bluuebunny/crossref_metadata_2025 huggingface dataset:
Image-Guided Biopsy of Intracranial Lesions with a Small Robotic Device (iSYS1): A Prospective, Exploratory Pilot Study
Authors: Legnani Federico G , Franzini Andrea , Mattei Luca , Saladino Andrea , Casali Cecilia , Prada Francesco , Perin Alessandro , Cojazzi Vittoria , Saini Marco , Kronreif Gernot , Wolfsberger Stefan , DiMeco Francesco
Published: January 2019

BACKGROUND

Robotic technologies have been used in the neurosurgical operating rooms for the last 30 yr. They have been adopted for several stereotactic applications and, particularly, image-guided biopsy of intracranial lesions which are not amenable for open surgical resection.

OBJECTIVE

To assess feasibility, safety, accuracy, and diagnostic yield of robot-assisted frameless stereotactic brain biopsy with a recently introduced miniaturized device (iSYS1; Interventional Systems Medizintechnik GmbH, Kitzbühel, Austria), fixed to the Mayfield headholder by a jointed arm.

METHODS

Clinical and surgical data of all patients undergoing frameless stereotactic biopsies using the iSYS1 robotized system from October 2016 to December 2017 have been prospectively collected and analyzed. Facial surface registration has been adopted for optical neuronavigation.

RESULTS

Thirty-nine patients were included in the study. Neither mortality nor morbidity related to the surgical procedure performed with the robot was recorded. Diagnostic tissue samples were obtained in 38 out of 39 procedures (diagnostic yield per procedure was 97.4%). All patients received a definitive histological diagnosis. Mean target error was 1.06 mm (median 1 mm, range 0.1-4 mm).

CONCLUSION

The frameless robotic iSYS1-assisted biopsy technique was determined to be feasible, safe, and accurate procedure; moreover, the diagnostic yield was high. The surface matching registration method with computed tomography as the reference image set did not negatively affect the accuracy of the procedure.
Tales of Broken Water Mains and ASDA Employees: Drafting Evolution or Drafting for Confusion?
Authors: Walsh Bernadette
Published: January 2019

Values and beliefs pertaining to the best approach to drafting legislation change over time. It is therefore inevitable that, when engaged in the replacement of older legislation, drafters will seek to change the style to better reflect current values and beliefs. But how easy is it for courts to distinguish between a change that simply represents an evolution of drafting style and a change of substance? This article explores that question through the lens of two recent cases and asks whether drafters, in their zeal to modernize and improve, may underestimate the risk that their changes will cause confusion.
Marginal Likelihoods in Phylogenetics: A Review of Methods and Applications
Authors: R Oaks Jamie , A Cobb Kerry , N Minin Vladimir , D Leaché Adam
Published: January 2019

By providing a framework of accounting for the shared ancestry inherent to all life, phylogenetics is becoming the statistical foundation of biology. The importance of model choice continues to grow as phylogenetic models continue to increase in complexity to better capture micro- and macroevolutionary processes. In a Bayesian framework, the marginal likelihood is how data update our prior beliefs about models, which gives us an intuitive measure of comparing model fit that is grounded in probability theory. Given the rapid increase in the number and complexity of phylogenetic models, methods for approximating marginal likelihoods are increasingly important. Here, we try to provide an intuitive description of marginal likelihoods and why they are important in Bayesian model testing. We also categorize and review methods for estimating marginal likelihoods of phylogenetic models, highlighting several recent methods that provide well-behaved estimates. Furthermore, we review some empirical studies that demonstrate how marginal likelihoods can be used to learn about models of evolution from biological data. We discuss promising alternatives that can complement marginal likelihoods for Bayesian model choice, including posterior-predictive methods. Using simulations, we find one alternative method based on approximate-Bayesian computation to be biased. We conclude by discussing the challenges of Bayesian model choice and future directions that promise to improve the approximation of marginal likelihoods and Bayesian phylogenetics as a whole.
Alpha2B-Adrenergic Receptor Overexpression in the Brain Potentiate Air Pollution-induced Behavior and Blood Pressure Changes
Authors: Rao Xiaoquan , Asico Laureano D , Zanos Panos , Mahabeleshwar Ganapati H , Singh Gangwar Roopesh , Xia Chang , Duan Lihua , Cisse Yasmine-Marie , Rengasamy Palanivel , Jose Pedro A , Gould Todd D , Nelson Randy , Biswal Shyam , Chen Lung-Chi , Zhong Jixin , Rajagopalan Sanjay
Published: January 2019

