bluuebunny/crossref_metadata_2025_split huggingface dataset:
Patient and Health Care Provider Factors Associated With Prescription of Opioids After Delivery
Authors: Badreldin Nevert , Grobman William A. , Chang Katherine T. , Yee Lynn M. 
Published: September 2018

OBJECTIVE:
To identify patient and health care provider characteristics associated with receipt of a high amount of prescribed opioids at postpartum discharge.

METHODS:
This was a retrospective case–control study of all opioid-naïve women delivering at a single, high-volume tertiary care center between December 1, 2015, and November 30, 2016. Inpatient, outpatient, pharmacy, and billing records were queried for clinical, prescription, and health care provider (training, age, gender) data. The discharging health care provider, whether an opioid prescription was provided, and the details of any opioid prescription were determined. A high amount of prescribed opioids was defined as morphine milligram equivalents greater than the 90th percentile (determined as 300 morphine milligram equivalents for vaginal and 500 morphine milligram equivalents for cesarean delivery). Multivariable logistic regression models with random effects were used to identify patient and health care provider factors independently associated with receipt of a high amount of prescribed opioids at discharge. Findings were analyzed separately by mode of delivery.

RESULTS:
The analysis included 12,362 women. High amounts of opioids were prescribed for 636 of 9,038 (7.0%) women who delivered vaginally and 241 of 3,288 (7.3%) of those delivering by cesarean. In multivariable analysis, patient factors associated with receipt of a high amount of prescribed opioids at discharge after a vaginal delivery included nulliparity, intrapartum neuraxial anesthesia, major laceration, and infectious complication. Discharge by a trainee physician was associated with decreased odds of receiving a high amount of opioids (8.5% vs 1.9%; adjusted odds ratio [OR] 0.08, 95% CI 0.01–0.53). For women who underwent cesarean delivery, the only patient factor associated with receipt of a high amount of prescribed opioids was hemorrhage. Discharge by a trainee physician was associated with decreased odds of being provided a high-amount opioid prescription (7.9% vs 0.4%; adjusted OR 0.01, 95% CI 0.00–0.36).

CONCLUSION:
Even after adjusting for patient factors, discharge by a trainee physician is significantly associated with decreased odds of a high amount of prescribed opioids at postpartum discharge.
Maternal Outcomes Associated With Lower Range Stage 1 Hypertension
Authors: Sutton Elizabeth F. , Hauspurg Alisse , Caritis Steve N. , Powers Robert W. , Catov Janet M. 
Published: September 2018

OBJECTIVE:To evaluate maternal and neonatal outcomes in healthy, nulliparous women classified with stage 1 hypertension under the revised American College of Cardiology and American Heart Association Guidelines and to evaluate the effects of low-dose aspirin on maternal and neonatal outcomes in this population.METHODS:We conducted a secondary analysis of data from a multicenter randomized, double-blind, placebo-controlled trial of low-dose aspirin for prevention of preeclampsia in nulliparous, low-risk women recruited between 13 and 25 weeks of gestation. Of the 3,134 nulliparous women enrolled in the original study, 2,947 women with singleton pregnancies and without missing data were included in this analysis. Blood pressure was measured at enrollment between 13 and 25 weeks of gestation and outcomes were adjudicated from the medical record.RESULTS:One hundred sixty-four participants were identified with lower range stage 1 hypertension (5.6%), systolic blood pressure 130–135 mm Hg, diastolic blood pressure 80–85 mm Hg, or both by the new American College of Cardiology–American Heart Association guidelines. Within the placebo group (n=1,482), women with stage 1 hypertension had a significantly increased incidence of preeclampsia compared with normotensive women, 15.3% (15/98) vs 5.4% (75/1,384) (relative risk 2.66, 95% CI 1.56–4.54,P<.001). Moreover, women with stage 1 hypertension had an increased incidence of gestational diabetes mellitus (6.1% vs 2.5%,P=.03) and more indicated preterm deliveries (4.2% vs 1.1%,P=.01). Comparing women with stage 1 hypertension and normotensive women receiving low-dose aspirin during pregnancy (n=1,465), no differences in rates of preeclampsia (7.6% vs 4.4%, respectively,P=.2), gestational diabetes mellitus, or indicated preterm deliveries were observed. Rates of placenta abruption, small for gestational age, and spontaneous preterm birth did not differ significantly between groups.CONCLUSION:Application of the new American College of Cardiology–American Heart Association guidelines in a pregnant population identifies a cohort of women who are at increased risk for preeclampsia, gestational diabetes mellitus, and preterm birth.
Delivery-to-Delivery Weight Gain and Risk of Hypertensive Disorders in a Subsequent Pregnancy
Authors: Dude Annie M. , Shahawy Sarrah , Grobman William A. 
Published: September 2018

