Ana I. , Espinoza Carolina Avilés , Mombello Franco L. , Redlich Alex , Chaparro Felipe R. , Carcuro Giovanni M. , Pellegrini Manuel J.
Published: November 2022

Category:

Basic Sciences/Biologics; Midfoot/Forefoot

Introduction/Purpose:

The first ray is an inherently unstable structure that relies on a fine balance between its static and dynamic stabilizers to maintain its alignment. Multiple risk factors have been associated with hallux valgus development. The dynamic stabilizers, particularly the flexor hallucis longus (FHL), has been mentioned as a potential deforming force that could contribute and accentuate hallux valgus deformity due to its spatial situation and insertion morphology. The aim of this study is to describe FHL distal insertion morphology and it spatial relationship with interphalangeal (IP) and metatarso-phalangeal (MTTP) joint.

Methods:

10 fresh frozen cadaver hallux were dissected up to the MTT-F joint, exposing FHL and bony structures, leaving in situ ligamentous attachments. We evaluated FHL distal insertion morphology in terms of width of insertion and distance between insertion borders of the FHL and medial-lateral phalangeal borders. The spatial relationship of the FHL with IP and MTTP joint was measured by the position of the FHL long axis width midpoint in relation to the phalangeal and metatarsal width 1cm proximal to the joint.

Results:

The FHL mean width of insertion was 12,1mm (range 10-15) SD (+-1,5). All specimens showed a lateral tendon fascicle that was inserted more lateral and distal than the tendon main insertion. Mean lateral distance of insertion to phalangeal border was 3mm (range3-4) SD (+-0,7), mean medial distance of insertion to phalangeal border 5,2mm (range 4-7) SD (+-1,1). FHL long axis width midpoint was on average 12.36% laterally deviated from the osseous midpoint at MTTP joint and 14.07% lateral deviated at IP joint.

Conclusion:

The FHL has a closer insertion to the lateral phalanx border and it long axis midpoint is laterally located in relation to IP and MTTP joint, creating a laterally directed force vector over both joints that could be involved in the pathogenesis of hallux valgus.
Behavior of the Subtalar Joint after Arthroereisis in Adult Acquired Flatfoot, Evaluation with WBCT
Authors: Ortiz Cristian A. , Chaparro Felipe R. , Redlich Alex , Pellegrini Manuel J. , Carcuro Giovanni M. , Espinoza Carolina Avilés , Mombellos Franco L.
Published: November 2022

Category:

Hindfoot

Introduction/Purpose:

Flatfoot is a common deformity in adult and pediatric populations, with a 5% incidence. It corresponds to a complex three-dimensional pathology characterized by peritalar subluxation (PTS) of the hindfoot, with a dynamic behavior during weight-bearing. This is how weight-bearing computed tomography (WBCT) has become a fundamental tool for optimizing staging in flatfoot deformities. The indication for arthroereisis is a symptomatic flexible flat foot or hindfoot valgus in the pediatric or adolescent population in most publications. There are no studies that evaluate the behavior of the subtalar joint and degree of three-dimensional correction achieved in adult patients who underwent arthroereisis for symtomatic flexible flatfoot.

Methods:

After obtaining IRB approval, our prospectively collected surgical database was queried for patients undergoing arthroereisis for symptomatic flexible flatfoot. Patients were included if they had preoperative weight-bearing CT (WBCT). Patients were excluded if they had less than four months postoperative, had revision surgery, or declined to participate. Nine patients (15 feet) met the inclusion/exclusion criteria. All patients were brought back to the clinic for weight-bearing CT scan and to sign informed consent for the specific needs of this study. All measurements were performed by one of the authors in two time-frames (alignment of the hindfoot and talonavicular joint), separated for one month each.

Results:

Median age of 39 years. 14 feet showed a significant correction of the evaluated parameters. The preoperative median Talonavicular Coverage angle and Posterior and Middle Facet Subluxation of the subtalar joint were 33°, 19° and 39° respectively in preoperative WBCT, and 18°, 10° and 27° respectively in postoperative WBCT. The t test showed p < 0.01 for the change between preoperative and postoperative angles. The incidence of sinus tarsi pain was 20%, 2 patients required removal of the implant, 1 of them bilateral, without loss of correction in control with WBCT at the final follow-up (6 months after extraction).