Fine ambient particulate matter (PM2.5) is able to induce sympathetic activation and inflammation in the brain. However, direct evidence demonstrating an essential role of sympathetic activation in PM2.5-associated disease progression is lacking. We assess the contribution of α2B-adrenergic receptor (Adra2b) in air pollution-associated hypertension and behavioral changes in this study. Wild-type mice and Adra2b-transgenic mice overexpressing Adra2b in the brain (Adra2bTg) were exposed to concentrated PM2.5 or filtered air for 3 months via a versatile aerosol concentrator exposure system. Mice were fed with a high salt diet (4.0% NaCl) for 1 week at week 11 of exposure to induce blood pressure elevation. Intra-arterial blood pressure was monitored by radio-telemetry and behavior changes were assessed by open field, light-dark, and prepulse inhibition tests. PM2.5 exposure increased Adra2b in the brain of wild-type mice. Adra2b overexpression enhanced the anxiety-like behavior and high salt diet-induced blood pressure elevation in response to air pollution but not filtered air exposure. Adra2b overexpression induced upregulation of inflammatory genes such as TLR2, TLR4, and IL-6 in the brain exposed to PM2.5. In addition, there were increased frequencies of activated effector T cells and increased expression of oxidative stress-related genes, such as SOD1, NQO1, Nrf2, and Gclm in Adra2bTg mice compared with wild-type mice. Our results provide new evidence of distinct behavioral changes consistent with anxiety and blood pressure elevation in response to high salt intake and air pollution exposure, highlighting the importance of centrally expressed Adra2b in the vulnerability to air pollution exposure.
Can You Escape Nursing School? Educational Escape Room in Nursing Education
Authors: Morrell Briyana L. M. , Ball Heather M.
Published: January 2019

Escape rooms, a form of collaborative live-action gaming requiring participants to solve clues to escape a locked room, have grown in popularity across the nation. Games bring together problem solving, critical thinking, and teamwork. This game method has not yet appeared in nursing education literature. The authors describe two versions of the innovative escape room pedagogical method used in undergraduate nursing education. Theoretical bases, learning activities, and types of game clues that could be used are detailed. Future research will address the ability of students to reach learning objectives before and after the game.
Adelante (Moving Forward): An Innovative Program for Nursing and Prenursing Students
Authors: Zamora Herlinda , Rogers Norma Martínez
Published: January 2019

The US population reflects a rich diversity of people that is not reflected in the health care workforce. This article describes the Adelante (Moving Forward) Program, an innovative model designed to increase nursing workforce diversity. Adelante was created to advance baccalaureate nursing students and prenursing students by using supportive developmental relationships and mentoring strategies. Graduates stated that they planned to advance their education. Further development of innovative programs for nursing students from diverse backgrounds is imperative to increase health care workforce diversity.
Intentional Application of Nursing Theory in Simulated Practice
Authors: Singleterry Lisa
Published: January 2019

A simulation focused on nursing theory was designed to replace one clinical day experience for 37 senior-level baccalaureate students. Pretest-posttest self-evaluations were used in the study to rate student confidence in using Locsin's technology competency as caring in nursing theory and in describing critical care equipment and monitoring technology. A dependent t-test showed improvements in confidence using theory in practice after the simulation and debriefing session. Using one-on-one debriefing sessions, students and faculty had an opportunity to discuss how nursing theory can guide nursing practice. Intentionally developed simulation and debriefing experiences can provide students experience using nursing theory.
Automated Titration of Vasopressor Infusion Using a Closed-loop Controller
Authors: Joosten Alexandre , Delaporte Amélie , Alexander Brenton , Su Fuhong , Creteur Jacques , Vincent Jean-Louis , Cannesson Maxime , Rinehart Joseph
Published: January 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Multiple studies have reported associations between intraoperative hypotension and adverse postoperative complications. One of the most common interventions in the management of hypotension is vasopressor administration. This approach requires careful and frequent vasopressor boluses and/or multiple adjustments of an infusion. The authors recently developed a closed-loop controller that titrates vasopressors to maintain mean arterial pressure (MAP) within set limits. Here, the authors assessed the feasibility and overall performance of this system in a swine model. The authors hypothesized that the closed-loop controller would be able to maintain MAP at a steady, predefined target level of 80 mmHg for greater than 85% of the time.

Methods

The authors randomized 14 healthy anesthetized pigs either to a control group or a closed-loop group. Using infusions of sodium nitroprusside at doses between 65 and 130 µg/min, we induced four normovolemic hypotensive challenges of 30 min each. In the control group, nothing was done to correct hypotension. In the closed-loop group, the system automatically titrated norepinephrine doses to achieve a predetermined MAP of 80 mmHg. The primary objective was study time spent within ±5 mmHg of the MAP target. Secondary objectives were performance error, median performance error, median absolute performance error, wobble, and divergence.

Results

The controller maintained MAP within ±5 mmHg of the target for 98 ± 1% (mean ± SD) of the time. In the control group, the MAP was 80 ± 5 mmHg for 14.0 ± 2.8% of the time (P< 0.0001). The MAP in the closed-loop group was above the target range for 1.2 ± 1.2% and below it for 0.5 ± 0.9% of the time. Performance error, median performance error, median absolute performance error, wobble, and divergence were all optimal.

