bluuebunny/crossref_metadata_2025_split huggingface dataset:
Accessory Cuboid Facet Associated With Calcaneonavicular Coalitions
Authors: Scott Daniel J. , Riccio Anthony I. , Kanaan Yassine , Zide Jacob R. 
Published: April 2021

Background:
Calcaneonavicular (CN) coalitions are the most commonly encountered tarsal coalition. No study has assessed anatomic variations of the adjacent joints in the presence of a CN coalition. This study sought to identify differences in the anatomy of the calcaneocuboid (CC) articulation in feet with and without CN coalitions.

Methods:
An institutional review board approved retrospective analysis of patients with symptomatic CN coalitions presenting to a single tertiary care pediatric orthopaedic hospital was performed. Patients without computed tomographic or magnetic resonance imaging were excluded. The morphology and dimensions of the cuboid portion of the CC joint were documented. When contralateral imaging was available in patients with a unilateral coalition, the morphology of the uninvolved side was evaluated to provide a cohort of controls for comparison.

Results:
Imaging was available for 55 patients who had a mean age of 11.7 years. There were 80 CN coalitions and 18 normal feet. An accessory cuboid facet was identified articulating with the calcaneal portion of the coalition in 60/80 (75%) feet in the coalition group. In feet with a coalition and an accessory facet, the mean total length of the cuboid articular surface measured 25.3 mm (range, 17.7 to 33.3 mm). The average length of the accessory facet was 10.7 mm (range, 5.4 to 15.5 mm), while the length of the primary vertical cuboid articulation with the calcaneus was 14.6 mm (range, 6.4 to 21 mm). The accessory facet comprised 42.3% of the cuboid articular surface in these patients. Feet without a coalition as well as feet with a coalition and no accessory facet had primary vertical cuboid articulations that were significantly larger than feet with a coalition and an accessory facet (P<0.0001). An accessory cuboid facet was identified in only a single control foot (5.6%).

Conclusions:
This study reports the frequent presence of an accessory cuboid facet in patients with CN coalitions. This facet was present in 75% of patients with CN coalitions and comprised just over 40% of the cuboid articular length. This anatomic variation represents a significant difference in CC joint morphology between feet with and without CN coalitions. This information may be useful when planning surgical resections.

Level of Evidence:
Level III—retrospective cohort study.
Does Surgical Experience Decrease Radiation Exposure in the Operating Room?
Authors: Magee Lacey C. , Karkenny Alexa J. , Nguyen Jie C. , Fazal Faris Z. , Talwar Divya , Zhu Xiaowei , Shah Apurva S. 
Published: April 2021

Background:
Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy.

Methods:
This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables.

Results:
A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases.

Conclusion:
Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator’s extremity from the field, and judicious use and placement of each additional pin.

Level of Evidence:
Level III.
Retrograde Extramedullary Lengthening of the Femur Using the PRECICE Nail: Technique and Results
Authors: Iobst Christopher A. , Bafor Anirejouritse 
Published: April 2021

Background:
Lengthening of long bones by distraction osteogenesis is now possible using intramedullary lengthening nails. Constraints of bone size, medullary canal obstruction, and the presence of an open physis are contraindications in skeletally immature patients. We present a technique describing the “off-label” use of a magnetic lengthening nail placed extramedullary and in retrograde manner, for lengthening of the femur in skeletally immature patients.

Methods:
A retrospective review of 5 skeletally immature patients with significant length discrepancy of the femur are presented along with a description of the surgical technique. Data collected included age, sex, date of surgery, diagnosis, presence of associated deformities, the magnitude of length discrepancy, the amount of length gained, the amount of time to achieve full weight-bearing, the time to hardware removal, and any complications.