Conclusion:

The application of subtalar arthroereisis is a minimally invasive alternative and effective therapy for adult acquired flatfoot, which achieves an adequate three-dimensional correction observed with WBCT after surgery. No loss of correction was observed in patients who required implant removal.
Emergency Department Visits Within 90 Days of Total Ankle Arthroplasty
Authors: Ratnasamy Philip P. , Kammien Alexander J. , Gouzoulis Michael J. , Grauer Jonathan N.
Published: November 2022

Category:

Arthroscopy; Ankle

Introduction/Purpose:

Emergency department (ED) visits following total ankle arthroplasty (TAA) may impact patient satisfaction and healthcare cost. Elucidating the timing of and risk factors for ED visits in this patient population might help facilitate targeted risk reduction strategies.

Methods:

This retrospective cohort study utilized data from the 2010 to 2019 M91Ortho PearlDiver administrative dataset to identify patients who underwent TAA with at least 90 days of follow-up. Patient factors were extracted including: age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which their procedure was performed (midwest, northeast, south, west), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, frequency, and primary diagnoses for 90-day postoperative ED visits were identified and interpreted in the context of one-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for such ED visits.

Results:

Of 7,600 TAA patients identified, 743 (9.8%) visited the ED within 90 days of their procedure. Of those who visited the ED, one ED visit was reported for 571 patients, two for 117 patients, three for 26 patients, and four or more visits for 29 patients. 37.2% of all ED visits occurred within two weeks following surgery; weekly visits returned to within 0.5% of the population baseline by three weeks after surgery. 90-day readmissions were identified for 289 patients (3.80%) of the cohort. Multivariate analysis revealed several predictors of ED utilization following TAA: younger age (odds ratio (OR) 1.40 per decade decrease), female sex (OR 1.18), higher ECI (OR 1.36 per 2-point increase), and Medicaid coverage (OR 2.74; 1.92-3.90 relative to Medicare) (p < 0.05 each). Regarding reasons for ED visits, surgical site issues were identified for 74.4%, with the most common reason being surgical site pain (60.4%).

Conclusion:

Of 7,600 TAA patients, 9.8% returned to the ED within 90 days of surgery, with predisposing demographic actors identified. The highest incidence for these ED visits was in the first two postoperative weeks, with surgical site pain being the most common reason. By identifying the timing, predisposing factors, and reasons for ED visits following TAA, targeted care pathways should be able to be adjusted to minimize their occurrence, improve patient experience, and minimize health care utilization/costs.
Physical Therapy Utilization Within 90 Days of Total Ankle Arthroplasty
Authors: Ratnasamy Philip P. , Gouzoulis Michael J. , Kammien Alexander J. , Grauer Jonathan N.
Published: November 2022

Category:

Ankle; Arthroscopy; Other

Introduction/Purpose:

Physical therapy (PT) following total ankle arthroplasty (TAA) is often considered, but guidelines for its use are not standardized. While there may be patient factors that dictate recommendations, establishing a baseline of utilization practices may set the stage for establishing generalizable recommendations.

Methods:

This retrospective cohort study employed data from the 2010 to 2019 M91Ortho PearlDiver administrative dataset. Those undergoing TAA were identified based on coding, and patient factors were extracted, including: age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients' surgery was performed (midwest, northeast, south, west), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of PT utilization in the 90-days following TAA were identified as occurring at home or in an outpatient setting. Univariate and multivariate logistic regression analyses allowed the identification of predictive factors for PT utilization.

Results:

Of 6,563 TAA patients identified, 2788 (42.5%) utilized postoperative PT services. Most services were done as an outpatient (63.4%), compared to at home (6.1%). Weekly utilization of PT was greatest in the first week following surgery (17.7% of those who utilized PT) and thereafter followed a roughly bell-shaped curve of utilization with the greatest incidence at seven weeks following surgery (14.9% of those who utilized PT). Multivariate analysis identified multiple predictors of PT utilization following TAA, including: older age (odds ratio [OR] 1.23 per decade increase, p < 0.0001), higher ECI (OR 1.03 per 2-point increase, p = 0.0383), having surgery performed in the midwest, northeast, or western US (relative to the South OR 1.43, p < 0.0001; 1.20, p = 0.0109; and 1.32, p < 0.0001, respectively), and having commercial or Medicaid insurance coverage (relative to Medicare OR 1.96, p < 0.0001 and 1.62, p = 0.0006, respectively).