Conclusions

In this experimental model of induced normovolemic hypotensive episodes in pigs, the automated controller titrated norepinephrine infusion to correct hypotension and keep MAP within ±5 mmHg of target for 98% of management time.
Imaging the Injured Lung
Authors: Cereda Maurizio , Xin Yi , Goffi Alberto , Herrmann Jacob , Kaczka David W. , Kavanagh Brian P. , Perchiazzi Gaetano , Yoshida Takeshi , Rizi Rahim R.
Published: January 2019

Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging—either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.
Point-of-Care Intrapartum Group B Streptococcus Molecular Screening
Authors: El Helali Najoua , Habibi Fakher , Azria Elie , Giovangrandi Yves , Autret Fanny , Durand-Zaleski Isabelle , Le Monnier Alban
Published: January 2019

OBJECTIVE:

To assess outcomes and costs associated with around-the-clock point-of-care intrapartum group B streptococcus (GBS) polymerase chain reaction (PCR) screening.

METHODS:

Intrapartum PCR screening was implemented in 2010. Intrapartum PCR was compared with antenatal culture screening in an uncontrolled, single institution, preintervention and postintervention study. The study periods included 4 years before and 6 years after the intervention, commencing in 2006 and concluding in 2015. The primary outcome measure was rate of early-onset neonatal GBS disease. Secondary outcomes included length of stay, days of antibiotics, and costs.

RESULTS:

During the 4 years of antenatal culture screening, 11,226 deliveries were recorded compared with 18,835 in the 6 years of intrapartum GBS PCR screening, corresponding to 11,818 and 18,980 live births, respectively. During the antenatal culture period, 3.8% of term deliveries did not undergo GBS testing compared with 0.1% during the intrapartum PCR period (P<.001). Between the two periods, the rate of proven early-onset GBS disease cases decreased from 1.01/1,000 to 0.21/1,000 (P=.026) and probable early-onset GBS disease cases from 2.8/1,000 to 0.73/1,000 (P<.001); the risk ratio for both was 0.25, 95% CI (0.14–0.43). Total days of hospital and antibiotic therapy for early-onset GBS disease declined by 64% and 60%, respectively, with no significant difference for average length of stay or antibiotic duration preintervention and postintervention. The yearly cost of delivery and treatment of newborns with GBS infection was reduced from $41,875±6,823 to $11,945±10,303 (P<.001). The estimated extra cost to avoid one early-onset GBS disease was $5,819.

CONCLUSION:

Point-of-care intrapartum GBS PCR screening was associated with a significant decrease in the rate of early-onset GBS disease and antibiotic use in newborns. The additional PCR costs were offset in part by the reduction in early-onset GBS disease treatment costs.
Nomogram for Predicting Individual Survival After Recurrence of Advanced-Stage, High-Grade Ovarian Carcinoma
Authors: Rose Peter G. , Java James J. , Salani Ritu , Geller Melissa A. , Secord Angeles Alvarez , Tewari Krishnansu S. , Bender David P. , Mutch David G. , Friedlander Michael L. , Van Le Linda , Method Michael W. , Hamilton Chad A. , Lee Roger B. , Wenham Robert M. , Guntupalli Saketh R. , Markman Maurie , Muggia Franco M. , Armstrong Deborah K. , Bookman Michael A. , Burger Robert A. , Copeland Larry J.
Published: January 2019

OBJECTIVE:

To analyze clinical prognostic factors for survival after recurrence of high-grade, advanced-stage ovarian–peritoneal–tubal carcinoma and to develop a nomogram to predict individual survival after recurrence.

METHODS:

We retrospectively analyzed patients treated in multicenter Gynecologic Oncology Group protocols for stage III and IV ovarian–peritoneal–tubal carcinoma who underwent primary debulking surgery, received chemotherapy with paclitaxel and a platinum compound, and subsequently developed recurrence. Prognostic factors affecting survival were identified and used to develop a nomogram, which was both internally and externally validated.

RESULTS:

There were 4,739 patients included in this analysis, of whom, 84% had stage III and 16% had stage IV ovarian carcinoma. At a median follow-up of 88.8 months (95% CI 86.2–92.0 months), the vast majority of patients (89.4%) had died. The median survival after recurrence was 21.4 months (95% CI 20.5–21.9 months). Time to recurrence after initial chemotherapy, clear cell or mucinous histology, performance status, stage IV disease, and age were significant variables used to develop a nomogram for survival after recurrence, which had a concordance index of 0.67. The time to recurrence alone accounted for 85% of the prognostic information. Similar results were found for patients who underwent second look laparotomy and had a complete pathologic response or received intraperitoneal chemotherapy.

CONCLUSION:

For individuals with advanced-stage ovarian carcinoma who recur after standard first-line therapy, estimated survivals after recurrence are closely related to the time to recurrence after chemotherapy and prognostic variables can be used to predict subsequent survival.

CLINICAL TRIAL REGISTRATION:

ClinialTrials.gov, NCT00002568, NCT00837993, NCT00002717, NCT01074398, and NCT00011986.
Seven-Year Outcomes After Hysteroscopic and Laparoscopic Sterilizations
Authors: Mao Jialin , Guiahi Maryam , Chudnoff Scott , Schlegel Peter , Pfeifer Samantha , Sedrakyan Art
Published: January 2019

OBJECTIVE:

To evaluate 7-year outcomes after hysteroscopic and laparoscopic sterilizations, including subsequent tubal interventions and hysterectomies.