Results:
There were 5 patients (3 females). The mean age was 7.2±2.7 years (4 to 10 y). The mean limb length discrepancy was 6.5±3.7 cm (3.5 to 11 cm). A mean length of 3.46±0.4 cm (3.1 to 4 cm) was achieved which represents 12.9±1.8% (10.32 to 13.47%) of the bone length. The time taken to achieve full weight-bearing ambulation was 89.2±19.3 days (60 to 109 d) or 12.7 weeks. All hardware was removed 247.6±215.6 days (99 to 628 d) after surgery. Patients were followed up for a mean duration of 19.2 months (11 to 30 mo). No supplemental fixation was required and no complications were noted. Acute deformity correction was also performed at the time of surgery in 2 patients who had distal femur valgus deformity.

Conclusions:
Retrograde extramedullary lengthening of the femur is an option that should be considered for limb length equalization in skeletally immature patients. It avoids the inconvenience of external fixation and can be used to simultaneously correct deformities of the distal femur. Although the total amount of length gained is modest, we believe it is a promising limb lengthening technique that merits further investigation.

Level of Evidence:
Level III.
Combining Lower Extremity Radiographic Markers Begets More Accurate Predictions of Remaining Skeletal Growth
Authors: Yu Kristin E. , Coghill Griffin A. , Vernik David , Lapow Justin M. , Cooperman Daniel R. 
Published: April 2021

Background:
Radiographic markers of skeletal maturity are vital to the prediction and interpretation of skeletal growth patterns. Accurate predictions of skeletal maturity factor into the management of common musculoskeletal disorders. Bone age is conventionally measured using hand and wrist radiographs. The primary study objective was to optimize skeletal maturity estimates based on the morphology of markers at the hip, knee, and foot rather than conventional upper extremity radiographs.

Methods:
This was a retrospective analysis of children from the Bolton-Brush collection with anteroposterior radiographs of the hip and anteroposterior and lateral radiographs of the knee and foot, and heights recorded at the time of each radiograph. The percent growth achieved (%GA) was calculated as a function of final patient height. Poor quality radiographs were excluded, leaving 50 patients—32 females and 18 males—and 1068 radiographs for analysis. Skeletal maturity was evaluated using the Oxford bone, O’Connor knee, and calcaneal apophyseal scores. Interrater and intrarater reliability analyses were performed for hip and knee scores. Multiple linear regressions were conducted on these scores and chronologic age as predictors of %GA. Mean differences were calculated between actual and estimated %GAs. All analyses were performed in Prism 8.0.

Results:
Each lower extremity skeletal maturity score served as statistically significant, independent predictors of %GA, the accuracy and strength of which increased with the addition of chronologic age. The integration of all 3 systems and chronologic age yielded the most predictive, accurate model predictive of %GA, which can be used to determine percent growth remaining. However, this fully integrated system was not statistically superior to the combination of knee and foot scores and knee score and chronologic age, which yield similarly accurate %GA predictions. The hip and knee systems demonstrated good to excellent interrater and intrarater reliability.

Conclusions:
Integration of bone age scores across different regions of the lower extremity has the potential to facilitate orthopaedic decision-making using radiographs already obtained in the treatment of pediatric musculoskeletal conditions.

Level of Evidence:
Level IV.
Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic*
Authors: Mathews Kusum S. , Seitz Kevin P. , Vranas Kelly C. , Duggal Abhijit , Valley Thomas S. , Zhao Bo , Gundel Stephanie , Harhay Michael O. , Chang Steven Y. , Hough Catherine L. 
Published: April 2021

OBJECTIVES:
The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic.

DESIGN:
We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates.

SETTING AND PARTICIPANTS:
U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients.

CONCLUSIONS:
The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.
Quality of Life and Long-Term Mortality Among Survivors of Extracorporeal Membrane Oxygenation: A Nationwide Cohort Study in South Korea
Authors: Cho Hyoung-Won , Song In-Ae , Oh Tak Kyu 
Published: April 2021

OBJECTIVES:
The quality of life after extracorporeal membrane oxygenation therapy has emerged as an important issue for extracorporeal membrane oxygenation survival; however, its association with long-term prognosis has not been identified. We investigated the changes in the quality of life after extracorporeal membrane oxygenation among the survivors and examine the association between a worse quality of life and 3-year all-cause mortality.

