bluuebunny/crossref_metadata_2025 huggingface dataset:
A Prospective Study of Interbody Fat Graft Application With the Anterior Contralateral Cervical Microdiscectomy to Preserve Segmental Mobility
Authors: Aydın Yunus , Çavuşoğlu Halit , Yüce İsmail , Özdilmaç Ahmet , Kahyaoğlu Okan
Published: February 2017

BACKGROUND

Any surgical procedure aims at protecting mobile segments at the operated level, and the sagittal balance of the columna vertebralis. Interbody fusion has become an often applied technique in anterior cervical discectomy.

OBJECTIVE

To indicate that a minimally invasive technique in which we use interbody fat graft placement showed great results and effectiveness, especially in patients who were suffering from cervical paramedian disc herniation.

METHODS

In this study, 432 patients were observed from 2000 to 2013. All these consecutive patients had paramedian disc herniation. The initial 239 patients (group 1) underwent microdiscectomy without graft placement, whereas the remaining 193 patients (group 2) had a microdiscectomy with interbody fat graft insertion. The Neck Disability Index (NDI) and Short Form-36 (SF-36) were used to evaluate clinical outcomes. They were followed up for 5.3 years (range 2-13 years).

RESULTS

Spontaneous radiological fusion was noticed in 12% of group 1 patients and none of the group 2 patients. It has been observed that the mean overall cervical curvature (C2-7) angles and segmental lordosis did not change significantly in late follow-up findings. During both early and late follow-ups, all patients indicated a decreasing NDI score, but in late follow-up, an improving SF-36 score.

CONCLUSION

This surgical technique provides good direct decompression and preserves mobility at the treated level, while preventing disc collapse.
Proposal for the Rapid Reversal of Coagulopathy in Patients with Nonoperative Head Injuries on Anticoagulants and/or Antiplatelet Agents: A Case Study and Literature Review
Authors: Watson Victoria L , Louis Nundia , Seminara Brittany V , Muizelaar J Paul , Alberico Anthony
Published: February 2017

BACKGROUND

Emergency room physicians, trauma teams, and neurosurgeons are seeing increasing numbers of head-injured patients on anticoagulants, many of whom are nonoperative. Head injury and anticoagulation can lead to devastating consequences. These patients need immediate evaluation and often reversal of anticoagulation in order to decrease their high rates of morbidity and mortality.

OBJECTIVE

To review data on the prevalence, risks, treatment, and complications of head-injured anticoagulated patients and provide a proposal for their anticoagulant management, and imaging requirements.

METHODS

A PubMed database search was performed for articles on the prevalence, risks, treatment, and complications of patients who have sustained a head injury while on anticoagulant or antiplatelet agents.

RESULTS

A total of 1877 articles were found, of which 64 were selected for use based on direct relevance, information quality, and contribution of the article to the current understanding of anticoagulated head injury patients.

CONCLUSION

There are very few guidelines for the management of nonoperative head-injured patients. Rapid reversal guided by international normalized ratio values, Platelet Function Assays, computed tomography imaging of the head, and physical exam is suggested. The proposal presented in this paper enables patient management to begin quickly in a systematic approach, with the goal of achieving a significant decrease in the morbidity and mortality for the anticoagulated head-injured patient. Rapid reversal can potentially decrease mortality by as much as 38%.
Morphological and Hemodynamic Differences Between Aneurysmal Middle Cerebral Artery Bifurcation and Contralateral Nonaneurysmal Anatomy
Authors: Song Jianping , Zhu Fengping , Qian Yi , Ou Chubin , Cai Jiajun , Zou Xiang , Wu Zehan , Zhu Wei , Chen Liang , Mao Ying
Published: February 2017

BACKGROUND

The morphological and hemodynamic features differ between middle cerebral artery (MCA) bifurcations with and without aneurysms.

OBJECTIVE

To investigate the morphological and hemodynamic differences between aneurysmal MCA bifurcation and contralateral nonaneurysmal anatomy.

METHODS

Computed tomography angiography of 36 patients with unilateral small saccular MCA bifurcation aneurysms was evaluated. The parent–daughter angles (φ1 for larger branch and φ2 for smaller branch), bifurcation angle (φ = φ1 + φ2), inclination angle (γ angle), and their relationships with the MCA bifurcation locations were analyzed. Computational fluid dynamics simulation was performed in 6 cases to explore the hemodynamics influenced by the bifurcation morphology.

RESULTS

The φ angle was significantly higher in aneurysmal than contralateral nonaneurysmal bifurcations (160.8° ± 31.0° vs 99.0° ± 19.2°, respectively; P = .000); the φ1, φ2, and γ angles were also higher. However, by regression analysis combined with MCA bifurcation locations, only the φ angle might be associated with the aneurysm presence (odds ratio = 1.120, 95% confidence interval = 1.059-1.185) and a φ angle cut-off of 124.8° was established. Computational fluid dynamics simulation demonstrated that flow resistance of the wider aneurysmal MCA bifurcation was significantly higher than that on the contralateral side.

CONCLUSION

A larger φ angle was more prevalent in aneurysmal than nonaneurysmal MCA bifurcations, and the higher flow resistance caused by the larger φ angle might be a potential hemodynamic factor associated with MCA aneurysm presence.
Interactive iBook-Based Patient Education in a NeuroTrauma Clinic
Authors: Sahyouni Ronald , Mahmoodi Amin , Mahmoodi Amir , Rajaii Ramin R , Hasjim Bima J , Bustillo David , Huang Melissa , Tran Diem Kieu , Chen Jefferson W
Published: February 2017

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Educational interventions may alleviate the burden of TBI for patients and their families. Interactive modalities that involve engagement with the educational material may enhance patient knowledge acquisition when compared to static text-based educational material.