METHODS:

This observational cohort study included women undergoing hysteroscopic and laparoscopic sterilizations in outpatient and ambulatory surgical settings in New York State during 2005–2016. We examined subsequent procedures (tubal ligation or resection, and hysterectomy not related to uterine leiomyomas or gynecologic tumors) after the index procedures. After propensity score matching, we used Kaplan-Meier analysis to obtain estimated risks of subsequent procedures within 7 years of index sterilization procedures, and Cox proportional hazard models to compare the differences between groups.

RESULTS:

We identified 10,143 and 53,206 women who underwent interval hysteroscopic and laparoscopic sterilizations, respectively, in New York State during 2005–2016. The mean age of the cohort was 34.2 years (range 18–80). The propensity score–matched cohort consisted of 10,109 pairs of women. The estimated risk of undergoing an additional tubal ligation or resection within 7 years was higher after hysteroscopic sterilization than it was after laparoscopic sterilization (3.9% vs 1.6%, HR 2.89, 95% CI 2.33–3.57). The difference was most pronounced within the initial year after attempted sterilization (1.5% vs 0.2%; HR 6.39, 95% CI 4.16–9.80). There was no significant difference in the risk of receiving a hysterectomy (0.9% vs 1.2%; HR 0.73, 95% CI 0.53–1.00) between women who underwent hysteroscopic and laparoscopic sterilizations.

CONCLUSION:

Patients undergoing hysteroscopic sterilization have a higher risk of receiving an additional tubal resection or ligation than those undergoing laparoscopic sterilization, particularly within the first year of the index procedure. There is no difference in undergoing a subsequent hysterectomy between the two groups. With limited evidence of outcomes after hysteroscopic sterilization beyond 7 years and existing reports of removals years after initial implantations, continuous monitoring of long-term outcomes for women who received the device is warranted.
Use of Direct-Connect for Remote Speech-Perception Testing in Cochlear Implants
Authors: Sevier Joshua D. , Choi Sangsook , Hughes Michelle L.
Published: January 2019

Objectives:

Previous research has demonstrated the feasibility of programming cochlear implants (CIs) via telepractice. To effectively use telepractice in a comprehensive manner, all components of a clinical CI visit should be validated using remote technology. Speech-perception testing is important for monitoring outcomes with a CI, but it has yet to be validated for remote service delivery. The objective of this study, therefore, was to evaluate the feasibility of using direct audio input (DAI) as an alternative to traditional sound-booth speech-perception testing for serving people with CIs via telepractice. Specifically, our goal was to determine whether there was a significant difference in speech-perception scores between the remote DAI (telepractice) and the traditional (in-person) sound-booth conditions.

Design:

This study used a prospective, split-half-design to test speech perception in the remote DAI and in-person sound-booth conditions. Thirty-two adults and older children with CIs participated; all had a minimum of 6 months of experience with their device. Speech-perception tests included the consonant–nucleus–consonant (CNC) words, Hearing-in-Noise test (HINT) sentences, and Arizona Biomedical Institute at Arizona State University (AzBio) sentences. All three tests were administered at levels of 50 and 60 dBA in quiet. Sentence stimuli were also presented in 4-talker babble at signal to noise ratios (SNRs) of +10 and +5 dB for both the 50- and 60-dBA presentation levels. A repeated-measures analysis of variance was used to assess the effects of location (remote, in person), stimulus level (50, 60 dBA), and SNR (if applicable; quiet, +10, +5 dB) on each outcome measure (CNC, HINT, AzBio).

Results:

The results showed no significant effect of location for any of the tests administered (p > 0.1). There was no significant effect of presentation level for CNC words or phonemes (p > 0.2). There was, however, a significant effect of level (p < 0.001) for both HINT and AzBio sentences, but the direction of the effect was opposite of what was expected—scores were poorer for 60 dBA than for 50 dBA. For both sentence tests, there was a significant effect of SNR, with poorer performance for worsening SNRs, as expected.

Conclusions:

The present study demonstrated that speech-perception testing via telepractice is feasible using DAI. There was no significant difference in scores between the remote and in-person conditions, which suggests that DAI testing can be used as a valid alternative to standard sound-booth testing. The primary limitation is that the calibration tools are presently not commercially available.
Orthopaedic Trauma Quality Measures for Value-Based Health Care Delivery: A Systematic Review
Authors: DeBaun Malcolm R. , Chen Michael J. , Bishop Julius A. , Gardner Michael J. , Kamal Robin N.
Published: January 2019

Objectives:

To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery.

Data Sources:

We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries.

Data Extraction:

Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian.

Data Synthesis:

From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified.

