bluuebunny/crossref_metadata_2025 huggingface dataset:
Change in ankle–brachial index and mortality among individuals with chronic kidney disease: findings from the Chronic Renal Insufficiency Cohort Study
Authors: Dorans Kirsten S , He Hua , Chen Jing , Dobre Mirela , Go Alan S , Hamm L Lee , Jaar Bernard G , Mehta Rupal C , Rahman Mahboob , Ricardo Ana C , Rosas Sylvia E , Srivastava Anand , He Jiang ,   the CRIC Study Investigators
Published: September 2020

Background

Patients with chronic kidney disease (CKD) have an increased risk of peripheral arterial disease (PAD). The ankle–brachial index (ABI), a noninvasive measure of PAD, is a predictor of adverse events among individuals with CKD. In general populations, changes in ABI have been associated with mortality, but this association is not well understood among patients with CKD.

Methods

We conducted a prospective study of 2920 participants in the Chronic Renal Insufficiency Cohort Study without lower extremity revascularization or amputation at baseline and with at least one follow-up ABI measurement (taken at annual visits) during the first 4 years of follow-up. The ABI was obtained by the standard protocol.

Results

In Cox proportional hazard regression analyses, we found a U-shaped association of average annual change in ABI with all-cause mortality. After adjusting for baseline ABI and other covariates, compared with participants with an average annual change in ABI of 0–<0.02, individuals with an average annual change in ABI <−0.04 or ≥0.04 had multivariable-adjusted hazard ratios (HRs) of 1.81 [95% confidence interval (CI) 1.34–2.44) and 1.42 (95% CI 1.12–1.82) for all-cause mortality, respectively. Compared with the cumulative average ABI of 1.0–<1.4, multivariable-adjusted HRs for those with a cumulative average ABI of <0.9, 0.9–<1.0 and ≥1.4 were 1.93 (95% CI 1.42–2.61), 1.20 (0.90–1.62) and 1.31 (0.94–1.82), respectively.

Conclusions

This study indicates both larger decreases and increases in average annual changes in ABI (>0.04/year) were associated with higher mortality risk. Monitoring changes in ABI over time may facilitate risk stratification for mortality among individuals with CKD.
Intracranial Myxoid Mesenchymal Tumor/Myxoid Subtype Angiomatous Fibrous Histiocytoma: Diagnostic and Prognostic Challenges
Authors: Domingo Ricardo A , Vivas-Buitrago Tito , Jentoft Mark , Quinones-Hinojosa Alfredo
Published: September 2020

BACKGROUND AND IMPORTANCE

In the setting of intracranial neoplasms, EWSR1-cAMP Response Element-Binding Protein (CREB) transcription factor family fusions have been described in myxoid mesenchymal tumors, extremely rare entities with a close histopathologic and immunologic resemblance to myxoid subtype angiomatoid fibrous histiocytomas (AFH). Controversy exists on whether these central nervous system lesions are a subtype of myxoid AFH or a completely separate entity, which entitles a distinct clinical behavior and, consequently, a different approach to management. Upon review of the literature, only 14 cases of intracranial tumors harboring an EWSR1-CREB family fusion were identified, with only 3 cases presenting in middle-aged adults, none of which reported an EWSR1-CREM fusion mutation. Significant variability in reported radiographic and histopathological characteristics, as well as in clinical outcomes, was noted. Their similarity with other soft tissue tumors, added to the scarce information on its clinical behavior, represents a great diagnostic and therapeutic challenge to the treating physician.

CLINICAL PRESENTATION

We present a rare case of EWSR1-CREM mutated intracranial myxoid mesenchymal tumor/myxoid subtype AFH presenting as persistent headaches in a 36-yr-old woman with radiographic evidence of rapid growth and extensive vasogenic edema, for which she underwent surgical resection.

CONCLUSION

This represents a unique case of EWSR1-CREM mutated intracranial myxoid mesenchymal tumor presenting in adulthood, with evidence of aggressive behavior.
Masterpiece Cakeshop and the Foundations of Free Speech and Toleration
Authors: Tedesco Jeremy D
Published: September 2020

What do Masterpiece Cakeshop, Ltd v Colorado Civil Rights Commission, other leading cases from the USA, Canada, and the UK, and Teresa Bejan’s concept of ‘mere civility’, teach us about free speech and toleration? This article seeks to answer that question and suggest a path forward that allows people with deep disagreements about fundamental social and moral issues to live peaceably together despite their differences. This article defends two primary claims: First, ‘mere civility’ is complimentary to a broader legal argument for protecting the freedom of all members of a society to espouse and live out their views within the context of the public square and marketplace; and Second, compelling speech (or agreement) under the guise of civility endangers liberty and genuine equality. When freedom is properly protected, ‘mere civility’ is the natural result, while attempts to achieve something more than ‘mere civility’ invariably jeopardize freedom.
Preoperative Acute Pain Is Associated with Postoperative Delirium
Authors: Ding Xian , Gao Xiang , Chen Qizhong , Jiang Xuliang , Li Yi , Xu Jingjing , Qin Guowei , Lu Shunmei , Huang Dongxiao
Published: September 2020

Background

Studies have provided some evidence that pain is a risk factor for postoperative delirium (POD). Therefore, we investigated the relationship between preoperative pain and POD after noncardiac surgery.