OBJECTIVE

To determine the effects of educational interventions in the outpatient setting on self-reported patient knowledge, with a focus on iPad-based (Apple, Cupertino, California) interactive modules.

METHODS

Patients and family members presenting to a NeuroTrauma clinic at a tertiary care academic medical center completed a presurvey assessing baseline knowledge of TBI or concussion, depending on the diagnosis. Subjects then received either an interactive iBook (Apple) on TBI or concussion, or an informative pamphlet with identical information in text format. Subjects then completed a postsurvey prior to seeing the neurosurgeon.

RESULTS

All subjects (n = 152) significantly improved on self-reported knowledge measures following administration of either an iBook (Apple) or pamphlet (P < .01, 95% confidence interval [CI]). Subjects receiving the iBook (n = 122) performed significantly better on the postsurvey (P < .01, 95% CI), despite equivalent presurvey scores, when compared to those receiving pamphlets (n = 30). Lastly, patients preferred the iBook to pamphlets (P < .01, 95% CI).

CONCLUSION

Educational interventions in the outpatient NeuroTrauma setting led to significant improvement in self-reported measures of patient and family knowledge. This improved understanding may increase compliance with the neurosurgeon's recommendations and may help reduce the potential anxiety and complications that arise following a TBI.
Variation in Tularemia Clinical Manifestations—Arkansas, 2009–2013
Authors: Lester Rothfeldt Laura K. , Jacobs Richard F. , Wheeler J. Gary , Weinstein Susan , Haselow Dirk T.
Published: February 2017

Background

Francisella tularensis, although naturally occurring in Arkansas, is also a Tier 1 select agent and potential bioterrorism threat. As such, tularemia is nationally notifiable and mandatorily reported to the Arkansas Department of Health. We examined demographic and clinical characteristics among reported cases and outcomes to improve understanding of the epidemiology of tularemia in Arkansas.

Methods

Surveillance records on all tularemia cases investigated during 2009–2013 were reviewed.

Results

The analytic dataset was assembled from 284 tularemia reports, yielding 138 probable and confirmed tularemia cases during 2009–2013. Arthropod bite was identified in 77% of cases. Of 7 recognized tularemia manifestations, the typhoidal form was reported in 47% of cases, approximately double the proportion of the more classic manifestation, lymphadenopathy. Overall, 41% of patients were hospitalized; 3% died. The typhoidal form appeared to be more severe, accounting for the majority of sepsis and meningitis cases, hospitalizations, and deaths. Among patients with available antibiotic data, 88% received doxycycline and 12% received gentamicin.

Conclusions

Contrary to expectation, lymphadenopathy was not the most common manifestation observed in our registry. Instead, our patients were more likely to report only generalized typhoidal symptoms. Using lymphadenopathy as a primary symptom to initiate tularemia testing may be an insensitive diagnostic strategy and result in unrecognized cases. In endemic areas such as Arkansas, suspicion of tularemia should be high, especially during tick season. Outreach to clinicians describing the full range of presenting symptoms may help address misperceptions about tularemia.
Sequential Extradural Release of the V3 Vertebral Artery to Facilitate Intradural V4 Vertebral Artery Reanastomosis: Feasibility of a Novel Revascularization Technique
Authors: Meybodi Ali Tayebi , Lawton Michael T. , Benet Arnau
Published: February 2017

BACKGROUND: Revascularization of the intradural vertebral artery (VA) usually involves V3-V4 bypass using an interposition graft. The interposition of a graft increases surgical time, adds risks, and requires 2 suture lines.

OBJECTIVE: To assess the feasibility of an excision-reanastomosis of V4 by sequentially releasing V3.

METHODS: Twenty specimens were prepared for surgical simulation of a far-lateral approach. The third and fourth segments of the VA were exposed through the far-lateral approach bilaterally. The V3 segment was divided into three subsegments: (1) V3f: from entry to C1 transverse foramen to the point of exit from C1 transverse foramen; (2) V3s: from V3f to the distal point of V3 within the sulcus arteriosus; and (3) V3d: from point V3 leaves the sulcus arteriosus to its dural entrance. After transecting the VA 2 mm proximal to the posterior inferior cerebellar artery origin, each subsegment was released sequentially. We measured the lengths obtained before and after releasing each segment by pulling the VA along its main axis to recreate a V3-V4 excision-reanastomosis.

RESULTS: The V3 could not be effectively mobilized without release. When totally released, an average length of 13.15 mm was available for completing V3-V4 reanastomosis.

CONCLUSION: Complete release of V3 from all its adhesions in its extracranial course can provide an average length of 13.15 mm for excision-reanastomosis. The present study shows the anatomic feasibility of the use of V3 segment in primary anastomosis after excision of a diseased segment of the intradural VA, laying the basis for future clinical application.
Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain
Authors: Cheatle Martin D , Gallagher Rollin M , O’Brien Charles P
Published: February 2017

Objective

To examine the risk of developing aberrant behaviors that might lead to a substance use disorder (addiction) when prescribing opioids for the relief of chronic noncancer pain in primary care settings.