Conclusions:

As quality measures progressively inform reimbursement in value-based health care models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.
Salter–Harris II Ankle Fractures in Children: Does Fracture Pattern Matter?
Authors: Binkley Allison , Mehlman Charles T. , Freeh Ellen
Published: January 2019

Objectives:

To determine the correlation of Salter–Harris II fracture patterns with premature physeal closure (PPC) and resultant angular deformity of the ankle.

Design:

Retrospective review.

Setting:

Cincinnati Children's Hospital Medical Center (outpatient level of care).

Patients/Participants:

We searched the digital ankle radiographs taken at our institution from 2001 to 2010, identifying all skeletally immature patients with confirmed ankle fractures.

Intervention:

Fracture patterns were subclassified according to the Dias–Tachdjian classification system. Only patients with a minimum of 6 months of follow-up were included.

Main Outcome Measures:

Rates of PPC, initial operative interventions, subsequent surgical interventions, and final angular deformities of the ankle in the coronal plane were recorded and considered significant if more than 10 degrees.

Results:

One hundred forty-one patients met our criteria. Fifty-two pronation-external rotation (PER) injuries, 35 supination-external rotation (SER) injuries, and 54 supination-plantar flexion (SPF) injuries were included. Of the PER injuries, 15 (28.8%) PPCs occurred with 6 patients having a resultant angular deformity of the ankle of at least 10 degrees at latest follow-up. Thirteen (24.1%) of the SPF patients went on to PPC with no resultant angular deformities. Of the SER injuries, 4 (11.4%) went on to PPC also with no patients having resultant angular deformities. The PER group had a statistically significantly higher rate of resultant angular deformity (P = 0.021).

Conclusions:

Salter–Harris II fractures of the ankle are common in children, with fracture pattern directly related to PPC and the chance for angular deformity. PER injuries are more likely to have a PPC associated with an angular deformity compared with SER and supination-plantar flexion injuries. The odds ratio of having an angular deformity with PER injuries compared with SER and SPF injuries is 25.

Significance:

Fracture pattern of the ankle is related to growth disturbance, which must be taken into consideration when treating these injuries and addressed with the patient and family.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Biomechanical Evaluation of Interfragmentary Compression of Lag Screw Versus Positional Screw at Different Angles of Fixation
Authors: Kuzma Alexander L. , Luo Tianyi David , De Gregorio Michael , Coon Grayson D. , Danelson Kerry , Halvorson Jason J. , Carroll Eben A. , Aneja Arun
Published: January 2019

Objectives:

To compare the compressive force achieved and retained with the lag versus positional screw technique at various angles of screw application.

Methods:

Sixty humeral sawbones were stratified into 6 groups based on the technique (lag or positional) and fixation angle (30, 60, or 90 degrees relative to the fracture plane). A sensor was placed between fragments to record compressive force. Absolute screw force is the final screw force. Normalized force is the final screw force minus force generated by reduction forceps. Retained force is the quotient of absolute force relative to reduction forceps force.

Results:

Lag screws attained higher force than positional at 60 degrees (absolute force 41% higher, P = 0.041; normalized force 1300% higher, P = 0.008; retained force 60% higher, P = 0.008) and 90 degrees (absolute force 86% higher, P = 0.006; normalized force 730% higher, P = 0.005; retained force 70% higher, P = 0.011), but not at 30 degrees. For lag screws, compressive force was similar at 60 and 90 degrees (absolute force P = 0.174, normalized force P = 0.364, and retained force P = 0.496), but not 30 degrees. For positional screws, no difference was found between the 3 angles of fixation for absolute force (P = 0.059). Normalized force and retained force were similar at 60 and 90 degrees (P = 0.944 and P = 0.725, respectively), but not 30 degrees.

Conclusions:

Lag screw technique compressive force was superior to positional screw technique at 60 and 90 degrees. Comparison of force at angles of 60 and 90 degrees showed no significant difference for both techniques. Indicating 30 degrees deviation from perfect technique is tolerated without significant decrease in compressive force.
Correlation of Fracture Energy With Sanders Classification and Post-traumatic Osteoarthritis After Displaced Intra-articular Calcaneus Fractures
Authors: Rao Karan , Dibbern Kevin , Day Molly , Glass Natalie , Marsh J. Lawrence , Anderson Donald D.
Published: January 2019

Objectives:

To quantify fracture severity for a series of displaced intra-articular calcaneal fractures (DIACFs) and to correlate it with Sanders classification, post-traumatic osteoarthritis (PTOA), and patient outcomes.

Design:

Retrospective review and fracture severity analysis.

Setting:

Level 1 trauma center affiliated with the University of Iowa in Iowa City, IA.

Patients/Participants:

Thirty-six patients with 48 DIACFs were selected from 153 patients previously treated. All patients 18 years of age and older who had available electronic preop and postop computed tomography (CT) scans, good-quality postop and follow-up radiographs, and a follow-up ≥18 months were selected for study.

Intervention:

Fractures were treated with percutaneous reduction, using multiple small stab incisions and fluoroscopy to guide manipulation of articular fragments using cork screws or Steinmann pins, with subsequent fixation using 3.5- and 4.0-mm screws.

