bluuebunny/crossref_metadata_2025_split huggingface dataset:
Pediatric Supracondylar Humerus Fractures: Does After-Hours Treatment Influence Outcomes?
Authors: Paci Gabrielle M. , Tileston Kali R. , Vorhies John S. , Bishop Julius A. 
Published: February 2018

Objective:
To compare the outcomes of pediatric supracondylar humerus fractures treated during daytime hours to those treated after-hours.

Design:
Retrospective.

Setting:
Academic Level I trauma center.

Patients/Participants:
Two hundred ninety-eight pediatric patients treated with surgical reduction and fixation of closed supracondylar fractures were included.

Intervention:
Seventy-seven patients underwent surgery during daytime hours (06:00–15:59 on weekdays). One hundred eighty-six patients underwent surgery after-hours (16:00–05:59 on weekdays and any surgery on weekends or holidays).

Main Outcome Measures:
Surgeon subspecialty, operative duration, and radiographic and clinical outcomes, including range of motion and carrying angle, were extracted from the patient medical records.

Results:
There were no patient-related demographic differences between the daytime hours and after-hours groups. Daytime surgery was more likely to be performed by a pediatric orthopaedic surgeon than after-hours surgery. Fractures treated after-hours had more severe injury patterns. After-hours surgery was not independently associated with rate of open reduction, operative times, complications, achievement of functional range of motion, or radiographic alignment. A late-night surgery subgroup analysis demonstrated an increased rate of malunion in patients undergoing surgery between the hours of 23:00 and 05:59.

Conclusions:
There is no difference in the operative duration or outcomes after surgical treatment of pediatric supracondylar humerus fractures performed after-hours when compared with daytime surgery. However, late-night surgery performed between 23:00 and 05:59 may be associated with a higher rate of malunion. Surgeons can use these data to make better-informed decisions about the timing of surgery in this patient population.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Helical Blade or the Integrated Lag Screws: A Matched Pair Analysis of 100 Patients With Unstable Trochanteric Fractures
Authors: Gavaskar Ashok S. , Tummala Naveen C. , Srinivasan Parthasarathy , Gopalan Hitesh , Karthik Bhupesh , S Santosh 
Published: February 2018

Objectives:
To compare the radiological and clinical results with PFNA-II and InterTan in the treatment of unstable trochanteric fractures in the elderly.

Design:
Retrospective, multicenter, matched pair.

Setting:
Three tertiary level trauma centers.

Patients:
Hundred elderly patients who underwent intramedullary stabilization with either the PFNA-II or the InterTan for osteoporotic unstable trochanteric fractures.

Interventions:
Fifty matched pairs consisting of OTA/AO–A2 and A3 fractures were created from a cohort of 290 patients who underwent internal fixation for unstable trochanteric fractures with the PFNA-II or InterTan nails.

Outcome Measurements:
Radiological assessment was performed to compare union rates, varus collapse, medial or lateral screw/blade migration, and cut-out. Functional outcome at 1 year was assessed and compared using Harris hip score, Timed Up and Go test, and the mobility score.

Results:
Union rates, fracture reduction, neck shaft angle, and tip–apex distance were similar in both groups. The PFNA-II group had a significantly higher degree of lateral sliding of the helical blade (P < 0.001). The InterTan group had a better Harris hip score, mobility score, Timed Up and Go test scores, and abductor strength (P < 0.05) at 1 year. The incidence of varus collapse and medial blade migration were higher in the PFNA-II group (P > 0.05). The need for repeat surgery to address surgery-related complications were significantly high in the PFNA-II group (P = 0.045).

Conclusions:
The InterTan may provide superior functional outcome and reduced complications than does the Proximal Femur Nail - Antirotation in elderly patients with unstable trochanteric fractures.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Are Variable-Angle Locking Screws Stable Enough to Prevent Calcaneal Articular Surface Collapse? A Biomechanical Study
Authors: Jordan Martin C. , Fuchs Konrad , Heintel Timo M. , Jansen Hendrik , Hoelscher-Doht Stefanie , Meffert Rainer H. 
Published: February 2018

Purpose:
To compare fixed- or variable-angle locking screws in calcaneal fracture plates using a sawbones biomechanical model.