Design

Longitudinal, prospective, descriptive design with repeated measures.

Setting

Private community-based internal medicine and family medicine clinics.

Subjects

Patients with chronic musculoskeletal pain.

Methods

Standardized measures of patient status (pain, functional impairment, psychiatric disorders, family history) and treatments provided, urine drug monitoring, and medical chart audits (presence of aberrant drug-related behaviors) were obtained in a cohort of 180 patients at the time of initiating opioids for chronic noncancer pain and at three, six, and 12 months thereafter.

Results

Over the 12-month follow-up period, subjects demonstrated stable, mild to moderate levels of depression (PHQ-9 scores ranging from 9.43 to 10.92), mild anxiety (BAI scores ranging from 11.80 to 14.67), minimal aberrant drug-related behaviors as assessed by chart reviews, and a low percentage of illicit drug use as revealed by results of urine drug monitoring. Less than 5% of our study population revealed any evidence of substance use disorder.

Conclusions

This prospective study suggests that patients without a recent or prior history of substance use disorder who were prescribed primarily short-acting opioids in low doses for chronic noncancer pain have a low risk for developing a substance use disorder. This finding supports the importance of prescreening patients being considered for opioid therapy and that prescription of opioids for noncancer pain may carry a lower risk of abuse in selected populations such as in private, community-based practices.
Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis
Authors: Perlas Anahi , Chaparro Luis E. , Chin Ki Jinn
Published: February 2017

(Reg Anesth Pain Med. 2016;41:251–260)

Spinal anesthesia and lumbar epidural anesthesia are safe and effective anesthetic techniques. However, neuraxial blocks can sometimes be difficult to perform especially when the spinal anatomy is altered. This technical challenge poses a potential risk of procedural failure and consequent complications including postdural puncture headache and backache, epidural hematoma, and spinal cord injury. A neuraxial ultrasound of the spine delineates its anatomy precisely, thus facilitating successful insertion of a spinal or epidural needle. This study aimed to assess the evidence favoring the use of preprocedural neuraxial ultrasound for spinal or lumbar epidural anesthesia and to put forward recommendations for practice.
Restriction of Oral Intake During Labor: Whither are We Bound?
Authors: Sperling Jeffrey D. , Dahlke Joshua D. , Sibai Baha M.
Published: February 2017

(Am J Obstet Gynecol. 2016;214(5):592–596)

Oral intake during labor is encouraged in some settings while being restricted in others. Dr Curtis Mendelson in 1946 suggested that aspiration during general anesthesia in obstetrics could be avoided with oral restriction during labor. The American Congress of Obstetricians and Gynecologists (ACOG) and the American Society of Anesthesiologists (ASA) in 2013 reiterated that oral intake of small amounts of clear liquids but not solids may be allowed in uncomplicated cases. Contradictory to this, the World Health Organization (WHO) suggested that healthcare providers should not prevent a woman from oral intake during labor as the energy demands are huge and replenishment could ensure maternal and fetal well-being. Patients at greater risk for aspiration are those who have gastrointestinal and neurological disorders, and other obstetric conditions. This commentary aimed to assess the evidence of restricting oral intake in low-risk patients and to inquire into the role of this general practice in modern obstetrics.
Pregnancy Outcomes in Women With Sickle-Cell Disease in Low and High Income Countries: A Systematic Review and Meta-Analysis
Authors: Boafor T.K. , Olayemi E. , Galadanci N. , Hayfron-Benjamin C. , Dei-Adomakoh Y. , Segbefia C. , Kassim A.A. , Aliyu M.H. , Galadanci H. , Tuuli M.G. , Rodeghier M. , DeBaun Michael R. , Oppong S.A.
Published: February 2017

(BJOG. 2016;123:691–698)

Pregnant women with sickle-cell disease (SCD) are generally considered to have a high risk of developing maternal and fetal complications. However, data from well-designed studies are limited regarding this topic. Therefore, this meta-analysis aimed to determine whether women with and without SCD have similar risks of pregnancy complications, and whether these outcomes differ based on residence in low-income or high-income countries.
Does Ondansetron Modify Sympathectomy Due to Subarachnoid Anesthesia?: Meta-Analysis, Meta-Regression, and Trial Sequential Analysis
Authors: Terkawi Abdullah S. , Mavridis Dimitris , Flood Pamela , Wetterslev Jørn , Terkawi Rayan S. , Bin Abdulhak Aref A. , Nunemaker Megan S. , Tiouririne Mohamed
Published: February 2017

(Anesthesiology. 2016;124:846–869)

Subarachnoid anesthesia, used in abdominal and lower extremity surgeries, has side effects including hypotension and bradycardia. Ondansetron, a potent 5-HT3 receptor antagonist, was found to prevent the consequences of sympathectomy in earlier studies but these were underpowered and presented variable results. This study evaluated the existing data on the efficacy of ondansetron in preventing hypotension and bradycardia due to subarachnoid anesthesia. A literature search was performed from the MEDLINE databases using PubMed, Cochrane Library, and Web of Science. The primary outcomes were the incidence of hypotension and bradycardia after subarachnoid anesthesia, and secondary outcomes were vasopressor (phenylephrine and ephedrine) consumption. Random-effects models were used to determine the ondansetron effect a priori. Data were analyzed by standard meta-analysis and recently developed statistical techniques such as small trial bias assessments, selection models, trial sequential analyses (TSAs) to estimate adjusted confidence intervals (CIs), and the Grading of Recommendations on Assessment, Development, and Evaluation system.
How Long is Safe? Setting the Cutoff for Uncomplicated Third Stage Length: A Retrospective Case-Control Study
Authors: Shinar Shiri , Schwartz Anat , Maslovitz Sharon , Many Ariel
Published: February 2017