Conclusion:

Of 6,563 TAA patients, 42.5% utilized PT within 90 days of surgery. PT utilization was highest in the first- and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAA, algorithms for PT usage may be better defined and consistently employed.
Development and Validation of a Patient Decision Aid for the Treatment of Ankle Arthritis
Authors: Raymond Oluseye , Cordery Kyla , Hsu Nigel , Humbyrd Casey J.
Published: November 2022

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

Choosing a treatment course can be challenging for patients with ankle osteoarthritis given the multiple operative and nonoperative options. We developed and validated the Ankle Arthritis Patient Decision Aid as a tool to improve shared decision-making for such patients.

Methods:

Eighty patients of 2 surgeons at a US academic foot and ankle practice were recruited from October 2020 to June 2021 using an electronic medical record messaging system. Participants reviewed the tool and answered survey questions evaluating its quality and factors affecting treatment choice in a hypothetical patient scenario. We evaluated the tool using decisional conflict scores (maximum, 40 points, with higher scores indicating greater uncertainty), pre- and post-knowledge test scores (maximum, 8 points), and helpfulness scores (maximum, 7 points). We compared pre- and post-test knowledge scores using paired Student t- tests. Alpha=.05.

Results:

Mean (+- standard deviation) knowledge scores improved from 4.8 +- 1.2 (pre-test) to 6.7 +- 1.3 (post-test), for a mean improvement of 1.9 +- 1.4 (p<.001). The mean decisional conflict score was 4.1 +- 5.7, reflecting minimal uncertainty. Factors greatly affecting participants' treatment choices were desire to maintain a high level of physical activity (n=58), risk of complications (n=35), recovery time (n=33), and risk of increased rate of arthritis in adjacent joints (n=32). The mean reported helpfulness score was 5.9 +- 1.2, reflecting substantial benefit.

Conclusion:

The Ankle Arthritis Patient Decision Aid is a comprehensible tool that significantly improves patient knowledge regarding treatment options for ankle arthritis.
First Metatarsophalangeal Arthrodesis Outcomes of Hallux Rigidus vs Hallux Valgus
Authors: Roth Warren J. , Hoch Caroline P. , Gross Christopher E. , Scott Daniel J.
Published: November 2022

Category:

Midfoot/Forefoot; Other

Introduction/Purpose:

First metatarsophalangeal (MTP) joint arthrodesis is a commonly performed surgical procedure for patients with hallux rigidus (HR) or severe hallux valgus (HV). The purpose of this study was to compare patient outcomes of 1st MTP arthrodesis between HR and HV cohorts. We hypothesized that there would be no difference in patient-reported outcome measures (PROMs) or complication rates between groups.

Methods:

A retrospective review was conducted at a single academic medical center of patients who underwent 1st MTP arthrodesis with one of two fellowship-trained foot and ankle orthopaedic surgeons between 2009 and 2021. A total of 136 patients (148 feet: HR=75, HV=47, both=44) met the inclusion criteria of the three-month follow-up minimum. Data collection included PROMs (i.e., Visual Analogue Scale [VAS], 12-item Short Form Survey [SF-12], Foot and Ankle Outcome Score [FAOS], and Foot and Ankle Ability Measure [FAAM], Patient-Reported Outcomes Measurement Information System [PROMIS]), radiographic markers, and complication and reoperation rates. The VAS, SF-12, FAOS, and FAAM were collected preoperatively; the FAOS and FAAM were collected postoperatively; and all were collected via prospective phone interview. Forty-six patients (50 feet: HR=21, HV=15, both=14) completed the phone interview at an average of 3.04 (range, 0.58-10.01) years postoperatively. Mean clinical follow-up was 1.25 (range, 0.25-6.14) years.

Results:

The HR had a significantly smaller improvement in HVA (HR=-3.60, HV=-17.44, combined=-15.27; p<.001), IMA (HR=- 0.16, HV=-2.80, combined=-2.55; p<.001), and 1st-5th metatarsal width (HR=-0.98, HV=-4.59, combined=-4.60; p<.001). There was a trend toward improved PROMs, although only significant for all groups with the VAS (p<.001, p<.001, p<.001), FAOS Quality of Life (p<.001, p=.030, p=.001), and FAAM Activities of Daily Living (p<.001, p=.046, p=.002) and Total (p=.001, p=.024, p=.016) scores. The HV group significantly improved among the least PROMs. (Table 1) Complication (HR=28.07%, HV=38.30%, combined=36.36%; p=.499) and reoperation (HR=14.04%, HV=25.53%, combined=20.45%; p=.334) rates did not differ by group, although both were lowest for the HR group. Superficial infection (HR=12.28%, HV=17.02%, combined=9.09%; p=.521) and nonunion (HR=17.54%, HV=10.64%, combined=13.64%; p=.599) rates also did not differ.