Methods

POD was assessed with the Montreal Cognitive Assessment, and preoperative cognition was assessed with the Mini-Mental State Examination. Plasma C-reactive protein (CRP) was detected by enzyme-linked immunosorbent assay before surgery. Preoperative pain was classified by its duration before surgery as chronic pain (lasting more than 1 month), acute pain (lasting less than 1 month), or no pain (no obvious pain). Multiple linear regression was used to adjust for confounding.

Results

From October 15, 2018, through August 12, 2019, a total of 67 patients were randomized; 7 were excluded because they were discharged before the seventh postoperative day. The prevalence of POD was significantly higher in the acute pain group (13 of 20; 65%) than in the chronic pain group (5 of 20; 25%) or the no pain group (6 of 20; 30%) (P = 0.019), indicating that delirium is associated with preoperative acute pain. The plasma level of preoperative CRP was also higher in the acute pain group than in the other two groups (mean [interquartile range]: 10.7 [3.3, 29.3] vs 1 [0.5, 3.8]mg/l; P < 0.001), suggesting that elevated preoperative plasma levels of CRP were associated with delirium.

Conclusions

Preoperative acute pain was associated with POD, and increased plasma levels of CRP provide a marker. In addition, we found that illiteracy and advanced age were risk factors for POD.
The Effectiveness of Hospital in Motion, a Multidimensional Implementation Project to Improve Patients’ Movement Behavior During Hospitalization
Authors: van Delft Lotte M M , Bor Petra , Valkenet Karin , Slooter Arjen J C , Veenhof Cindy
Published: September 2020

Objective

Hospital in Motion is a multidimensional implementation project aiming to improve movement behavior during hospitalization. The purpose of this study was to investigate the effectiveness of Hospital in Motion on movement behavior.

Methods

This prospective study used a pre-implementation and post-implementation design. Hospital in Motion was conducted at 4 wards of an academic hospital in the Netherlands. In each ward, multidisciplinary teams followed a 10-month step-by-step approach, including the development and implementation of a ward-specific action plan with multiple interventions to improve movement behavior. Inpatient movement behavior was assessed before the start of the project and 1 year later using a behavioral mapping method in which patients were observed between 9:00 am and 4:00 pm. The primary outcome was the percentage of time spent lying down. In addition, sitting and moving, immobility-related complications, length of stay, discharge destination home, discharge destination rehabilitation setting, mortality, and 30-day readmissions were investigated. Differences between pre-implementation and post-implementation conditions were analyzed using the chi-square test for dichotomized variables, the Mann Whitney test for non-normal distributed data, or independent samples t test for normally distributed data.

Results

Patient observations demonstrated that the primary outcome, the time spent lying down, changed from 60.1% to 52.2%. For secondary outcomes, the time spent sitting increased from 31.6% to 38.3%, and discharges to a rehabilitation setting reduced from 6 (4.4%) to 1 (0.7%). No statistical differences were found in the other secondary outcome measures.

Conclusion

The implementation of the multidimensional project Hospital in Motion was associated with patients who were hospitalized spending less time lying in bed and with a reduced number of discharges to a rehabilitation setting.

Impact

Inpatient movement behavior can be influenced by multidimensional interventions. Programs implementing interventions that specifically focus on improving time spent moving, in addition to decreasing time spent lying, are recommended.
Construct validity of the ASAS health index in psoriatic arthritis: a cross-sectional analysis
Authors: Morante Isla , Aurrecoechea Elena , Villa Ignacio , Santos Montserrat , Riancho Leyre , Queiro Rubén
Published: September 2020

Objectives

The Assessment of SpondyloArthritis international Society health index (ASAS-HI) was designed to assess the global health of patients with spondyloarthritis, but its performance in psoriatic arthritis (PsA) is hardly known. We addressed the clinimetric properties of this instrument in patients with PsA.

Methods

This was a cross-sectional observational study that included 90 consecutive patients with PsA. The measurement properties of ASAS-HI were analysed against the Disease Activity index for PSoriatic Arthritis (DAPSA) and the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire. A multivariate analysis was performed to weigh the ASAS-HI items associated with DAPSA active disease and PsAID high impact.

Results

Mean ASAS-HI was 5.8 (4.3). Convergent validity was high both against DAPSA (ρ 0.78, P < 0.0001) and PsAID (ρ 0.80, P < 0.0001). ASAS-HI showed a high discriminant capacity for both DAPSA remission [optimal criterion ≤ 2, area under the receiver operating characteristic curve (AUC) 0.92 (95% CI: 0.85, 0.97), P < 0.0001], and low activity [optimal criterion ≤6, AUC 0.87 (95% CI: 0.79, 0.94), P < 0.0001]. The ASAS-HI items significantly associated with DAPSA active disease were: ‘I find it hard to stand for long’ (β 4.48, P < 0.0001), ‘I find it hard to concentrate’ (β 2.94, P = 0.042) and ‘I sleep badly at night’ (β 1.86, P = 0.044). As for PsAID, the only item significantly associated with a high impact was ‘I sleep badly at night’ (β −3.29, P = 0.015).