OBJECTIVE:
To estimate whether weight gain between deliveries is associated with an increased risk of hypertensive disorders in a subsequent pregnancy.

METHODS:
This is a case–control study of women who had two live singleton births of at least 24 weeks of gestation at a single maternity hospital from January 1, 2005, to December 31, 2015, with no hypertensive disorder documented in the index pregnancy. Maternal weight gain between deliveries was measured as the change in body mass index (BMI) at delivery. Women who were diagnosed with any hypertensive disorder in the subsequent pregnancy were compared with those who experienced no hypertensive disorder in the subsequent pregnancy using χ2 statistics for categorical variables and t tests for continuous variables. Logistic regression was used to determine whether weight gain remained independently associated with hypertensive disorders after adjusting for potential confounders.

RESULTS:
Of 1,033 women, 188 (18.2%) were diagnosed with a hypertensive disorder in the subsequent pregnancy. Of these, 166 (88.3%) had a hypertensive disorder specific to pregnancy (gestational hypertension; preeclampsia; superimposed preeclampsia; or hemolysis, elevated liver enzymes, and low platelet count syndrome), and 22 (11.7%) had chronic hypertension only. Greater weight gain between deliveries was significantly associated with a higher frequency of hypertensive disorders, which remained significant for a BMI increase of at least 2 kg/m2 in multivariable analyses (adjusted odds ratio [OR] 1.76, 95% CI 1.14–2.74 for 2 to less than 4 kg/m2, adjusted OR 3.19, 95% CI 1.86–5.47 for 4 kg/m2 or more). Conversely, weight loss of 2 kg/m2 or more was associated with a decreased risk of a hypertensive disorder (adjusted OR 0.41, 95% CI 0.21–0.81).

CONCLUSION:
Among women with no hypertensive disorder noted in an index pregnancy, an increase in BMI of at least 2 kg/m2 between deliveries was independently associated with an increased risk of a hypertensive disorder in a subsequent pregnancy.
Mozart for Reducing Patient Anxiety During Colposcopy
Authors: Hilal Ziad , Alici Ferizan , Tempfer Clemens B. , Rath Katrin , Nar Kirnjit , Rezniczek Günther A. 
Published: September 2018

OBJECTIVE:
To test whether music by Mozart reduces anxiety among patients undergoing colposcopy.

METHODS:
In a randomized multicenter trial, we measured the reduction of the situation-specific anxiety of women hearing Mozart’s Symphony No. 40 during colposcopy compared with women not hearing music using the State-Trait Anxiety Inventory. Secondary endpoints were reduction of heart rate (beats per minute), pain during and 10 minutes after colposcopy, general unpleasantness, anxiety during colposcopy, and overall satisfaction (11-item visual analog scales). Analysis was by intention to treat. A sample size of 104 per group (N=208) was calculated to achieve 80% power to detect a difference of 4.8 with a SD of 12.3 in anxiety scores.

RESULTS:
Between February 2017 and May 2018, 212 women were randomized. The mean anxiety reduction was −9.4±10.8 SD in 103 women in the music group and −9.0±10.6 in 102 women in the control group (P=.40). The secondary endpoints reduction of heart rate (−16.3±16.9 vs −15.4±17.1; P=.37), pain during procedure (median 2 [interquartile range 1–4] vs 2 [1–3.5]; P=.80), pain 10 minutes after examination (1 [0–1.75] vs 1 [0–2]; P=.42), general unpleasantness (3 [1–5.75] vs 4 [1–5.5]; P=.35), anxiety during examination (2 [1–5] vs 2 [1–6]; P=.28), and overall satisfaction (10 [9–10] vs 10 [9–10]; P=.81) were also not different between the two study groups.