DESIGN:
This was a population-based cohort study.

SETTING:
Data were obtained from the National Health Insurance Service database in South Korea.

PATIENTS:
Adult individuals (≥ 18 yr old) who received extracorporeal membrane oxygenation therapy from 2006 to 2017 were included. Extracorporeal membrane oxygenation survivors were defined as patients who had survived for 1-year after the initiation of extracorporeal membrane oxygenation therapy.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
The income level, employment status, and registered disability were examined before and 1-year after extracorporeal membrane oxygenation therapy. The decreased income level, job loss, and newly acquired disability were considered as change in the quality of life among extracorporeal membrane oxygenation survivors. A total of 5,821 adult extracorporeal membrane oxygenation survivors were included in the final analysis, and 2,959 patients (50.8%) experienced quality of life change. Specifically, 1,782 patients (30.6%) experienced a decrease in income, 682 (11.7%) lost their jobs, and 1,540 (26.5%) had a new disability within 1-year after extracorporeal membrane oxygenation therapy. In the multivariable Cox regression model, newly acquired disability was associated with 2.31-fold higher 3-year all-cause mortality among extracorporeal membrane oxygenation survivors (hazard ratio, 2.31; 95% CI, 1.79–2.97; p < 0.001), while job loss (p = 0.180) and decreased income (p = 0.993) were not associated with the 3-year all-cause mortality.

CONCLUSIONS:
At 12 months after extracorporeal membrane oxygenation therapy, nearly half survivors experienced quality of life worsening such as unemployment, decreased income, and new disability. Additionally, among the three factors, acquiring a new disability might significantly increase the 3-year mortality. This is the first study to report the association between changes in the quality of life and long-term prognosis in extracorporeal membrane oxygenation survivors.
Current Trends in Sepsis-Related Mortality in the United States*
Authors: Prest Jonathan , Sathananthan Matheni , Jeganathan Niranjan 
Published: April 2021

OBJECTIVES:
Sepsis is a life-threatening condition and is one of the leading causes of death in the United States. The burden of sepsis-related mortality in the United States in recent years is not well characterized. We sought to describe sepsis-related mortality rates and mortality trends in the United States from 2005 to 2018.

DESIGN:
Retrospective population-based study.

SETTING:
We used the Multiple Cause of Death Database available through the Centers for Disease Control and Prevention website.

PATIENTS:
Decedents with sepsis-related deaths were identified using previously validated International Classification of Diseases codes.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
From 2005 to 2018, 6.7% of decedents had a diagnosis of sepsis. The overall sepsis-related mortality rates remained stable in both males (57 deaths per 100,000) and females (45.1 deaths per 100,000) during this period. Compared with Whites, the sepsis-related mortality rates were higher in Blacks (rate ratio = 1.78), Native Americans (rate ratio = 1.43), and Hispanics (rate ratio = 1.04) and were lower in Asians (rate ratio = 0.73). Sepsis-related mortality rates declined in Blacks, Hispanics, and Asians but increased in Whites and Native Americans. The majority of sepsis-related deaths occurred in the hospital. The percentage of deaths in the nursing home decreased, whereas deaths occurring at home and hospice increased.

CONCLUSIONS:
From 2005 to 2018, the overall sepsis-related mortality rates were stable, but there were significant racial and gender disparities in mortality trends. Further research is needed to evaluate the genetic and environmental contributors to these differences.
Coronavirus Disease 2019 Policy Restricting Family Presence May Have Delayed End-of-Life Decisions for Critically Ill Patients
Authors: Azad Tej D. , Al-Kawaz Mais N. , Turnbull Alison E. , Rivera-Lara Lucia 
Published: April 2021

OBJECTIVES:
To determine if a restrictive visitor policy inadvertently lengthened the decision-making process for dying inpatients without coronavirus disease 2019.