(Birth. 2016;43(1):36–41)

Postpartum hemorrhage (PPH) is one of the main risk factors of a prolonged third stage of labor, which is usually 5 to 20 minutes; only 8% of placentae remain undelivered by 20 minutes. The incidence of PPH worldwide is about 6% for >500 mL of blood loss and 1.86% for >1000 mL of blood loss despite active management of the third stage. The objective of this study was to determine the optimal time until undertaking manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion.
Epidural Volume Extension During Combined Spinal-Epidural Labor Analgesia Does Not Increase Sensory Block
Authors: Zaphiratos Valerie , George Ronald B. , Macaulay Bruce , Bolleddula Prasad , McKeen Dolores M.
Published: February 2017

(Anesth Analg. 2016;123:684–689)

Combined spinal-epidural (CSE) provides faster and better first-stage analgesia and fewer epidural top-up boluses than traditional epidural methods. Deliberate injection into the epidural space can increase anesthetic level. This mechanism, referred to as epidural volume extension (EVE), is not fully understood; the fluid in the epidural space may be compressing the dural sac. The current authors thus tested 2 hypotheses. First, an epidural injection of 10 mL normal saline while initiating CSE would increase the initial anesthetic sensory block height by 15 minutes. Second, compared with CSE alone, CSE with EVE would result in a higher sensory block at 30 minutes while decreasing pain scores, analgesia onset time, and motor block.
Randomized Study of Postcesarean Analgesia With Intrathecal Morphine Alone or Combined With Clonidine
Authors: Carvalho F.A. , Tenório S.B. , Shiohara F.T. , Maia L.R. , Mota A.
Published: February 2017

(J Clin Anesth. 2016;33:395–402)

Intrathecal morphine provides long-lasting pain relief after cesarean deliveries but can be difficult to dose properly (range is 25 to 500 μg). It is possible that the concomitant use of clonidine, an alpha-2-adrenoceptor agonist, with morphine may help to improve the quality of analgesia and reduce opioid consumption and side effects. Therefore, the authors of the present study compared the efficacy of 50 μg intrathecal morphine combined with 75 μg clonidine to the efficacy of 50 μg or 100 μg intrathecal morphine alone for postcesarean analgesia.
The Validity and Reliability of the Turkish Version of the Neonatal Skin Risk Assessment Scale
Authors: Sari Çiğdem , Altay Naime
Published: February 2017

PURPOSE:

The study created a Turkish translation of the Neonatal Skin Risk Assessment Scale (NSRAS) that was developed by Huffines and Longsdon in 1997. Study authors used a cross-sectional survey design in order to determine the validity and reliability of the Turkish translation.

SUBJECTS AND SETTING:

The study was conducted at the neonatal intensive care unit of a university hospital in Ankara between March 15 and June 30, 2014. The research sample included 130 neonatal assessments from 17 patients.

METHODS:

Data were collected by questionnaire regarding the characteristics of the participating neonates, 7 nurse observers, and the NSRAS and its subarticles. After translation and back-translation were performed to assess language validity of the scale, necessary corrections were made in line with expert suggestions, and content validity was ensured. Internal consistency of the scale was assessed by its homogeneity, Cronbach’s α, and subarticle–general scale grade correlation.

RESULTS:

Cronbach’s α for the scale overall was .88, and Cronbach’s α values for the subarticles were between .83 and .90. Results showed a positive relationship among all the subarticles and the overall NSRAS scale grade (P < .01) with correlation values between 0.333 and 0.721. Explanatory and predicative factor analysis was applied for structural validity. Kaiser-Meyer-Olkin analysis was applied for sample sufficiency, and Bartlett test analysis was applied in order to assess the factor analysis of the sample. The Kaiser-Meyer-Olkin coefficient was 0.73, and the χ
2
value found according to the Bartlett test was statistically significant at an advanced level (P < .05). In the 6 subarticles of the scale and in the general scale total grade, a high, positive, and significant relationship among the grades given by the researcher and the nurse observers was found (P < .05).

CONCLUSION:

The Turkish NSRAS is reliable and valid.
Leveraging Telemedicine Infrastructure to Monitor Quality of Operating Room to Intensive Care Unit Handoffs
Authors: Barry Mark E. , Hochman Beth R. , Lane-Fall Meghan B. , Zappile Denise , Holena Daniel N. , Smith Brian P. , Kaplan Lewis J. , Huffenberger Ann , Reilly Patrick M. , Pascual Jose L.
Published: February 2017

Purpose

To analyze in-room video recordings of operating room (OR) to intensive care unit (ICU) handoffs to determine tempo and quality of team interactions on nights and weekends compared with weekdays, and to demonstrate how existing telemedicine technology can be used to evaluate handoffs.

Method

This prospective observational study of OR-to-ICU bedside handoffs was conducted in the surgical ICU of the Hospital of the University of Pennsylvania in July 2014–January 2015. Handoff video recordings were obtained for quality improvement purposes using existing telemedicine cameras. Evaluators used adapted validated in-person assessment measures to analyze basic characteristics and quality measures (timing, report types, report duration, presence of physical exam, teamwork skills, engagement, report delivery skills, listening skills, interruptions, unprofessional comments or actions).