Conclusion

We demonstrated construct validity of ASAS-HI, a spondyloarthritis instrument, for the assessment of global health in patients with PsA.
Genetic Polymorphisms in Multispecific Transporters Mitigate Mercury Nephrotoxicity in an Artisanal and Small-Scale Gold Mining Community in Colombia
Authors: Sánchez Rodríguez Luz Helena , Medina Pérez Olga Marcela , Rondón González Fernando , Rincón Cruz Giovanna , Rocha Muñoz Linda , Flórez-Vargas Oscar
Published: September 2020

In artisanal and small-scale gold mining, occupational exposure to mercury (Hg) vapor is related to harmful effects on several organs, including the kidneys. We previously reported significantly increased levels of Hg in blood and urine despite normal kidney function in individuals from Colombia occupationally exposed to Hg compared with those nonexposed. We evaluated the contribution of 4 genetic variants in key genes encoding the transporters solute carrier (SLC; rs4149170 and rs4149182) and ATP-binding cassette(ABC; rs1202169 and rs1885301) in the pathogenesis of nephrotoxicity due to Hg exposure in these groups. Regression analysis was performed to determine the association between the blood- and urine-Hg concentration with SLC and ABC polymorphisms in 281 Colombian individuals (160 exposed and 121 nonexposed to Hg). We found an enrichment of ABCB1 rs1202169-T allele in the exposed group (p = .011; OR= 2.05; 95% CI = 1.18–3.58) compared with the nonexposure group. We also found that carriers of SLC22A8 rs4149182-G and ABCB1 rs1202169-T alleles had a higher urinary clearance rate of Hg than noncarriers (β = 0.13, p = .04), whereas carriers of SLC22A6 rs4149170-A and ABCB1 rs1202169-C alleles showed abnormal levels of estimated glomerular filtration rate (β = −84.96, p = .040) and beta-2-microglobulin (β = 743.38, p < .001). Our results suggest that ABCB1 rs1202169 and its interaction with SLC22A8 rs4149182 and SLC22A6 rs4149170 could mitigate Hg nephrotoxicity by controlling the renal proximal tubule cell accumulation of inorganic Hg. This will be useful to estimate the risk of kidney toxicity associated to Hg and the genetic selection to aid adaptation to Hg-rich environments.
Hypernatremic Dehydration in Breast Fed Infants: Lessons from a Baby-Friendly Hospital
Authors: Butler B , Trotman H
Published: September 2020

Aim

To determine the incidence, presentation and outcome of all neonates admitted to the University Hospital of the West Indies with a diagnosis of breastfeeding associated hypernatremic dehydration during a 15-year period and make comparisons with an earlier study done at the institution.

Methods

A retrospective review of the files of neonates admitted to the neonatal unit with breastfeeding associated hypernatremic dehydration between January 2002 and December 2016 was conducted. Data on maternal and neonatal demographics, presentation, laboratory results and outcome were extracted and descriptive analyses performed. Statistical significance was taken at the level p < 0.05.

Results

Eighty neonates were entered into the study, 79 were inborn giving an incidence of 2.5 per 1000 live births. Fifty-five (71%) mothers were primiparous, with a mean ± SD age of 29.5 ± 5.6 years and mean ± SD length of hospital stay 2.6 ± 1.5 days. Fifty-six (71%) neonates were exclusively breastfed with a mean ± SD age at presentation of 5.6 ± 3.8 days, mean ± SD percentage weight loss of 16.3% ± 6.1% and a mean serum ± SD sodium of 156.1 ± 8.3 mmol/l. Fifty-four (68%) neonates were admitted from home and 22 (28%) from the postnatal ward. Complications seen included acute kidney injury 6 (8%), seizures 2 (3%), hypotonia 1 (1%) and bradycardia 1 (1%). The neonates were detected earlier, presented with a significantly lower mean serum sodium, urea and creatinine (p < 0.05), had less severe complications and no deaths compared with neonates in the previous study.

Conclusion

Early intervention can make a positive impact on the severity and complications of breastfeeding associated hypernatremia.
Diplura in caves: diversity, ecology, evolution and biogeography
Authors: Sendra Alberto , Palero Ferran , Jiménez-Valverde Alberto , Reboleira Ana Sofia P S
Published: September 2020

Diplurans (Hexapoda) are considered the ‘ideal cavernicolous animal’ having one of the highest ratios of cave-adapted vs. non-cave-adapted species. They are successful colonizers of subterranean habitats, thriving in all cryptic, dark, terrestrial environments. Diplurans play an important role in the decomposition of organic matter below the ground and are sensitive to anthropogenic pressures. We present the first comprehensive review about cave Diplura diversity, ecology, evolution, distribution and biogeography. We provide a roadmap for research questions regarding the ecology, aimed at stimulating the pursuit of new studies on this fascinating group. Filling these current knowledge gaps will contribute to conservation efforts for cave ecosystems.
The Use of Allograft Skin for the Treatment of Darier Disease
Authors: D’Acunto Carmine , Orlandi Catuscia , Purpura Valeria , Melandri Davide
Published: September 2020