CONCLUSION:
Mozart’s Symphony No. 40 does not reduce anxiety in women undergoing colposcopy.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT03005795.
New insights in myositis-specific autoantibodies
Authors: Ghirardello Anna , Doria Andrea 
Published: September 2018

Purpose of review
The aim of this study was to provide the most recent evidence on clinical utility of myositis-specific autoantibodies (MSAs) in the management of patients with myositis.

Recent findings
In the last few years, several evidences have emerged on the clinical and pathogenetic role of established and novel MSA. Antisynthetase antibodies represent a reliable biomarker for pulmonary involvement also in patients with connective tissue diseases other than myositis. Antisignal recognition particle and antihydroxy-3-methylglutaryl coenzyme A reductase autoantibodies are able to induce complement-dependent muscle damage. Dermatomyositis-specific antibodies are useful indicators of clinical diversity. The pivotal role of antitranscription intermediary factor 1γ autoimmune response in adult-age paraneoplastic dermatomyositis has been further asserted. AnticN1A and antifour-and-a-half LIM protein 1 antibodies are newly conceived myositis-related antibody specificities, which can contribute to patients’ stratification into more homogeneous groups.

Summary
Distinct autoantibody-associated clinical phenotypes can be predicted by extended MSA testing in serum. Standardization and validation of MSA laboratory detection methods is strongly recommended for better supporting myositis diagnosis, management and prognosis definition.
Understanding the Opioid Epidemic: Factors Predictive of Inpatient and Postdischarge Prescription Opioid Use After Orthopaedic Trauma
Authors: Flanagan Christopher D. , Wysong Elena F. , Ramey James Scott , Vallier Heather A. 
Published: September 2018

Objective:
The purpose of this study was to determine which factors influence inpatient and postdischarge opioid use after orthopaedic trauma.

Design:
Retrospective cohort study.

Setting:
Single Level 1 trauma center.

Participants:
The study included 235 adult trauma patients treated operatively for fracture with minimum 1 overnight hospital stay.

Intervention:
Operative fracture management.

Main Outcome Measurement:
Total opioid pain medication use, in oral morphine equivalents, in inpatient and postdischarge settings.

Results:
Controlling for length of stay, inpatient opioid use was negatively correlated with age and positively correlated with Injury Severity Score, intensive care unit (ICU) admission, and baseline tobacco use (P < 0.0001, adjusted R2 = 0.274). Discharge opioid prescription amount was negatively correlated with age, the presence of a complication, and ICU admission and positively correlated with inpatient opioid use (P < 0.0001, adjusted R2 = 0.201). Postdischarge opioid use was associated with larger amounts of opioids prescribed at discharge, a patient history of alcohol use at baseline, and ICU admission (P < 0.0001, R2 = 0.123).

Conclusion:
Nonmodifiable factors accounted for the level of inpatient opioid use in a trauma population. Higher inpatient use predicts larger opioid prescriptions at discharge, whereas larger discharge prescription predicts greater postdischarge opioid use. Strategies to reduce postdischarge opioid use should begin with reductions in inpatient opioid use. Multimodal pain strategies may be needed to achieve this goal.

Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Importance of Mechanoreceptors and Other Neural Structures Within the Anterior Intermeniscal Ligament in the Etiology of Anterior Knee Pain After Tibial Nailing
Authors: Franke Jörg , Brobeil Alexander , Lips Katrin Susanne , Gattenloehner Stefan , Franke Anissa Paulina , Hohendorff Bernd , Alt Volker , Schnettler Reinhard 
Published: September 2018

Background:
Anterior knee pain is the most common complication after intramedullary tibial nailing. The cause is often multifactorial and varies among individuals. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible source of postsurgical anterior knee pain. Although there is a certain ambiguity regarding the importance and function of the AIL, neural structures in the AIL tissue might play a significant role with respect to functional purposes and pain perception.

Methods:
We subjected 6 AIL specimens to histologic examination to identify the neural structures that are a mandatory requirement as a source of anterior knee pain. Specifically, we performed three-dimensional immunohistochemical investigation of subtyping, orientation, and detailed characterization of neural structures within the AIL tissue.