Conclusion:

Indication for MTP arthrodesis does not appear to influence subjective outcomes of 1st MTP arthrodesis, as only one postoperative PROM differed between cohorts. All groups trended toward PROM improvements at 1-year and 3-years postoperative, although the HR group was the only group to continue improving from 1-year to 3-years postoperative. Thus, this study begins to provide insight into the role that specific forefoot pathology plays in 1st MTP arthrodesis outcomes, as we only found radiographic measures to be significantly different.
Hallux Valgus with Increased DMAA Correction by Modified Lapidus Procedure
Authors: Shah Milaan A. , Stirling Briana E. , Gonzalez Tyler A. , Jackson J. Benjamin
Published: November 2022

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

Hallux valgus is one of the most common deformities treated by orthopedic foot and ankle surgeons. Hallux valgus can frequently present with an increased distal metatarsal articular angle (DMAA), which may require correction in addition to treating the hallux valgus deformity. Many surgical procedures can correct hallux valgus with an increased DMAA with varying levels of success. Thus, we investigate the efficacy of the modified Lapidus procedure, a triplanar correction, in correcting the DMAA in hallux valgus surgery.

Methods:

A retrospective chart review was performed on patients who underwent the hallux valgus reconstruction with a modified Lapidus procedure between April 26th, 2018 and November 19th, 2020. Exclusion criteria included any patient undergoing hallux valgus correction not receiving a modified Lapidus procedure and patients with inadequate follow up. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and DMAA were measured on pre-operative, immediate post-operative and at final follow up weight bearing radiographs.

Results:

The study included a total of 99 cases of modified Lapidus procedure for hallux valgus on 85 subjects with an average follow up of 5.4 months. On radiologic assessment, the average DMAA decreased from 17.72 +- 6.18 degrees pre-operatively to 9.19 +- 5.19 degrees immediately post-operatively (p < 0.0001) and 9.79 +- 4.62 degrees at the final follow up (p < 0.0001). The average HVA decreased from 31.34 +- 10.39 degrees pre-operatively to 13.34 +- 6.16 degrees immediately post-operatively (p < 0.0001) and 15.05 +- 7.43 degrees at final follow up (p < 0.0001). Lastly, the IMA decreased from 14.99 +- 3.82 pre-operatively (p < 0.0001) to 4.66 +- 2.59 immediately post-operative and 6.62 +- 3.46 degrees at final follow up (p < 0.0001). The rate of recurrence was 3.03%.

Conclusion:

The modified Lapidus procedure is an effective procedure in correcting the HVA, IMA, and DMAA in hallux valgus surgery without the need for additional distal or proximal metatarsal osteotomies. Surgeons should consider this technique in patients with moderate to severe hallux valgus deformity who may require correction of their DMAA.
Impact of E-Scooter Injuries: A Systematic Review of 34 Studies
Authors: Singh Priya K. , Jami Meghana , Geller Joseph , Granger Caroline , Geaney Lauren E. , Aiyer Amiethab A.
Published: November 2022

Category:

Trauma; Ankle

Introduction/Purpose:

Due to the rapid expansion of scooter sharing companies in recent years, there has been a dramatic increase in the number of electric scooter injuries. The purpose of our study was to conduct a systematic review to characterize the demographics, most common injuries, and management of patients injured from electric scooters.

Methods:

This systematic review searched PubMed, EMBASE, Scopus, and Web of Sciences databases using variations of the terms 'motorized scooter', 'electric scooter', etc. Exclusion criteria included studies prior to 2015, study population less than 50, case reports, presentations or posters only, and studies focused on other devices. Two independent reviewers screened articles and data was analyzed using t-tests with Welch's correction. Sub-group analyses were performed to address data heterogeneity.