Darier disease is an autosomal dominant skin disorder characterized by keratotic papules. After their appearance, these lesions tend to grow over time, producing large and exudative plaques that compromise the general condition of the affected patient’s skin. The authors report the clinical case of a patient affected by Darier disease with superinfected de-epithelialized areas over 30% of his body. In addition to antibiotic and antifungal therapy, providers used allograft skin to cover the injured areas and stimulate their progressive re-epithelialization with complete healing after 2 months. To the authors’ knowledge, this is the first clinical case of treating Darier disease with allograft skin on an extensively damaged area. The effectiveness of this treatment may lead clinicians to consider allograft skin tissue a new, alternative dressing to treat Darier disease when this pathologic condition manifests with extensive eroded skin.
Physiotherapist Adaptations to Cancer, HIV/AIDS, and Hospice and Palliative Care in the COVID-19 Era: A Global Perspective Paper
Authors: Drouin Jacqueline S. , Chigbo Nnenna Nina , Newstead Ann H.
Published: September 2020

In the early stages of the COVID-19 pandemic, physiotherapists (PTs) across the globe were required to rapidly adapt clinical practice to provide safe and effective care for people with HIV/AIDS and cancer and those in hospice and palliative care. These rapid decisions included developing criteria for in-person versus remote care and developing equitable platforms for telehealth and telerehabilitation. Most decisions were made with limited guidelines or evidence for practice related to the pandemic. The purpose of this perspective was to provide a synopsis of the experiences of 25 PTs from 16 countries regarding their clinical decisions for (1) rapid adaptation of patient care delivery, (2) evaluation criteria to treat in-person or remotely, (3) utilization decisions for telerehabilitation, (4) determinations for future practice and research needs, and (5) promotion of health equity in an environment rapidly transformed by a highly infectious and deadly disease.
Intrawound Antibiotic Powder in Acetabular Fracture Open Reduction Internal Fixation Does Not Reduce Surgical Site Infections
Authors: Cichos Kyle H. , Spitler Clay A. , Quade Jonathan H. , Ponce Brent A. , McGwin Gerald , Ghanem Elie S.
Published: September 2020

Objectives:

To compare the risks of surgical site infection (SSI) and postoperative complications after acetabular fracture open reduction internal fixation (ORIF) in patients receiving topical intrawound antibiotic powder compared with those not receiving antibiotic powder (control group).

Design:

Retrospective cohort.

Setting:

Level I trauma center.

Patients and Intervention:

We reviewed 789 acetabular fracture ORIF cases from 2010 to 2019 at our institution, with mean follow-up of 18 months (3–112 months). Overall, 326 patients comprised the control group and 463 received topical antibiotic powder (294 vancomycin and 169 vancomycin/tobramycin).

Main Outcome Measurement:

The study groups were compared for risk of SSI, seroma formation, wound dehiscence, acute kidney injury (AKI), and other postoperative complications.

Results:

There were 63 total SSI (8.0%), 50 (6.3%) deep SSI and 13 suprafascial SSI (1.6%) cases. There was no difference in the risk of total SSI (8.3% vs. 7.8%, P = 0.80) or deep SSI (6.1% vs. 6.5%, P = 0.64). This was confirmed by multivariate analysis adjusting for covariates (odds ratio = 0.93; 95% confidence interval, 0.52–1.67; P = 0.80). Similar results were demonstrated when comparing the control group with the vancomycin and vancomycin/tobramycin subgroups. The control group and antibiotic powder groups had similar risks of all outcomes of interest, including seroma formation (1.8% vs. 1.7%, P = 1.00), wound dehiscence (1.2% vs. 2.2%, P = 0.42), total AKI (5.2% vs. 8.2%, P = 0.12), and RIFLE classification AKI (injury; 0.9% vs. 2.2%, P = 0.50).

Conclusions:

The addition of topical intrawound antibiotic powder, whether vancomycin alone or vancomycin/tobramycin before closure, does not reduce the risk of SSI after acetabular fracture ORIF compared with standard normal saline irrigation alone.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Acute Femoral Nailing and Ipsilateral Knee-Spanning External Fixation: Improved Early Stability for Floating Knee Injuries Involving the Tibial Plateau
Authors: Brown J. Turner , Bergin Patrick F. , Prather J. Wells , DiPaolo Daniella , Spitler Clay A.
Published: September 2020

Ipsilateral femoral shaft and tibial plateau fractures, termed a “floating knee,” are rare and challenging injuries. There is limited literature guiding the operative technique and the outcomes associated with these injuries. The author's preferred technique is early intramedullary of the femoral shaft fracture with knee-spanning external fixation of any length unstable plateau fractures in the same operative setting. Early fixation of the femur fracture allows for improved hemodynamic and inflammatory stability. External fixation of the tibial plateau restores length and alignment and allows for soft tissue rest until definitive fixation. The purpose of this study is to describe this operative technique and determine the infection rate and complications requiring return to the operating room in patients with femoral shaft fractures and length unstable plateau fractures.
The Association of Surgical Timing and Injury Severity With Systemic Complications in Severely Injured Patients With Pelvic Ring Injuries
Authors: Rojas David G. , Coleman Julia R. , Moore Ernest E. , Dean Chase S. , Parry Joshua A. , Elrick Bryant P. , Ryan Weston K. , Nadeau Jason T. , Maher Michael , Hwang Jihyo , Byun Seongeun , Mauffrey Cyril P.
Published: September 2020

Objectives:

To evaluate the relationship between timing of definitive fixation, injury severity, and the development of systemic complications in severely injured patients with pelvic ring injuries.