Main Outcome Measurements:

Preop CT scans were used to grade fractures according to the Sanders classification and to quantify fracture severity. Fracture severity was objectively quantified using a CT-based measure of fracture energy. PTOA was assessed on follow-up radiographs using the Kellgren–Lawrence scale. Patient outcomes were assessed using the Short Form 36 (SF-36) questionnaire and a visual analog scale pain score.

Results:

Fracture energies for the 48 DIACFs ranged from 14.1 to 26.2 J (19.3 ± 3.1 J) and correlated with Sanders classification (rho = 0.53, P = 0.0001); type I (16.3 ± 0.9 J); type II (18.0 ± 2.7 J); type III (20.8 ± 2.8 J); and type IV (22.0 ± 0.7 J). Fracture energy was higher for fractures in which the subtalar joint developed PTOA (19.5 ± 2.7 J) than for those that did not (18.9 ± 3.3 J), but the difference did not reach statistical significance. The Sanders classification predicted PTOA risk [odds ratio (OR) = 4.04, 95% confidence interval = 1.43–11.39, P = 0.0084]. No relationship was observed between fracture energy and visual analog scale pain scores. Higher fracture energy correlated with lower SF-36 scores.

Conclusions:

Fracture energy positively correlates with Sanders classification for DIACFs, which can be used to identify more severe fractures at greater risk of progressing to PTOA.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Effect of Mental Health Conditions on Complications, Revision Rates, and Readmission Rates Following Femoral Shaft, Tibial Shaft, and Pilon Fracture
Authors: Foster Brock D. , Kang Hyunwoo Paco , Buser Zorica , Carney John , Wang Jeffrey C. , Marecek Geoffrey S.
Published: January 2019

Objectives:

To evaluate the effect of pre-existing mental health (MH) conditions on 90-day complication, 90-day readmission, and all-time revision surgical intervention rates following femoral, tibial, and pilon fractures.

Design:

Data were collected using a commercially available database software for which Current Procedural Terminology codes were used to identify patients who underwent surgical treatment of tibial, femoral, or pilon fractures. These patients were then subdivided into those with and without pre-existing MH condition using International Classification of Disease, Ninth Edition codes. Ninety-day postoperative complications, revision surgery, and 90-day readmission rates were then compared between those with and without MH conditions.

Setting:

National databases of 70 million combined patients from 2007 to 2015.

Patients/Participants:

Humana and Medicare insured patients.

Intervention:

Surgical treatment of tibial, femoral, and pilon fractures.

Main Outcome Measurements:

Ninety-day readmission, 90-day complications, and all-time revision surgical intervention.

Results:

The total number of patients for femoral, tibial, and pilon treatment, respectively, included 6207, 6253, and 5940 without MH conditions and 4879, 5247, and 2911 with MH conditions. Femoral, tibial, and pilon readmission rates, revision rates, and complication rates were significantly higher among patients with MH disorders in matched cohorts after controlling for medical comorbidities (P ≤ 0.05 for all).

Conclusions:

Comorbid MH conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated femoral, tibial, and pilon fractures.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Fewer Hospitals Provide Operative Fracture Care to Medicaid Patients Than Otherwise-Insured Patients in 4 Large States
Authors: Brodke Dane J. , Morshed Saam
Published: January 2019

Objective:

To determine whether Medicaid patients receive operative fracture care at an equal number of hospitals as otherwise-insured patients and to compare travel distances between Medicaid and otherwise-insured patients.

Design:

Retrospective, population-based cohort study of administrative health data.

Setting:

One thousand seventy-five hospitals in California, Florida, New York, and Texas.

Participants:

Two hundred forty thousand three hundred seventy-six patients who underwent open reduction and internal fixation of a fracture of the radius/ulna, tibia/fibula, or humerus between 2006 and 2010 in Texas or New York, or between 2010 and 2014 in California or Florida.

Intervention:

Open reduction and internal fixation of the radius/ulna, tibia/fibula, or humerus.

Main Outcome Measurements:

The number of unique hospitals visited and the distance traveled for care were compared by payer status and admission acuity. The distance traveled was also stratified by urban versus rural geographic area.

Results:

In nonemergent settings, 7%–16% fewer hospitals saw Medicaid patients than otherwise-insured patients. In emergent settings, the gap between the number of hospitals seeing Medicaid and otherwise-insured patients was less than 5% in every state except Texas, where the gap was 11%–14%. The Medicaid and Medicare groups had longer travel distances in the nonemergent setting than in the emergent setting. Medicaid patients did not travel longer distances than otherwise-insured patients except in Texas, where they traveled 3–5 miles further than otherwise-insured patients in the nonemergent, urban setting.

Conclusions:

Fewer hospitals provide operative fracture care to Medicaid patients than otherwise-insured patients, but Medicaid patients do not travel longer distances to the hospital on a population level.