Results

Sixteen weekday and 16 night and weekend handoffs were compared. There were no significant differences in basic characteristics. Most quality measures were similar on weekdays compared with nights and weekends. Surgeons demonstrated better report delivery skills and engagement on nights and weekends (P = .002 and P = .04, respectively), whereas OR anesthesiologists’ scores were similar during both time frames.

Conclusions

This study presents a novel approach of assessing handoff quality in OR-to-ICU handoffs using an existing telemedicine infrastructure. Using this approach, quality measures of night and weekend handoffs were found to be no worse—and sometimes better—than those during weekdays. Video analysis may emerge as an ideal unobtrusive quality improvement methodology to monitor handoffs and improve education and compliance with institutional handoff policies.
Engaging Learners to Advance Medical Education
Authors: Burk-Rafel Jesse , Jones R. Logan , Farlow Janice L.
Published: February 2017

Learners are a pillar of academic medicine, yet their voice is seldom heard in national and international scholarly conversations on medical education. However, learners are eager to contribute: in response to a recent open call from Academic Medicine, medical students and residents representing 98 institutions across 11 countries submitted 224 Letters to the Editor on wide-ranging topics. In this Invited Commentary, the authors—three medical students serving in national leadership roles—contextualize several themes discussed in these learner-authored letters.

The authors first explore the unique voice learners contribute to educational innovation, highlighting the value learners add to curricular and systemic educational reform efforts. They then turn to the broader implications of the many submitted letters addressing the culture and humanism of medicine, proposing that learners can be powerful catalysts and partners in cultural change. Despite these benefits, the authors note that learners are largely untapped change agents who are particularly underrepresented in medical education scholarship, finding that students were just 2.8% (39/1,396) of authors and 3.5% (12/340) of first authors among all print publications in Academic Medicine in 2016. The authors conclude by offering tangible steps for the academic medical community to engage learners in leadership, advocacy, and scholarship.
Treatment of lupus nephritis: current paradigms and emerging strategies
Authors: Dall’Era Maria
Published: February 2017

Purpose of review

Lupus nephritis is the most common organ-threatening manifestation of lupus and continues to result in end-stage renal disease. This review describes the contemporary treatment of lupus nephritis as well as emerging therapeutic strategies.

Recent findings

Lupus nephritis management consists of an initial (induction) phase and a maintenance (extended) phase in which steroids are used in combination with another immunosuppressive medication. Current treatments are incompletely effective and associated with substantial toxicity. Despite disappointing results of several recent trials, novel therapies targeting diverse immunologic pathways are being actively studied in lupus nephritis. Two promising strategies include the use of B-cell depletion therapy and multitarget therapy with calcineurin inhibitors. In parallel with the conduct of these trials, there are ongoing efforts to improve trial design. Two recent studies of outcome measures reported that a level of proteinuria of less than 0.7–0.8 g at 12 months is most predictive of good long-term renal outcome, and that the inclusion of urine red blood cells worsens the predictive value of proteinuria alone.

Improved understanding of lupus nephritis pathogenesis, development of novel therapies, and optimization of clinical trial design are leading the path forward for successful drug development in lupus nephritis. The ultimate goal of these efforts is to treat our patients in a more strategic, personalized manner that improves long-term outcomes.
Percutaneous or Open Reduction of Closed Tibial Shaft Fractures During Intramedullary Nailing Does Not Increase Wound Complications, Infection or Nonunion Rates
Authors: Auston Darryl A. , Meiss Jordan , Serrano Rafael , Sellers Thomas , Carlson Gregory , Hoggard Timothy , Beebe Michael , Quade Jonathan , Watson David , Simpson Robert Bruce , Kistler Brian , Shah Anjan , Sanders Roy , Mir Hassan R.
Published: February 2017

Objective:

To compare the incidence of complications (wound, infection, and nonunion) among those patients treated with closed, percutaneous, and open intramedullary nailing for closed tibial shaft fractures.

Design:

Retrospective review.

Setting:

Multiple trauma centers.

Patients:

Skeletally mature patients with closed tibia fractures amenable to treatment with an intramedullary device.

Intervention:

Intramedullary fixation with closed, percutaneous, or open reduction.

Main Outcome Measurements:

Superficial wound complication, deep infection, nonunion.

Results:

A total of 317 tibial shaft fractures in 315 patients were included in the study. Two-hundred fractures in 198 patients were treated with closed reduction, 61 fractures in 61 patients were treated with percutaneous reduction, and 56 fractures in 56 patients were treated with formal open reduction. The superficial wound complication rate was 1% (2/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 3.6% (2/56) for the open group with no statistical difference between the groups (P = 0.179). The deep infection rate was 2% (4/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 7.1% (4/56) for the open group with no significant difference between the groups (P = 0.133). Nonunion rate was 5.0% (10/200) for the closed group, 4.9% (3/61) for the percutaneous group, and 7.1% (4/56) for the open group, with no statistical difference between the groups (P = 0.492).