Methods:
Intra-articular calcaneal fractures were created in synthetic bones. Reduction and stabilization was performed with 3 different plates. In group A, a fixed-angle locking plate was used with screws fastened perpendicularly to the plate (3.5 LCP, DePuySynthes). In groups B and C (2.7 VA-LCP, DePuySynthes and 3.5 Aptus, Medartis, respectively), fracture fixation was performed using variable-angle locking plates. Biomechanical testing was conducted. Displacement of the subtalar articular surface, stiffness, maximum displacement, change in the angle of Gissane, and mode of failure under cyclic loading at 200 N, 600 N, and 1000 N (500 cycles each) were determined.

Results:
No statistically significant difference of articular surface dislocation under cyclic loading was detected. The stiffness and maximum displacement did not reveal any disparity as well. The change in the angle of Gissane showed only minor displacement of the articular surface.

Conclusion:
In our study, the resistance of variable-angle locking plates against articular surface displacement was similar to fixed-angle locking screws.
Predicting Likelihood of Surgery Before First Visit in Patients With Back and Lower Extremity Symptoms
Authors: Boden Lauren M. , Boden Stephanie A. , Premkumar Ajay , Gottschalk Michael B. , Boden Scott D. 
Published: February 2018

Study Design.
Retrospective analysis of prospectively collected data.

Objective.
To create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within 1 year of presentation.

Summary of Background Data.
Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained before the initial physician-patient encounter to direct patients to the optimal physician type.

Methods.
We analyzed patient-reported data from 8006 patients with a chief complaint of low back pain and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within 1 year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort, and validated on the remaining 20%.

Results.
The baseline 1-year surgery rate within our cohort was 39% for all patients and 42% for patients with LE symptoms. Those identified as high likelihood by the center's existing triage process had a surgery rate of 45%. The new triage scoring system proposed in this study was able to identify a high likelihood group in which 58% underwent surgery, which is a 46% higher surgery rate than in nontriaged patients and a 29% improvement from our institution's existing triage system.

Conclusion.
The data-driven triage model and scoring system derived and validated in this study (Spine Surgery Likelihood-11), significantly improved existing processes in predicting the likelihood of undergoing spinal surgery within 1 year of initial presentation. This triage system will allow centers to more selectively screen for surgical candidates and more effectively direct patients to surgeons or nonoperative spine specialists.

Level of Evidence: 4
Utility of Supine Lateral Radiographs for Assessment of Lumbar Segmental Instability in Degenerative Lumbar Spondylolisthesis
Authors: Tarpada Sandip P. , Cho Woojin , Chen Foster , Amorosa Louis F. 
Published: February 2018

Study Design.
Retrospective chart review

Objective.
To determine whether supine lateral radiographs increase the amount of segmental instability visualized in single-level lumbar degenerative spondylolisthesis, when compared to traditional lateral flexion-extension radiographs. We hypothesized that supine radiographs increase the amount of segmental instability seen in single-level lumbar spondylolisthesis when compared to flexion-extension.

Summary of Background Data.
Accurate evaluation of segmental instability is critical to the management of lumbar spondylolisthesis. Standing flexion-extension lateral radiographs are routinely obtained, as it is believed to precipitate the forward-backward motion of the segment; however, recent studies with magnetic resonance imaging and computed tomography have shown that the relaxed supine position can facilitate the reduction of the anterolisthesed segment. Here, we show that inclusion of supine lateral radiographs increases the amount of segmental instability seen in single-level lumbar spondylolisthesis when compared to traditional lateral radiographs.

Methods.
Supine lateral radiographs were added to the routine evaluation (standing neutral/flexion/extension lateral radiographs) of symptomatic degenerative spondylolisthesis at our institution. In this retrospective study, 59 patients were included. The amount of listhesis was measured and compared on each radiograph: standing neutral lateral (“neutral”), standing flexion lateral (“flexion”), standing extension lateral (“extension”), and supine lateral (“supine”).