Results:

5550 patients from 34 studies were included. The median age was 33.07 years, and 58.3% (n=3325) of the patients were male. The most common mechanism of injury was falling (n=3595, 67.3%). Injured patients were more likely to not have been wearing a helmet at the time of injury (70.3%, p<0.001). The most common type of injury incurred were bony injuries (n=2761, 40.2%), of which, the most common fracture location was the upper extremity (n=1236, 44.8%). Head and neck injuries composed 22.2% of the reported injuries, which included traumatic brain injuries (2.5%), lacerations/abrasions/contusions (7.1%), intracerebral brain hemorrhages (1.9%), and concussions (3.2%). Standard radiographs were the most common mode of imaging utilized (n=2153, 57.7%). Most patients were treated and released without admission (n= 2895, 52.2%), and 16.4% of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs.

Conclusion:

Upper extremities fractures were the most common injury type incurred from e-scooter use, and the most common demographics were white, males in their early 30s. There should be more emphasis on wearing protective gear like wrist and elbow guards in addition to helmets. Future prospective studies with larger cohorts across multiple regions and hospitals are necessary to truly characterize the nature and cost of electric scooter injuries.
Management of GERD After Myotomy for Achalasia
Authors: Joelson Andrew M. , Sethi Amrita
Published: November 2022

Acid reflux is a well-known outcome after surgical or endoscopic myotomy, resulting from disruption of the natural anti-reflux barrier. The incidence of post-myotomy GERD remains difficult to estimate as studies cite variable definitions including endoscopic evidence of reflux, abnormal pH testing, and GERD symptoms. Future studies should focus on “clinically significant reflux” defined as abnormal pH testing associated with either GERD symptoms or endoscopic evidence of reflux esophagitis. Large meta-analyses have demonstrated significantly higher rates of abnormal acid exposure after peroral endoscopic myotomy (POEM) compared to laparoscopic heller myotomy (LHM). Focusing on POEM, studies show that while nearly half of patients will have esophagitis on follow-up endoscopy, the majority of these cases are mild or moderate and do not lead to significant clinical sequelae. While PPI therapy can be used effectively as treatment, new anti-reflux procedures are being developed, including transoral incisional fundoplication (TIF) and POEM + fundoplication (POEM + F) that may help to manage postmyotomy reflux in the same way the Dor fundoplication is performed with Heller myotomy. Currently, there is no reliable method for determining which patients are at risk for post-myotomy GERD. New methods are being developed to help risk- stratify these patients such as the use of EndoFLIP (endoscopic intraluminal functional imaging probe) to tailor the degree of myotomy. In addition, variable techniques of POEM are being studied to understand if the procedure can be performed in such a way as to minimize or even prevent post-myotomy GERD from occurring.
Kruppel-like factor 1–GATA1 fusion protein improves the sickle cell disease phenotype in mice both in vitro and in vivo
Authors: Zhu Jianqiong , Li Hongzhen , Aerbajinai Wulin , Kumkhaek Chutima , Pirooznia Mehdi , Saxena Ankit , Dagur Pradeep , Chin Kyung , Rodgers Griffin P.
Published: November 2022

Sickle cell disease (SCD) and β-thalassemia are among the most common genetic disorders worldwide, affecting global health and mortality. Hemoglobin A2 (HbA2, α2δ2) is expressed at a low level in adult blood due to the lack of the Kruppel-like factor 1 (KLF1) binding motif in the δ-globin promoter region. However, HbA2 is fully functional as an oxygen transporter, and could be a valid antisickling agent in SCD, as well as a substitute for hemoglobin A in β-thalassemia. We have previously demonstrated that KLF1-GATA1 fusion protein could interact with the δ-globin promoter and increase δ-globin expression in human primary CD34+ cells. We report the effects of 2 KLF1-GATA1 fusion proteins on hemoglobin expression, as well as SCD phenotypic correction in vitro and in vivo. Forced expression of KLF1-GATA1 fusion protein enhanced δ-globin gene and HbA2 expression, as well as reduced hypoxia-related sickling, in erythroid cells cultured from both human sickle CD34+ cells and SCD mouse hematopoietic stem cells (HSCs). The fusion proteins had no impact on erythroid cell differentiation, proliferation, and enucleation. Transplantation of highly purified SCD mouse HSCs expressing KLF1-GATA1 fusion protein into SCD mice lessened the severity of the anemia, reduced the sickling of red blood cells, improved SCD-related pathological alterations in spleen, kidney, and liver, and restored urine-concentrating ability in recipient mice. Taken together, these results indicate that the use of KLF1-GATA1 fusion constructs may represent a new gene therapy approach for hemoglobinopathies.