Level of Evidence:

Prognostic Level III.
Radiographic Outcome and Complication Rate of 34 Graduates After Treatment With Vertical Expandable Prosthetic Titanium Rib (VEPTR): A Single Center Report
Authors: Studer Daniel , Büchler Philippe , Hasler Carol C.
Published: January 2019

Background:

The final strategy for graduates from growth-sparing surgery is challenging. The purpose of this study was to evaluate the radiographic outcome and complications of patients with early onset scoliosis (EOS) who have graduated from vertical expandable prosthetic titanium rib (VEPTR) treatment, either undergoing final fusion surgery or following a nonfusion approach.

Methods:

Final treatment for VEPTR graduates was divided in “VEPTR in situ without final fusion,” “removal of VEPTR without final fusion,” and “removal of VEPTR with instrumented final fusion.” Radiographic evaluations included main coronal Cobb angle and main kyphosis pre and post VEPTR implantation, at the end of implant lengthening, after final fusion (if applicable), and at latest follow-up. Complications during VEPTR treatment and in case of final fusion were reported.

Results:

In total, 34 VEPTR graduates were included; 17 underwent final fusion surgery, and 17 followed a nonfusion strategy. Average coronal Cobb angle before VEPTR implantation was 70±23 degrees (range, 21 to 121 degrees), and 65±22 degrees (range, 17 to 119 degrees) at latest follow-up. Average main kyphosis angle was 53±27 degrees (range, 6 to 137 degrees) before VEPTR, and 69±34 degrees (range, 10 to 150 degrees) at latest follow-up. There was a 41% complication rate with final fusion surgery.

Conclusions:

There is a high complication rate during VEPTR treatment and with final fusion surgery. The stiffness of the spine and thorax allow for only limited correction when performing a final instrumented spondylodesis. Avoiding final fusion may be a viable alternative in case of good coronal and sagittal alignment.

Level of Evidence:

Level IV—therapeutic.
An In Vitro Study of the Intervertebral Disc Structure Using 3 T Magnetic Resonance Imaging
Authors: Wijayathunga Vithanage N. , Tanner Steven F. , Ridgway John P. , Wilcox Ruth K.
Published: January 2019

Study Design.

An in vitro magnetic resonance imaging (MRI) study.

Objective.

Investigate the potential of high-field MRI for producing higher quality images of the intervertebral disc (IVD) to better distinguish structural details.

Summary of Background Data.

Higher spatial and contrast resolution are important advantages when imaging the complex tissue structures in the spine such as the IVDs. However, at present it is challenging to capture the substructural details in the IVD such as the lamellae.

Methods.

Three MRI sequences; two-dimensional proton-density-weighted Turbo-Spin-Echo (PD-TSE), 2D T2-weighted Turbo-Spin-Echo (T2W-TSE) with fat-saturation (FS), and 3D Spoiled-Gradient-Echo (3D-GE), were modified based on the image quality and scan duration. IVDs of three intact cadaveric lumbar-spines (T12–S1, Age 83–94 yr) were imaged using these optimized sequences. Thereafter each IVD was transversely sectioned and the exposed surfaces were photographed. Landmark observations from corresponding MRI slices and photographs were compared to confirm the MRI captured morphology. The image quality was evaluated using signal-to-noise ratio (SNR), and relative-contrast values. Finally, the underlying tissue structures, including specific pathological features, were qualitatively compared between the MR images and photographs.

Results.

Observations from photographs and corresponding MRI slices matched well. The PD-TSE sequence had better overall SNR, but the relative contrast between the tissue types was relatively poor. The 3D-GE sequence had higher relative contrast between the IVD and bone, but not between annulus and nucleus regions. The T2W images provided the best relative contrast between the annulus and nucleus, however the standard deviations here were high. Structural details including fissures, vascular and granular tissue proliferation, and pathologies in the endplate region, were identifiable from the MR images obtained using the optimized sequences.

Conclusion.

The results demonstrate the potential of high-field MRI to capture the IVD structural details. Since the acquisition durations were within clinically acceptable levels, these methodological improvements have the potential to enhance clinical diagnostics.

Level of Evidence: 4
Factors Associated With Return-to-Work Following Cervical Spine Surgery in Non-Worker's Compensation Setting
Authors: Kim Elliott J. , Chotai Silky , Wick Joseph B. , Khan Inamullah , Sivaganesan Ahilan , Bydon Mohamad , Archer Kristin R. , Devin Clinton J.
Published: January 2019

Study Design.

This study retrospectively analyzes prospectively collected data.

Objective.

Here in this study we aim to determine the factors which impact a patient's ability to return to work (RTW) in the setting of cervical spine surgery in patients without worker's compensation status.

Summary of Background Data.

Surgical management of degenerative cervical disease has proven cost-effectiveness and shown significant improvement in quality of life. However, the ability to RTW is an important clinical outcome for preoperatively employed patients.

Methods.