Results.
A total of 59 patients (51 women, 8 men), with a mean age of 63.0 years (±9.85 yr) were included. The mean mobility seen with flexion-extension was 5.53 ± 4.11. The mean mobility seen with flexion-supine was 7.83% ± 4.67%. This difference was significant in paired t test (P = 0.00133), and independent of age and body mass index. Maximal mobility was seen between flexion and supine radiographs in 37 patients, between neutral and supine radiographs in 11 cases, and between traditional flexion-extension studies in 11 cases.

Conclusion.
Supine radiograph demonstrates more reduction in anterolisthesis than the extension radiograph. Incorporation of a supine lateral radiograph in place of extension radiograph can improve our understanding of segmental mobility when evaluating degenerative spondylolisthesis.

Level of Evidence: 3
Outcomes Reported After Surgery for Cauda Equina Syndrome
Authors: Srikandarajah Nisaharan , Wilby Martin , Clark Simon , Noble Adam , Williamson Paula , Marson Tony 
Published: February 2018

Study Design.
This is a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Objective.
To assess the outcomes reported in trials and observational studies of surgery for cauda equina syndrome (CES), and to inform the development of a core outcome set.

Summary of Background Data.
Scoping searches revealed that there were inconsistencies in which outcomes were reported and how they were measured in research studies for patients who had undergone surgery for CES.

Methods.
Ovid Medline, Embase, CINAHL Plus, and trial registries were searched from January 1, 1990 to September 30, 2016 with the term “cauda equina syndrome.” Inclusion and exclusion criteria were applied according to study design, diagnosis, procedure, publication date, language, and patient age. Data extracted included demographics, study design, the outcomes reported, and their definition. We also assessed variation in the use of terminology for each outcome domain.

Results.
A total of 1873 articles were identified, of which 61 met the inclusion criteria. Of these, 737 outcomes reported verbatim were categorized into 20 core outcome domains and 12 subdomains with a range of 1 to 141 outcomes per outcome domain or subdomain. The most commonly reported outcomes were bladder function (70.5%), motor function (63.9%), and sensation (50.8%). Significant variation in the terms used for each outcome was documented, for example, bladder function outcome domain had 141 different terms.

Conclusion.
There is significant heterogeneity in outcomes reported for studies after surgery for CES patients. This indicates a clear need for the development of a core outcome set, which has been registered as number 824 on the COMET (Core Outcome Measure in Effectiveness Trials) database.

Level of Evidence: 1
Trends of Incidence and Risk Factors of Ventilator-Associated Pneumonia in Elderly Patients Admitted to French ICUs Between 2007 and 2014*
Authors: Dananché Cédric , Vanhems Philippe , Machut Anaïs , Aupée Martine , Bervas Caroline , L’Hériteau François , Lepape Alain , Lucet Jean-Christophe , Stoeckel Vincent , Timsit Jean-François , Berger-Carbonne Anne , Savey Anne , Bénet Thomas 
Published: February 2018

Objectives:
To assess trends and risk factors of ventilator-associated pneumonia according to age, particularly in the elderly admitted to French ICUs between 2007 and 2014.

Design:
Multicenter, prospective French national Healthcare-Associated Infection surveillance network of ICUs (“Réseau REA-Raisin”).

Settings:
Two-hundred fifty six ICUs in 246 settings in France.

Patients:
Included were all adult patients hospitalized greater than or equal to 48 hours in ICUs participating in the network.

Interventions:
Ventilator-associated pneumonia surveillance over time.