Design:

Retrospective review.

Settings:

Level 1 trauma center.

Patients:

One hundred eighteen severely injured [Injury Severity Score (ISS) ≥ 16] adult patients with pelvic ring injuries undergoing definitive fixation, excluding patients treated with external fixation for hemodynamic instability.

Intervention:

Early fixation (≤36 hours) in 37 patients and delayed fixation (>36 hours) in 81 patients.

Main Outcome Measurements:

Systemic complications (acute respiratory distress syndrome, pulmonary embolism, deep venous thrombosis, sepsis, multi-organ failure, and death).

Results:

The delayed fixation group had a higher ISS and had more patients with chest injuries. There was no detectable difference in the number of patients with systemic complications between early versus delayed fixation groups [8 (22%) vs. 29 (35%), P = 0.1]. The only difference detected in specific complications was a higher incidence of pneumonia with delayed fixation [16 (20%) vs. 0 (0%), P = 0.004] with 11 of the 16 cases being associated with chest injury. Univariate analysis showed an association between complication and time to fixation, ISS, Glasgow Coma Scale, pH, base excess, and injuries to the head, chest, and abdomen. On multivariate analysis, only ISS remained significantly associated with the development of complications [Odds ratio 2.6 per 10 point increase, 95% confidence interval (CI), 1.4–4.4].

Conclusions:

These data suggest that the severity of injury is most highly associated with systemic complications after definitive fixation of pelvic ring injuries.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Impact of Frailty and Malnutrition on Outcomes After Surgical Fixation of Lower Extremity Fractures in Young Patients
Authors: Phen Huai Ming , Jones Corey , Kravets Victoria G. , Farley Kevin Xavier , Schwartz Andrew M. , Wilson Jacob M. , Schenker Mara L.
Published: September 2020

Objectives:

Evaluate the relationship of nutrition parameters and the modified frailty index (mFI) on postsurgical complications within a young patient population sustaining lower extremity orthopaedic trauma.

Design:

Retrospective observational cohort study.

Setting:

Urban, American College of Surgeons-Verified, Level-1, Trauma Center.

Patients/Participants:

Seventeen-thousand one hundred nine adult patients under the age of 65 sustaining lower extremity fractures undergoing operative intervention from 2006 to 2018.

Main Outcome Measures:

On admission, mFI and albumin levels were obtained, as well as complication data. Statistical analysis was used to analyze the association between frailty, malnutrition, and postoperative complications. Patients were stratified, healthy (mFI ≤1, albumin ≥3.5 g/dL), malnourished (mFI ≤1, albumin <3.5 g/dL), frail (mFI ≥2, albumin ≥3.5 g/dL), and frail and malnourished (mFI ≥2, albumin <3.5 g/dL).

Results:

60.4% of patients were healthy, 18.8% were malnourished, 11.7% were frail, and 9.0% were frail and malnourished. Frailty and/or malnourishment on admission predicted significantly higher odds of postoperative complications and mortality when compared with healthy patients. Frailty and malnourishment in conjunction predicted a significantly higher odds ratio of 1.46 (1.22–1.75) for developing postoperative complications when compared with the only malnourished. This was also observed when compared with the only frail (odd ratio: 1.61, P < 0.001); however, there was also a 2.72 (P < 0.001) increased odds of mortality.

Conclusions:

Frailty and malnutrition in conjunction predicts a subset of patients with a higher risk of postoperative complications beyond that of frailty or malnutrition in isolation. Identification of these physiological states on admission allows for interventional opportunities during hospitalization.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Surgical Site Infections After Routine Syndesmotic Screw Removal: A Systematic Review
Authors: Sanders Fay R. K. , Birnie Merel F. N. , Penning Diederick , Goslings J. Carel , Schepers Tim
Published: September 2020

Objectives:

To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries.

Data sources:

A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of “syndesmotic screw” (“ankle fractures” or “syndesmotic injury”) and “implant removal.”

Study Selection:

Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS.

Data extraction:

The 15 included articles were assessed for quality and risk of bias using the Newcastle–Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet.

Data synthesis:

The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified.

Conclusions:

The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2–5), compared with 2% deep infections (95% confidence interval: 1–4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Using the STTGMA Risk Stratification Tool to Predict Complications, Additional Operations, and Functional Outcomes After Ankle Fracture
Authors: Simske Natasha M. , Benedick Alex , Kavanagh Michael D. , Vallier Heather A.
Published: September 2020

Objectives:

To determine the usefulness of a validated trauma triage score to stratify postdischarge complications, secondary procedures, and functional outcomes after ankle fracture.

Design:

Retrospective cohort.

Setting:

Level 1 trauma center.