Conclusions:

This is the largest reported series of closed tibial shaft fractures nailed with percutaneous and open reduction. Percutaneous or open reduction did not result in increased wound complications, infection, or nonunion rates. Carefully performed percutaneous or open approaches can be safely used in obtaining reduction of difficult tibial shaft fractures treated with intramedullary devices.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Spanish Translation, Cross-Cultural Adaptation, and Validation of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire in Mexican-Americans With Traumatic Foot and Ankle Injuries
Authors: Zelle Boris A. , Francisco Ben S. , Bossmann James P. , Fajardo Roberto J. , Bhandari Mohit
Published: February 2017

Background:

Hispanics represent the largest minority group within the US population accounting for an estimated 55.4 million individuals. Enrolling Hispanics into clinical outcome studies is important in order for study populations to be externally valid and representative of the US population. Inclusion of Mexican-Americans in clinical studies is frequently limited by the lack of validated outcome measures. The goal of this study was to validate a Spanish version of the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (AAOS-FAOQ) in Mexican-Americans with traumatic foot and ankle injuries.

Methods:

The translation and cross-cultural adaptation procedure was performed by a committee of bilingual speakers using the following steps: (1) forward translation and adaptation, (2) synthesis, (3) back translation, (4) committee review, and (5) pilot testing. The validation was performed in 100 Mexican-Americans with traumatic foot and ankle injuries.

Results:

A total of 41 females and 59 males were enrolled in this study. The mean age was 42.98 years (range 18–88). The Spanish version of the Global Foot and Ankle Scale of the AAOS-FAOQ showed statistically significant correlations with all 8 subscales of the Spanish SF-36 as well as the Physical Component Summary scale and the Mental Component Summary scale (P < 0.05). The Global Foot and Ankle scale of the Spanish AAOS-FAOQ demonstrated a test–retest reliability of 0.68.

Conclusion:

We provide a Spanish translation and cross-cultural adaptation of the AAOS-FAOQ. The instrument demonstrates appropriate psychometric properties in Mexican-Americans with traumatic foot and ankle injuries.
Is This Autograft Worth It?: The Blood Loss and Transfusion Rates Associated With Reamer Irrigator Aspirator Bone Graft Harvest
Authors: Marchand Lucas S. , Rothberg David L. , Kubiak Erik N. , Higgins Thomas F.
Published: February 2017

Objectives:

To investigate the blood loss and transfusion rate associated with the use of reamer irrigator aspirator (RIA).

Design:

Retrospective review.

Setting:

Academic Level-I trauma hospital.

Patients:

One hundred eight patients requiring bone graft harvest for surgical reconstruction of nonunion or failed arthrodesis.

Intervention:

Bone graft harvest preformed via RIA or iliac crest bone graft (ICBG).

Main Outcome Measure:

Blood loss as measured by a change in preoperative and postoperative hematocrit (Hct). In addition, postoperative transfusion reported intraoperative blood loss, volume of graft harvested, and major complications.

Results:

The average Hct drop was found to be 13.7 (4.1–27.4) in the RIA cohort of 61 patients and 7.36 (1.2–14.5) in the ICBG cohort of 47 patients (P = 0.013). Operative reports documented an average estimated blood loss of 674 mL (100–2000 mL) in the RIA cohort compared with 255 mL (50–1000 mL) in the ICBG cohort (P < 0.001). Twenty-seven patients (44%) required blood transfusion after RIA, whereas 10 patients (21%) required blood transfusion after ICBG (odds ratio 5.32, 95% confidence interval 2.2–6.3, P < 0.001). RIA procedures collected an average 53 mL (20–100 mL) of bone graft compared with 27 mL (15–50 mL) with ICBG. There was no significant difference between groups regarding age, sex, medical comorbidities, or postoperative major complications.

Conclusions:

This series demonstrated that 44% of patients undergoing RIA bone graft harvest required transfusion, with a mean Hct drop of 13.7 across all subjects, which is significantly greater than that associated with ICBG.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Outcomes of Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fracture: A Medicare Cohort Study
Authors: Wang Zhong , Bhattacharyya Timothy
Published: February 2017

Objectives:

For patients with femoral neck fractures, total hip arthroplasty (THA) demonstrates superior outcomes compared with hemiarthroplasty. However, hemiarthroplasty remains a common treatment for femoral neck fractures and the conversion rates are unknown. We compared the results of the 2 procedures using a Medicare database.

Methods:

We assembled a cohort of 70,242 patients 65 to 90 years of age with an ICD9 diagnosis and matching Current Procedure Terminology code for femoral neck fracture between 2008 and 2012. Patients were followed forward for 2 years minimum. Incidences of dislocation and mortality were measured. Reoperation for revision of THA or conversion of hemiarthroplasty to THA was assessed by Current Procedure Terminology code. Groups were compared through proportional hazard models controlling for age, race, sex, and comorbidity index.

Results:

Hemiarthroplasty represented 95% of the patients treated using arthroplasty for femoral neck fracture. The proportional hazard of reoperation and dislocation were significantly lower for hemiarthroplasty than THA (P < 0.0001 for both). At 2 years, fewer than 2% of hemiarthroplasty patients underwent conversion to total hip replacement. Patients treated with THA were more likely to be alive for 2 years (adjusted hazard ratio = 1.67, 95% confidence interval: 1.59–1.92).

Conclusion:

Patients treated with hemiarthroplasty after femoral neck fractures had significantly lower proportional hazard of reoperation than those treated with THA. THA may be associated with lower mortality.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Open Tibia Shaft Fractures and Soft-Tissue Coverage: The Effects of Management by an Orthopaedic Microsurgical Team
Authors: VandenBerg James , Osei Daniel , Boyer Martin I. , Gardner Michael J. , Ricci William M. , Spraggs-Hughes Amanda , McAndrew Christopher M.
Published: February 2017

Objectives:

To compare the timing of soft-tissue (flap) coverage and occurrence of complications before and after the establishment of an integrated orthopaedic trauma/microsurgical team.