Measurements and Main Results:
Overall and multidrug-resistant organism–related ventilator-associated pneumonia incidence rates were expressed per 1,000 intubation days at risk. Age was stratified into three groups: young (18–64 yr old), old (65–74 yr old), and very old (75+ yr old). Age-stratified multivariate mixed-effects Poisson regressions were undertaken to assess trends of ventilator-associated pneumonia incidence over time, with center as the random effect. Ventilator-associated pneumonia risk factors were also evaluated. Of 206,223 patients, 134,510 were intubated: 47.8% were young, 22.3% were old, and 29.9% were very old. Ventilator-associated pneumonia incidence was lower in the very old group compared with the young group (14.51; 95% CI, 16.95–17.70 vs 17.32; 95% CI, 16.95–17.70, respectively, p < 0.001). Methicillin-resistant Staphylococcus aureus and third-generation cephalosporin-resistant Enterobacteriaceae were identified more frequently in very old patients (p < 0.001 and 0.014, respectively). Age-stratified models disclosed that adjusted ventilator-associated pneumonia incidence decreased selectively in the young and old groups over time (adjusted incidence rate ratios, 0.88; 95% CI, 0.82–0.94; p < 0.001 and adjusted incidence rate ratios, 0.95; 95% CI, 0.86–1.04; p = 0.28, respectively). Male gender and trauma were independently associated with ventilator-associated pneumonia in the three age groups, whereas antibiotics at admission was a protective factor. Scheduled surgical ICU and immunodeficiency were risk factors of ventilator-associated pneumonia in the old group (p = 0.003).

Conclusions:
Ventilator-associated pneumonia incidence is lower but did not decrease over time in very old patients compared with young patients.
An Exploratory Reanalysis of the Randomized Trial on Efficacy of Corticosteroids as Rescue Therapy for the Late Phase of Acute Respiratory Distress Syndrome*
Authors: Meduri G. Umberto , Bridges Lisa , Siemieniuk Reed A. C. , Kocak Mehmet 
Published: February 2018

Objectives:
In the Acute Respiratory Distress Syndrome Network randomized controlled trial, methylprednisolone treatment was associated with increased return to mechanical ventilation with partial loss of early improvements. We hypothesize a causal relationship between protocol-driven rapid discontinuation of methylprednisolone post extubation and return to mechanical ventilation. To explore this possibility, we investigated the timing that events occurred in each treatment arm during active treatment intervention (efficacy) and after stopping therapy.

Design and Settings:
Retrospective intention-to-treat analysis of multicenter randomized controlled trial.

Patients and Interventions:
Patients were randomized to methylprednisolone (2 mg/kg/d) or placebo (89 vs 91). The target sample size was reduced post hoc and provided 80% power for an optimistic 50% mortality reduction.

Measurements and Main Results:
Findings are reported as methylprednisolone versus placebo. By day 28, fewer patients died before achieving extubation (15.7% vs 25.3% and risk ratio, 0.62; 95% CI, 0.34–1.13), more achieved successful extubation (71.9% vs 49.5% and risk ratio, 1.45; CI, 1.14–1.85), time to successful extubation was shorter (hazard ratio, 2.05; CI, 1.42–2.96), and more were discharged alive from the ICU (65.2% vs 48.3%; risk ratio, 1.35; CI, 1.04–1.75). After treatment discontinuation, more methylprednisolone-treated patients returned to mechanical ventilation (26.6% vs 6.7%; risk ratio, 3.98; CI, 1.24–12.79)—consistent with reconstituted systemic inflammation in the presence of adrenal suppression. Participants returning to mechanical ventilation without reinstitution of methylprednisolone had increased risk of ventilator dependence and mortality. Despite loss of early benefits, methylprednisolone was associated with sizable and significant improvements in all secondary outcomes and reduction in serious complications (shock and severe infections).

Conclusions:
During active intervention, methylprednisolone was safe and effective in achieving disease resolution. Our findings support rapid glucocorticoid discontinuation post extubation as likely cause of disease relapse. Gradual tapering might be necessary to preserve the significant improvements achieved during methylprednisolone administration.
Lactate Level Versus Lactate Clearance for Predicting Mortality in Patients With Septic Shock Defined by Sepsis-3
Authors: Ryoo Seung Mok , Lee JungBok , Lee Yoon-Seon , Lee Jae Ho , Lim Kyoung Soo , Huh Jin Won , Hong Sang-Bum , Lim Chae-Man , Koh Younsuck , Kim Won Young 
Published: February 2018

Objectives:
This study aimed to compare the prognostic value of lactate level and lactate clearance at 6 hours after septic shock recognition. And, we performed it to determine lactate kinetics in the Sepsis-3 defined septic shock.