Patients:

Four hundred fifteen patients 55 years of age and older with 431 ankle fractures.

Intervention:

Closed or open reduction.

Main Outcome Measurements:

Score for Trauma Triage in Geriatric and Middle-Aged Patients (STTGMA), postdischarge complications, secondary operations, Foot Function Index (FFI, n = 167), and Short Musculoskeletal Function Assessment (SMFA, n = 165).

Results:

Mean age was 66 years, 38% were men, and 68% of fractures were secondary to ground-level falls. Forty patients (9.6%) required an additional procedure, with implant removal most common (n = 21, 5.1%), and 102 (25%) experienced a postdischarge complication. On multiple linear regression, STTGMA was not a significant independent predictor of complications or secondary procedures. Patients completed FFI and SMFA surveys a median of 62 months (5.2 years) after injury. On the FFI, low-risk STTGMA stratification was an independent predictor of worse functional outcomes. Similarly, low-risk stratification was a predictor of worse scores on the SMFA dysfunction and daily activity subcategories (both B > 10, P < 0.05).

Conclusions:

Low-risk STTGMA stratification predicted worse long-term function. The STTGMA tool was not able to meaningfully stratify risk of postdischarge complications and secondary procedures after ankle fracture.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Surgical Wound Complications After Percutaneous Posterior Pelvic Ring Fixation in Patients Who Undergo Pelvic Arterial Embolization
Authors: Namm Joshua D. , Obey Mitchel R. , Jo Sally , Berkes Marschall B. , McAndrew Christopher M. , Miller Anna N.
Published: September 2020

Objective:

To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits.

Design:

Retrospective cohort study.

Setting:

Academic level 1 trauma center.

Patients:

Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization.

Intervention:

Percutaneous posterior pelvic fixation and pelvic arterial embolization.

Main Outcome Measurements:

Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients.

Results:

Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group.

Conclusion:

Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
White-Light Body Scanning Captures Three-Dimensional Shoulder Deformity After Displaced Diaphyseal Clavicle Fracture
Authors: DeBaun Malcolm R. , Lai Cara , Schultz Blake J. , Oquendo Yousi A. , Campbell Sean T. , Goodnough L. Henry , Bishop Julius A. , Gardner Michael J.
Published: September 2020

Objective:

We sought to determine if white-light three-dimensional (3D) body scanning can identify clinically relevant shoulder girdle deformity after displaced diaphyseal clavicle fracture (DCF).

Methods:

Adult patients with DCF (OTA/AO 15A) were prospectively enrolled. Four subcutaneous osseous landmarks were used to measure shoulder girdle morphology of the injured and uninjured shoulder. Measurements were made both manually with a tape measure and digitally with a white-light 3D scanner. Bilateral radiographs were obtained, and clavicle length was recorded. Quick-Disabilities of the Arm, Shoulder, and Hand surveys were administered at injury and at 6 and 12 weeks.

Results:

Twenty-two patients were included in the study. At the initial visit, all patients had significant differences in deformity measurements between injured and uninjured shoulders as measured by 3D scanning. There was no difference between shoulders measured using manual measurements. At 6 and 12 weeks, shoulder asymmetry was significantly less in patients treated with surgery compared with nonoperative patients as measured by the 3D scanner alone. Clavicle shortening measured on 3D scanning had weak and moderate positive correlations to radiographs (R = 0.27) and manual measurements (R = 0.53), respectively. Patients treated with surgery had significant functional improvements by 6 weeks, and a similar improvement was not seen until 12 weeks in nonsurgical patients.

Conclusion:

White-light 3D scanning was able to identify and monitor clinically relevant shoulder girdle deformity after DCF. This tool may become a useful adjunct to clinical examination and radiographic assessment, when determining clinically relevant deformity thresholds. In the future, quantifying and understanding shoulder deformity may inform clinical decision making in these patients.

Level of Evidence:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Impact of Substance Use and Abuse on Opioid Demand in Lower Extremity Fracture Surgery
Authors: Cunningham Daniel J. , LaRose Micaela A. , Gage Mark J.
Published: September 2020

Objectives:

To describe the perioperative opioid demand in a large population of patients undergoing lower extremity fracture fixation and to evaluate mental disorders such as substance abuse as risk factors for increased use.

Design:

Retrospective, observational.

Setting:

National insurance claims database.

Patients/participants:

Twenty-three four hundred forty-one patients grouped by mental disorders such as depression, psychoses, alcohol abuse, tobacco abuse, drug abuse, and preoperative opioid filling undergoing operative treatment of lower extremity fractures (femoral shaft through ankle) between 2007 and 2017.

Intervention:

Operative treatment of lower extremity fractures.

Main Outcome Measures:

The primary outcome was filled opioid prescription volume converted to oxycodone 5-mg pill equivalents. Secondary outcomes included the number of filled prescriptions and the risk of obtaining 2 or more opioid prescriptions.

Results:

Of 23,441 patients, 16,618 (70.9%), 8862 (37.8%), and 18,084 (77.1%) filled opioid prescriptions within 1-month preop to 90-day postop, 3-month postop to 1-year postop, and 1-month preop to 1-year postop, respectively. On average, patients filled 104, 69, and 173 oxycodone 5-mg pills at those time intervals. Alcohol, tobacco, drug abuse, and preoperative opioid filling were associated with increased perioperative opioid demand. Psychoses had a small effect on opioid demand, and depression had no significant impact.