Design:

Retrospective cohort study.

Setting:

A single level 1 trauma center.

Patients:

Twenty-eight subjects (13 pre- and 15 post-integration) with open tibia shaft fractures (OTA/AO 42A, 42B, and 42C) treated with flap coverage between January 2009 and March 2015.

Intervention:

Flap coverage for open tibia shaft fractures treated before (“preintegration”) and after (“postintegration”) implementation of an integrated orthopaedic trauma/microsurgical team.

Main Outcome Measure:

Time from index injury to flap coverage.

Results:

The unadjusted median time to coverage was 7 days (95% confidence interval, 5.9–8.1) preintegration, and 6 days (95% confidence interval, 4.6–7.4) postintegration (P = 0.48). For preintegration, 9 (69%) of the patients experienced complications, compared with 7 (47%) postintegration (P = 0.23).

Conclusions:

After formation of an integrated orthopaedic trauma/microsurgery team, we observed a 1-day decrease in median days to coverage from index injury. Complications overall were lowered in the postintegration group, although statistically insignificant.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
The anxiolytic-like effect of rutin in rats involves GABAA receptors in the basolateral amygdala
Authors: Hernandez-Leon Alberto , González-Trujano María E. , Fernández-Guasti Alonso
Published: February 2017

Rutin is a bioflavonoid found in medicinal plants used to reduce anxiety. Evidence is lacking of rutin’s anxiolytic-like activity, putative mechanism(s) of action, and neural sites of effects. The basolateral amygdala (BLA) is the main brain region that regulates anxiety, through GABAA/benzodiazepine (BDZ) receptors, which are modulated by flavonoids. Therefore, the main aim of this study was to investigate whether the anxiolytic-like effect of rutin involves GABAA/BDZ receptors in the BLA. Rutin was administered systemically (30–1000 mg/kg, intraperitoneal) or microinjected into the BLA (16 nmol/4 µl, intracerebral), and its effects were assessed in the elevated plus-maze and open-field tests. Diazepam (1 mg/kg, intraperitoneal, or 7 nmol/4 µl, respectively) was used as a positive control. The mechanism of action was studied using flumazenil (BDZ antagonist, 5 mg/kg, intraperitoneal, or 7 nmol/4 µl, intracerebral) or picrotoxin (chloride channel GABAA antagonist, 0.3 nmol/4 µl, intracerebral). Rutin, administered systemically or intra-amygdala, induced anxiolytic-like responses, similar to those of diazepam. The effect of diazepam was completely blocked by flumazenil, which also partly antagonized the effects of systemic rutin. By contrast, flumazenil exerted no effect and picrotoxin had only a partial action when rutin was infused in the BLA. These results suggest that the anxiolytic-like effect of rutin in the BLA involves GABAergic neurotransmission that is not associated with BDZ receptors.
Pharmacological activation of protein kinase A improves memory loss and neuropathological changes in a mouse model of dementia of Alzheimer’s type
Authors: Kumar Amit , Singh Nirmal
Published: February 2017

The study investigates the therapeutic potential of the protein kinase A (PKA) activator forskolin in cognitive deficits of mice. Streptozotocin (STZ) [3 mg/kg, intracerebroventricularly (i.c.v.)] was used to induce memory deficits in mice, whereas aged mice served as natural model of dementia. Forskolin (2.5, 5, and 10 mg/kg/day, oral) treatment was administered to i.c.v. STZ-treated and aged mice for 14 days. The Morris Water Maze test was used to evaluate learning and memory. Estimation of brain acetylcholinesterase (AChE) activity, brain glutathione, thiobarbituric acid-reactive species, brain myeloperoxidase levels, and histopathological studies were also performed. Both STZ i.c.v. and aging resulted in a marked decline in Morris Water Maze performance, reflecting impairment of learning and memory. STZ i.c.v.-treated mice and aged mice showed a marked accentuation of AChE activity, thiobarbituric acid-reactive species and myeloperoxidase levels along with a decrease in the glutathione level. Further, the stained micrographs of STZ-treated mice and aged mice indicated pathological changes, severe neutrophilic infiltration, and amyloid deposition. Forskolin treatment significantly attenuated STZ-induced and age-related memory deficits, and biochemical and histopathological alterations. The findings indicate that the PKA activator forskolin probably alleviated memory deficits by virtue of its anticholinesterase, antiamyloid, antioxidative, and anti-inflammatory effects. It is concluded that PKA could be explored as a potential therapeutic target in dementia.
Renal cystic disease and associated ciliopathies
Authors: Kagan Karl O. , Dufke Andreas , Gembruch Ulrich
Published: February 2017

Purpose of review

To review disorders that are associated with renal cystic disease during prenatal life and to highlight the strong association between renal cystic disease and ciliopathies.

Recent findings

There are numerous causative genes for ciliopathies that can present with cystic kidney disease. In the group of single gene ciliopathies, autosomal dominant polycystic kidney disease is by far the most prevalent one. Other examples are autosomal recessive polycystic kidney disease, nephronophthisis, Bardet–Biedl syndrome, Meckel–Gruber syndrome, Joubert syndrome and related disorders as well as X-linked orofaciodigital syndrome type 1, respectively. The prevalence of these inherited disorders sums up to about in 1 : 2000 people. These disorders with their hepatorenal fibrocystic character should be classified as multisystem diseases.