Design:
This retrospective study was performed from a prospective septic shock registry.

Settings:
This study was performed at single urban tertiary center. And, all patients were treated with protocol-driven resuscitation bundle therapy between 2010 and 2016.

Patients:
We included septic shock patients who met the Sepsis-3 definition, which involves lactate levels greater than or equal to 2 mmol/L and vasopressor use.

Interventions:
Serum lactate levels were measured at initial and 6 hours from septic shock recognition.

Measurements and Main Results:
Lactate clearance was calculated as ([initial lactate – 6-hr lactate]/initial lactate) × 100. The prognostic value of measured lactate levels and lactate clearance for 28-day mortality was analyzed and compared with that of subsequent lactate levels greater than or equal to 2 mmol/L, greater than or equal to 3 mmol/L, and greater than or equal to 4 mmol/L and less than 10%, less than 20%, and less than 30% lactate clearance. A total of 1,060 septic shock patients by Sepsis-3, 265 patients died (28-d mortality: 25%). In survivor, groups had lower median 6-hour lactate level and higher lactate clearance than nonsurvivors (2.5 vs 4.6 mmol/L and 35.4% vs 14.8%; p < 0.01). Both lactate and lactate clearance were associated with mortality after adjusting for confounders (odd ratio, 1.27 [95% CI, 1.21–1.34] and 0.992 [95% CI, 0.989–0.995]), but lactate had a significantly higher prognostic value than lactate clearance (area under the curve, 0.70 vs 0.65; p < 0.01). The prognostic value of subsequent lactate levels (≥ 2, ≥ 3, and ≥ 4 mmol/L) and lactate clearances (< 10%, < 20%, and < 30%) was not significantly differed. However, lactate levels of greater than or equal to 2 mmol/L had the greatest sensitivity (85.3%).

Conclusions:
Our findings indicate lactate and lactate clearance are both useful targets in patients with septic shock defined by Sepsis-3. Serum lactate level at 6-hour can be an easier and more effective tool for prognosis of septic shock patients who were treated with protocol-driven resuscitation bundle therapy.
Impacts of Educating for Equity Workshop on Addressing Social Barriers of Type 2 Diabetes With Indigenous Patients
Authors: Crowshoe Lynden (Lindsay) , Han Han , Calam Betty , Henderson Rita , Jacklin Kristen , Walker Leah , Green Michael E. 
Published: February 2018

Introduction:
Health education about Indigenous populations in Canada (First Nations, Inuit, and Métis people) is one approach to enable health services to mitigate health disparities faced by Indigenous peoples related to a history of colonization and ongoing social inequities. This evaluation of a continuing medical education workshop, to enhance family physicians' clinical approach by including social and cultural dimensions within diabetes management, was conducted to determine whether participation in the workshop improved self-reported knowledge, skills, and confidence in working with Indigenous patients with type 2 diabetes.

Methods:
The workshop, developed from rigorous national research with Indigenous patients, diabetes care physicians, and Indigenous health medical educators, was attended by 32 family physicians serving Indigenous populations on three sites in Northern Ontario. A same-day evaluation survey assessed participants' satisfaction with workshop content and delivery. Preworkshop and postworkshop surveys consisting of 5-point Likert and open-ended questions were administered 1 week before and 3 month after the workshop. Descriptive statistics and t test were performed to analyze Likert scale questions; thematic analysis was used to elicit and cluster themes from open-ended responses.

Results:
Participants reported high satisfaction with all aspects of the workshop. Reporting improved understanding of socioeconomic (P = .002), psychosocial, and cultural factors (P = .001), participants also described adapting their clinical approach to more actively incorporating social and cultural factors and focusing on patient-centered care.

Discussion:
The workshop was effective in shifting physician's self-reported knowledge, attitudes, and skills resulting in clinical approach modifications within social, psychosocial, and cultural domains for their Indigenous patients with diabetes.