Conclusions:

This study reports the rate and volume of opioid prescription filling in patients undergoing lower extremity fracture surgery. Substance use and abuse were the main risk factors for increased perioperative opioid prescription filling. Providers should recognize these risk factors for increased use and be judicious when prescribing opioids. Enhanced patient education, increased nonopioid pain management strategies, and referral for substance use and abuse treatment may be helpful for these patients.

LEVEL OF EVIDENCE:

Level III. See Instructions for Authors for a complete description of levels of evidence.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Can Rapid Progression in Nonambulatory Cerebral Palsy Scoliosis Be Predicted Using Humeral Head Ossification?
Authors: Bram Joshua T. , Flynn John M. , Karkenny Alexa J. , Shah Ronit V. , Talwar Divya , Baldwin Keith D.
Published: September 2020

Background:

Patients with cerebral palsy scoliosis (CPS) experience higher complication rates compared with idiopathic scoliosis and often present for surgery with larger curves. Prediction of an inflection point for rapid deformity progression has proven difficult. A proximal humerus-based skeletal maturity staging system (HS) has been recently validated and is commonly visible on the posteroanterior radiograph. The authors hypothesize that this system can be used to identify a period at which CPS may progress rapidly, perhaps facilitating discussion of timely surgical intervention.

Methods:

A retrospective review was conducted for nonambulatory pediatric patients with CPS who presented between 2009 and 2018 at our institution. All patients were considered for inclusion regardless of operative or nonoperative management. Patients who were skeletally mature at initial evaluation or had prior spine surgery were excluded. The authors analyzed radiographs in each HS available. Survival was calculated for cutoffs of 60 and 70 degrees (numbers found to increase intraoperative and postoperative complications for CPS).

Results:

Eighty-six patients with CPS were identified (54 male individuals). Major curves increased significantly between HS 1 and 2 (27.7 to 46.6 degrees, P=0.009) and HS 3 and 4 (53.1 to 67.9 degrees, P=0.023). The proportion of curves ≥70 degrees were significantly different between HS (P<0.001), with the greatest increase between HS 3 and 4 (24% to 51%; ≥70 degrees). The largest drop in the 60/70-degree survival curves was between HS 3 and 4. In a subanalysis, 69% of patients with curves ≥40 degrees but <70 degrees in stage 3 would progress ≥70 degrees by stage 4.

Conclusions:

Identifying a period of rapid curve progression may guide surgical planning before CPS curves become large, stiff, and more difficult to fix. Our findings suggest that humeral skeletal maturity staging is a valuable decision-making tool in neuromuscular scoliosis, with the HS 3 to 4 transition representing the time of the greatest risk of progression. Consider a surgical discussion or shortened follow-up interval for patients with CPS with curves ≥40 degrees who are HS 3.

Level of Evidence:

Level II.
Depression Identified on the Mental Component Score of the Short Form-12 Affects Health Related Quality of Life After Lumbar Decompression Surgery
Authors: Divi Srikanth N. , Goyal Dhruv K.C. , Stull Justin D. , Morgenstern Monica , Galetta Matthew S. , Kaye I. David , Kurd Mark F. , Woods Barrett I. , Radcliff Kris E. , Rihn Jeffery A. , Anderson David Greg , Hilibrand Alan S. , Kepler Christopher K. , Vaccaro Alexander R. , Schroeder Gregory D.
Published: September 2020

Study Design:

This was a retrospective comparative study.

Objective:

The goal of this study was to further elucidate the relationship between preoperative depression and patient-reported outcome measurements (PROMs) following lumbar decompression surgery.

Summary of Background Data:

The impact of preoperative depression on PROMs after lumbar decompression surgery is not well established.

Methods:

Patients undergoing lumbar decompression between 1 and 3 levels were retrospectively identified. Patients were split into 2 groups using a preoperative Mental Component Score (MCS)-12 threshold score of 45.6 or 35.0 to identify those with and without depressive symptoms. In addition, patients were also split based on a pre-existing diagnosis of depression in the medical chart. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared, and a multiple linear regression analysis was performed.

Results:

A total of 184 patients were included, with 125 (67.9%) in the MCS-12 >45.6 group and 59 (32.1%) in the MCS-12 ≤45.6 group. The MCS-12 ≤45.6 and MCS<35.0 group had worse baseline Oswestry Disability Index (ODI) (P<0.001 for both) and Visual Analogue Scale Leg (P=0.018 and 0.024, respectively) scores. The MCS ≤45.6 group had greater disability postoperatively in terms of SF-12 Physical Component Score (PCS-12) (39.1 vs. 43.1, P=0.015) and ODI (26.6 vs. 17.8, P=0.006). Using regression analysis, having a baseline MCS-12 scores ≤45.6 before surgical intervention was a significant predictor of worse improvement in terms of PCS-12 [β=−4.548 (−7.567 to −1.530), P=0.003] and ODI [β=8.234 (1.433, 15.035), P=0.010] scores than the MCS-12 >45.6 group.