All adult patients undergoing elective surgery for cervical degenerative disease at our institution are enrolled in a prospective, web-based registry. A multivariable Cox proportional hazards regression model was built for time to RTW. The variables included in the model were age, sex, smoking status, occupation type, number of levels operated on, ASA grade, body mass index, history of diabetes, history of coronary artery disease (CAD), history of chronic obstructive pulmonary disease (COPD), anxiety, depression, myelopathy at presentation, duration of symptoms more than 12 months, diagnosis, type of surgery performed, and preoperative Neck Disability Index, EuroQol Five Dimensions, and Numeric Rating Scale pain scores for neck pain and arm pain scores.

Results.

Of the total 324 patients with complete 3-month follow-up data 83% (n = 269) returned to work following surgery. The median time to RTW was 35 days (range, 2–90 d). Patients with a labor-intensive occupation, higher ASA grade, history of CAD, and history of COPD were less likely to RTW. The likelihood of RTW was lower in patients with a diagnosis of disc herniation compared with cervical stenosis, patients undergoing cervical corpectomy compared laminectomy and fusion and patient with longer operative time.

Conclusion.

Our study identifies the various factors associated with a lower likelihood of RTW at 3 months after cervical spine surgery in the non-worker's compensation setting. This information provides expectations for the patient and employer when undergoing cervical spine surgery.

Level of Evidence: 3
PROMIS Pain Interference Is Superior to the Likert Pain Scale for Pain Assessment in Spine Patients
Authors: Bernstein David N. , St. John Matthew , Rubery Paul T. , Mesfin Addisu
Published: January 2019

Study Design.

Cross-sectional cohort analysis.

Objective.

(1) To assess the correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) in patients seeking spine care; (2) to assess the correlation between PROMIS PF and the Likert Pain Scale (LPS) in patients seeking spine care; (3) to determine which pain scale best correlates to physical function overall and by number of clinic visits.

Summary of Background Data.

An accurate understanding of a patient's pain level is beneficial in setting clinical and pain management expectations. There is limited work analyzing which instrument best captures pain and its impact on function in patients seeking spine care.

Methods.

Spine center patients from February 2015 to November 2017 were asked to complete PROMIS PF and PI domains, as well as to report their pain level on a 0 (no pain) to 10 (worst pain) LPS at each visit. Pearson correlation coefficients were calculated between PROMIS PF and PROMIS PI; PROMIS PI and LPS; and PROMIS PF and LPS. Fisher r–z transformation method was utilized for confidence intervals (CIs) and to determine significant correlation differences. Analyses were performed for all data, as well as by office visit. Significance was set at P < 0.01.

Results.

A total of 21,774 first visit, 11,130 second visit, 6575 third visit, 4202 fourth visit, and 2819 fifth visit patients’ data were recorded. PROMIS PF demonstrated a moderate correlation with the LPS over all visits (r = 0.46–0.49, P < 0.01). PROMIS PF demonstrated a strong correlation with PROMIS PI over all visits (r = 0.73–0.77, P < 0.01). Overall, PROMIS PI demonstrated significantly better correlation to self-reported physical function than the LPS (P < 0.01).

Conclusion.

While PROMIS PI and the LPS both demonstrated significant correlation with self-reported physical function, PROMIS PI had a significantly stronger correlation.

Level of Evidence: 2
Effects of Athermal Shortwave Diathermy Treatment on Somatosensory Evoked Potentials and Motor Evoked Potentials in Rats With Spinal Cord Injury
Authors: Xie Caizhong , Li Xiangzhe , Fang Lu , Wang Tong
Published: January 2019

Study Design.

A study on shortwave diathermy (SWD) versus no treatment following induced spinal cord injury (SCI) in rats.

Objective.

To investigate the effects of athermal SWD treatment on somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) and hindlimb movements in rats with SCI.

Summary of Background Data.

SWD has been proven to improve vascular circulation and reduce inflammation. However, there have been few studies on neuroprotective effect of SWD on SCI.

Methods.

Twenty-four female Sprague–Dawley (SD) rats were randomly divided into four groups: sham, SCI, SWD, and intact groups. The SCI model was established using the modified Allen weight-drop method. The SWD group received 15 sessions of athermal SWD treatment over a 3-week period of time at 24 hours after SCI. While the sham group and SCI group received no treatment after surgery. Hindlimb movements were evaluated by the Basso, Beattie, and Bresnahan (BBB) scale before surgery, and on days 1, 7, 14, and 21 after the surgery, respectively. The SEP and MEP measurements were simultaneously performed to detect the responses of neural conduction.

Results.

The week-by-week BBB scores showed a gradual improvement in the rats of both SCI and SWD groups from the first week to the end of the study; however, the BBB scores of the SWD group were higher than those of the SCI group over the course of 3 weeks. Data from the SEP and MEP measurements showed a significant improvement in the SWD group compared with the SCI group at each time point of observation, with a more prominent increase of amplitude and a more evident reduction of latency. There was a linear correlation between the BBB scores and the latency and amplitude of SEPs or MEPs.

Conclusion.

Athermal SWD treatment might facilitate the recovery of locomotor function and exert neuroprotective effect on the SCI.

Level of Evidence: N/A