Understanding of the origin of renal cystic disease and associated disorders is important to make the appropriate prenatal diagnosis and for counseling affected parents. In the future, understanding of the pathophysiology may help to develop new treatment strategies.
Invasive therapies for primary post-partum haemorrhage as missed opportunities for medical prevention
Authors: Kayem Gilles , Deneux-Tharaux Catherine
Published: February 2017

Purpose of review

Examine the available results from population-based studies to test the hypothesis that differences between countries in medical practices for the management of labour, delivery and early bleeding may lead to a differential risk of post-partum haemorrhage (PPH)-related maternal morbidity and in the need for PPH-related invasive therapies.

Recent findings

International comparison of ratios of maternal mortality due to PPH shows significant differences between developed countries. Direct international comparisons of PPH rates to investigate these differences are difficult because PPH definition is not homogeneous. One widely used proxy for severe PPH is the use of secondary invasive procedures for PPH treatment. Comparative analysis of results from population-based studies shows wide variations in the rates of invasive therapies for PPH across countries and suggests that high rates of such therapies may be explained partly by variations in practices for the management of first and third stages of labour and in the noninvasive steps of PPH treatment.

Invasive therapies for PPH may be considered markers of missed opportunities for primary or secondary prevention of PPH. Management of first and third stages of labour as well as the early steps of PPH treatment are important keys to prevent severe maternal complications of PPH and the need for invasive therapies.
EVALUATION OF FULL-FIELD ELECTRORETINOGRAM REDUCTIONS AFTER OCRIPLASMIN TREATMENT
Authors: Birch David G. , Benz Matthew S. , Miller Daniel M. , Antoszyk Andrew N. , Markoff Joseph , Kozma Petra , Meunier Esmeralda , Sergott Robert C. ,   for the OASIS Study Team
Published: February 2017

Purpose:

To explore a possible association between full-field electroretinograms with vitreomacular adhesion resolution and best-corrected visual acuity as part of the prospective, randomized, double-masked, sham-controlled Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole (OASIS) trial studying ocriplasmin.

Methods:

The ERG substudy enrolled 62 of 220 OASIS subjects (randomized 2:1) and analyzed full-field electroretinograms and their association with both vitreomacular adhesion resolution and best-corrected visual acuity from baseline through Month 24. Electroretinogram reductions were defined as acute full-field electroretinogram reductions in amplitude of ≥40% from baseline occurring at postinjection Day 7 or Day 28.

Results:

In the ocriplasmin group, 16/40 (40%) subjects developed ERG reductions, compared to 1/21 (4.8%) in the sham group; 13/16 (81.3%) and 1/1 (100%) resolved by study end, respectively. A total of 11/16 (68.8%) ocriplasmin-treated subjects with ERG reductions achieved vitreomacular adhesion resolution, compared to those without (9/24, 37.5%). The ocriplasmin-treated subjects with ERG reductions also gained more letters on average (11.3 vs. 9.3 letters) from baseline and had a difference of 6.7 letters in mean best-corrected visual acuity by study end compared to those without ERG reductions.

Conclusion:

Ocriplasmin-treated subjects with ERG reductions had a higher rate of vitreomacular adhesion resolution and showed better visual improvement than their counterparts without ERG reductions or sham subjects by study end.
Professional Nurses' Perceptions of Skills Required for Performing Preterm Infants' Follow-up Assessments
Authors: Cordewener Debbie , Lubbe Welma
Published: February 2017

Improved perinatal and neonatal care enhances preterm infant survival rates, but the adverse outcomes remain high. Nurses play vitally important roles regarding the follow-up assessments, treatment, and care of preterm infants. This explorative, descriptive study aimed to describe nurses' perceptions of skills required to perform effective preterm infant assessments. Thirteen semistructured interviews were conducted. Identified themes included the role of the professional nurse, the importance of preterm infant assessments, lack of skills and knowledge to conduct quality assessments, formal and continuous development training needs, the absence of assessment tools and physical resources to perform standardized assessments of preterm infants, and the required support and referral systems.
Intersection of prognosis and palliation in neurocritical care
Authors: Rubin Michael , Bonomo Jordan , Hemphill J. Claude
Published: February 2017

Purpose of review

Difficult discussions regarding end-of-life care are common in neurocritical care. Because of a patient's neurological impairment, decisions regarding continuing or limiting aggressive care must often be made by patients’ families in conjunction with medical providers. This review provides perspective on three major aspects of this circumstance: prognostication, family–physician discussions, and determination of death (specifically as it impacts on organ donation).

Recent findings

Numerous studies have now demonstrated that prediction models developed from populations of brain-injured patients may be misleading when applied to individual patients. Early care limitations may lead to the self-fulfilling prophecy of poor outcomes because of care decisions rather than disease course. A shared decision-making approach that emphasizes transmission of information and trust between families and medical providers is ethically appropriate in severely brain-injured patients and as part of the transition to end-of-life palliative care. Standard definitions of death by neurological criteria exist, although worldwide variation and the relationship to organ donation make this complex.

End-of-life care in patients with severe brain injuries is common and represents a complex intersection of prognostication, family communication, and decision-making. Skills to optimize this should be emphasized in neurocritical care providers.