Results:
Histologic and three-dimensional immunohistochemical examinations confirmed the presence of neural structures in all 6 AIL specimens. We identified myelinated and unmyelinated nerve fibers, as well as all types of mechanoreceptors.

Conclusions:
Free nerve endings are a mandatory requirement for pain perception as a result of AIL violation during tibial nailing. Our verification of all different types of mechanoreceptors in the AIL tissue makes a role of the ligament in knee joint function and proprioception highly probable. Further investigations are necessary to clarify possible correlations between neural supply and function of the AIL. Violation of the ligament during operative procedures should be avoided, although the significance of the AIL is still debated.
Radiographic and Clinical Outcomes of Periprosthetic Distal Femur Fractures Treated With Open Reduction Internal Fixation
Authors: Christ Alexander B. , Chawla Harshvardhan , Gausden Elizabeth B. , Villa Jordan C. , Wellman David S. , Lorich Dean G. , Helfet David L. 
Published: September 2018

Objectives:
To report outcomes and complications of periprosthetic distal femur fractures (PPDFF) treated with open reduction internal fixation (ORIF) using a plate construct, with or without endosteal augmentation.

Design:
Retrospective Case Series.

Setting:
One Level I trauma center and one tertiary care hospital.

Patients/Participants:
Forty patients with PPDFFs, treated by 3 surgeons, were identified using an institutional trauma registry. Thirty-two patients with 12 months of clinical and radiographic follow-up were included, and 8 patients were lost to follow-up before 12 months.

Intervention:
All patients underwent ORIF of the PPDFF with lateral locked plating, and 11 received additional endosteal augmentation using allograft fibula.

Results:
Thirty-two patients were available for the final follow-up. Ninety-four percent of patients achieved union at an average of 6.5 months postoperatively. Twenty-one percent of patients underwent subsequent surgery, with more than half of those being for removal of implants. Anatomic limb alignment was achieved in all cases (no malunions). Almost half of the patients required assistive devices for ambulation in the long term.

Conclusions:
ORIF of PPDFF with direct visualization using periarticular locking plates ± endosteal strut allograft resulted in a 94% union rate and no deep infections. There was no difference in outcomes between groups treated with or without additional endosteal fibular allograft. However, these are catastrophic injuries in frail patients, and 20% of patients either died or were lost to follow-up, and almost half required an assistive device for ambulation after surgery despite restoration of limb alignment.

Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Consortium of Orthopaedic Academic Traumatologists: A Model for Collaboration in Orthopaedic Surgery
Authors: Miclau Theodore , MacKechnie Madeline C. , Shearer David W. ,   on behalf of the COACT group
Published: September 2018

Summary:
In March 2016, North American academic leaders with an interest in and commitment to the field of global orthopaedics met in Orlando, Florida, to gauge each institution's clinical, research, and educational programs in developing countries, establish the main limitations to participating in global health efforts, and assess areas of need for both the participating institutions and their international partners. After this inaugural meeting, a needs assessment survey was distributed to the group to better understand how to organize and unify the individual institutional global efforts. The results revealed that surgeons believed there was a vital need for improved communication, mentorship, and infrastructural support between North American universities. To this end, the Consortium of Orthopaedic Academic Traumatologists (COACT) was founded. The COACT seeks to promote a novel framework geared toward improving trauma care capacity by building collaborative partnerships among leading academic centers across the United States and Canada. The consortium represents a comprehensive partnership that promotes communication, collaboration, and advocacy through a central network to facilitate investigative, educational, and clinical services. Academic partners share best practices, resources, and opportunities in their international outreach projects in low- and middle-income countries in the field of orthopaedic trauma. Over the course of the past 2 years, the COACT has grown to more than 80 faculty, fellow, resident, and student members, representing over 20 orthopaedic institutions across North America.
Practical Guide to Delivering Surgical Skills Courses in a Low-Income Country: Knowledge Gained From a Surgical Education Partnership in Haiti
Authors: Furey Andrew , O'Hara Nathan N. , Marshall Erin , Pollak Andrew N. 
Published: September 2018