DESIGN:
Regression discontinuity and time-to-event analysis.

SETTING:
Two large academic hospitals in a unified health system.

PATIENTS OR SUBJECTS:
Adult decedents who received greater than or equal to 1 day of ICU care during their terminal admission over a 12-month period.

INTERVENTIONS:
Implementation of a visit restriction policy.

MEASUREMENTS AND MAIN RESULTS:
We identified 940 adult decedents without coronavirus disease 2019 during the study period. For these patients, ICU length of stay was 0.8 days longer following policy implementation, although this effect was not statistically significant (95% CI, –2.3 to 3.8; p = 0.63). After excluding patients admitted before the policy but who died after implementation, we observed that ICU length of stay was 2.9 days longer post-policy (95% CI, 0.27–5.6; p = 0.03). A time-to-event analysis revealed that admission after policy implementation was associated with a significantly longer time to first do not resuscitate/do not intubate/comfort care order (adjusted hazard ratio, 2.2; 95% CI, 1.6–3.1; p < 0.0001).

CONCLUSIONS:
Policies restricting family presence may lead to longer ICU stays and delay decisions to limit treatment prior to death. Further policy evaluation and programs enabling access to family-centered care and palliative care during the ongoing coronavirus disease 2019 pandemic are imperative.
The LN Flap for Nasal Defect Reconstruction: An 84-case Experience with a Novel Technique
Authors: Iyer Hari , Bussière Nicholas , Salib George Emmanuel 
Published: April 2021

Background:
The nose is a common site for cutaneous malignancy and post-ablative reconstruction. To our knowledge, a myocutaneous island flap based on the levator labii superioris alaeque nasi (LLSAN) and nasalis muscles, with vascularity from the lateral nasal and angular arteries, has not been described for reconstruction of the lower lateral nose.

Methods:
A retrospective chart review of patients who underwent LLSAN-nasalis island flap reconstruction between 2015 and 2019 was performed. The surgical technique involved marking of an inverted-V flap on the nasal sidewall. The skin lateral to the flap was then developed in the subcutaneous plane to expose the LLSAN muscle and divide its origin on the maxillary frontal process and its caudal insertions into the alar dermis. The medial incision was down to periosteum and perichondrium, and dissection beneath the flap separated it from the nasal support structure. The resultant flap had a great caudal mobility. The donor site was closed in a V-to-Y pattern.

Results: In total,
84 procedures were completed, mostly for alar defects (57.1%) between 100 and 400 mm2 (71.4%). The average age of patients was 74.9 years. An estimated 27 patients were lost to follow-up. At mean follow-up of 24.3 weeks, there were no cases of flap necrosis, 1 case of hematoma (1.8%), 1 case of infection (1.8%), 3 cases of persistent trapdoor deformity (5.3%), and 3 cases of alar notching (5.3%), 1 of whom required revision surgery.

Conclusion:
The LLSAN-nasalis myocutaneous island flap is a simple, reliable technique for resurfacing lateral lower nasal defects up to 2 × 2 cm.
Factors associated with post-electroconvulsive therapy delirium
Authors: Jo Young Tak , Joo Sung Woo , Lee Jungsun , Joo Yeon Ho 
Published: April 2021

Abstract
Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions from December 2006 to July 2018 in a university hospital.
Demographic and clinical characteristics of sessions involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis was applied to analyze the correlation between variables and post-ECT delirium.
Post-ECT delirium developed in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was significantly different between delirium-positive and delirium-negative groups after Bonferroni correction. The regression model also indicated that etomidate use to be significantly associated with post-ECT delirium.
In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an association that appeared unrelated to other possible measured variables. Practitioners should take into account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation before sufficient therapeutic gain is achieved.