Conclusion:

Although all patients showed improved in all PROMs after surgery, those with MCS-12 ≤45.6 showed less improvement in PCS-12 and ODI scores.
Chemotherapy should be performed in epidermal growth factor receptor mutation-positive lung adenocarcinoma patients who had progressive disease to the first epidermal growth factor receptor-tyrosine kinase inhibitor
Authors: Kashiwabara Kosuke , Fujii Shinji , Tsumura Shinsuke , Sakamoto Kazuhiko
Published: September 2020

After the failure of first-line epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy, some non-small cell lung cancer patients desire to receive switching with another EGFR-TKI (TKI-switching), although cytotoxic chemotherapy has been recommended as second-line therapy. It is unclear who should not receive TKI-switching in these patients. We retrospectively evaluated overall survival (OS) from the initiation of first EGFR-TKI (first-TKI) therapy in advanced lung adenocarcinoma patients with active EGFR mutations (deletion of exon 19 or L858R in exon 21) who received TKI-switching according to the best response of the first-TKI. There was no difference in the OS between patients receiving TKI-switching (n = 35) and patients receiving additional chemotherapy between the first-TKI and second-TKI therapy (n =10) (P = 0.614). Among patients receiving TKI-switching, the OS in cases with progressive disease to the first-TKI (n = 9) was shorter than that in cases with disease control to the first-TKI (n = 26) (12.7 months vs. 49.4 months, P < 0.001). Five of the nine progressive disease cases who received TKI-switching missed an opportunity to receive chemotherapy. Their OS tended to be shorter than that in patients who received chemotherapy during the whole period of anticancer therapy (12.2 months vs. 20.3 months, P = 0.060). The multivariate analysis showed that disease control to the first-TKI therapy (P = 0.005) or the presence of chemotherapy (P = 0.087) decreased the risk of mortality. Chemotherapy should be performed in patients with progressive disease to the first-TKI.
MiR-338-3p inhibits cell migration and invasion in human hypopharyngeal cancer via downregulation of ADAM17
Authors: Hong Yuming , Chen Xiaofang , Liang Zhenyuan , Xu Zhihui , Li Yahong , Pan Yafeng
Published: September 2020

Studies have confirmed that microRNAs play important roles in the development and progression of cancer. Therefore, to identify the differentially expressed microRNAs between the cancer and the normal tissues, microRNAs will provide new clues for exploring the molecular mechanisms of cancer development and potential targeted therapies. In the present study, we found that miR-338-3p was downregulated in hypopharyngeal carcinoma and inversely correlated with the pathological grade. When the miR-338-3p was further downregulated, the migration and invasion ability of the FaDu hypopharyngeal carcinoma cells were enhanced, and these functions were inhibited when the miR-338-3p was upregulated. In addition, we demonstrated that ADAM17 was a target of miR-338-3p, and that ADAM17 directly activated the wnt/β-catenin signaling pathway and promoted the expression of its target gene MMP2, Nanog and SOX2, which affected the growth, migration and invasion of hypopharyngeal carcinoma cells. In conclusion, our results demonstrate for the first time that miR-338-3p targets ADAM17 and blocks the development of hypopharyngeal carcinoma involving the wnt/β-catenin signaling pathway, which may be a new target for clinical intervention in human cancer.
Sauchinone inhibits hypoxia-induced epithelial-mesenchymal transition in pancreatic ductal adenocarcinoma cells through the Wnt/β-catenin pathway
Authors: Qiao Yuan , Yan Li-Jun , Yan Chao
Published: September 2020

The hypoxic microenvironment is commonly found in various solid tumors including pancreatic ductal adenocarcinoma (PDAC). Saururus chinensis is a medicinal Chinese herb widely used because of documented anti-inflammatory and anti-angiogenic properties. Sauchinone is special active lignin extracted from S. chinensis and its biological functions have been extensively explored. Recent studies have found that sauchinone could affect tumor initiation, metastasis and progression of some cancers. However, the specific role of sauchinone in PDAC remains to be elucidated. The main aim of this study was to elucidate the involvement of sauchinone in the progression of PDAC under the hypoxic condition. The human PDAC cell lines PANC-1 and BxPC-3 were exposed to hypoxia and various concentrations of sauchinone. The CCK-8 assay was performed to detect cytotoxic effects of sauchinone on PDAC cells. The levels of vascular endothelial growth factor, hypoxia-inducible factor-1α, E-cadherin, N-cadherin, Wnt3a and β-catenin were examined by the western blot analysis. Wound healing and transwell assays were used to assess cell migration and invasion. The results showed that the migratory and invasive abilities of PDAC cells were enhanced after exposure to hypoxia and the expression of epithelial-mesenchymal transition markers was also significantly regulated by hypoxia. All these effects induced under the hypoxic condition were terminated by sauchinone treatment. In addition, sauchinone suppressed hypoxia-induced activation of the Wnt/β-catenin signaling pathway. Our study provided important insight into understanding the mechanisms of the anti-cancer effect of sauchinone. Taken together, we suggested that sauchinone may be considered a new therapeutic agent for PDAC treatment.