Summary:
Routine surgical skills training is known to advance a surgeon's technical proficiency. However, orthopaedic providers in low-income countries have limited access to skills training programs. International academic partnerships can augment locally available orthopaedic education, improving the quality of and capacity to deliver orthopaedic care in low-income countries. The objective of this study is to provide a practical guide to delivering an orthopaedic skills training course in a low-resource setting. The information provided is based on the experiences of the authors, along with specific feedback from previous course participants in Haiti.
Haitian Annual Conference on Orthopaedic Traumatology: Building Surgical Capacity Through Academic Collaboration
Authors: Dyer George S. M. 
Published: September 2018

Summary:
The Assemblée Annuelle Haitienne de Traumatologie Orthopedique (Haitian Annual Conference on Orthopaedic Traumatology) is an international orthopaedic conference, conducted each Spring in Haiti in French and English. It brings together most of Haiti's practicing orthopaedic surgeons, trainees from Haiti's 3 residency training programs, and a visiting faculty from overseas. The Haitian Annual Conference on Orthopaedic Traumatology has become an unexpected cornerstone of 1 program to support and nurture the development of orthopaedic surgery in that country.
Conducting a Randomized Controlled Trial in Tanzania: Institute for Global Orthopaedics and Traumatology and the Muhimbili Orthopaedic Institute
Authors: Ibrahim John , Liu Max , Yusi Kurt , Haonga Billy , Eliezer Edmund , Shearer David W. , Morshed Saam 
Published: September 2018

Introduction:
Low- and middle-income countries (LMICs) experience a large volume of orthopaedic trauma, but limited research exists to evaluate effective treatments using locally available means. Academic partners can help design and implement research studies through collaborative efforts with local investigators. We will describe the study design and lessons learned from a randomized controlled trial in Tanzania comparing outcomes of 2 operative treatments for open tibia fractures.

Study Design:
The Institute for Global Orthopaedics and Traumatology at the University of California, San Francisco, and the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania, partnered to design a prospective, randomized controlled trial. Adult patients with open tibia fractures were randomized to receive either intramedullary nailing or external fixation as definitive fixation. Our primary outcome was the rate of reoperation, and secondary outcomes included EQ-5D, pain, function, radiographic union, and return to work.

Results:
We enrolled 40 patients in a pilot study that informed improvements in the study design and standard operating procedures. These modifications included development of a specific outline of the technical standards for each surgical intervention and held training workshops to disseminate this knowledge among operative surgeons. This resulted in the successful enrollment and standardized treatment of our target sample of 240 patients.

Discussion:
There are several challenges in conducting high-quality, international research. Keys for success include maintaining a strong relationship between partners, having local research coordinators, simplifying data collection and storage, and incentivizing patients to attend follow-up visits.
Developing Sustainable Orthopaedic Care in Northern Tanzania: An International Collaboration
Authors: Sheth Neil P. , Hardaker W. Mack , Zakielarz Kevin S. , Rudolph Michele , Massawe Honest , Levin L. Scott , Premkumar Ajay 
Published: September 2018

Summary:
There is a devastating lack of access to surgical care, including orthopaedic surgery, in low- and middle-income countries. Similar to other low- and middle-income countries, Tanzania has a severe shortage of trained orthopaedic surgeons. The surgeons available are inundated with acute trauma care and musculoskeletal infections; elective procedures are infrequently performed and the burden of neglected care continues to rise annually. Over the past several years, our interdisciplinary team of both American and Tanzanian members has worked to understand the current local cultural and economic barriers to increasing surgical capacity, ensuring surgical safety, delivering affordable care, providing adequate patient follow-up, and improving surgical education. We propose a new paradigm for the delivery of musculoskeletal care and creation of sustained surgical capacity in this setting by building an Orthopaedic Center of Excellence in Moshi, Tanzania, augmented by international partner institutions year-round. This initiative is a public–private partnership led by the University of Pennsylvania in conjunction with Kilimanjaro Christian Medical Center. A growing number of contributors, including the Tanzanian Health Ministry, several universities, and industry partners, including general electric (GE) Health Care Africa, are currently helping to advance this concept into reality. Through our model, we aim to increase surgical capacity and quality, as well as enhance local surgical education, with the ultimate objective of training the next generation of African surgeons in the latest surgical techniques and equipment.