bluuebunny/crossref_metadata_2025_split huggingface dataset:
Clinical Outcomes and Complications of the Surgical Implant Generation Network (SIGN) Intramedullary Nail: A Systematic Review and Meta-Analysis
Authors: Usoro Andrew O. , Bhashyam Abhiram , Mohamadi Amin , Dyer George S. , Zirkle Lewis , von Keudell Arvind 
Published: October 2018

Objectives:
This study is a systematic review and meta-analysis of the clinical outcomes and pooled complication rate of femoral, tibial, and humeral fracture fixation using SIGN nails. We aimed at comparing the pooled rate of adverse events based on the country of study origin, acute versus delayed fracture fixation, and length of follow-up.

Methods:
We searched PubMed/MEDLINE/Cochrane databases from 2000 to 2016 for English language studies. There was substantial heterogeneity among included studies. Therefore, we used subgroup analysis of varying adverse events and removal of potential outlier studies based on the “remove one” sensitivity analysis to address the heterogeneity across studies. A funnel plot was drawn and inspected visually to assess publication bias. We reported pooled complication rates for each adverse event with 95% prediction interval.

Results:
There were 14 studies with 47,169 cases across 58 different low- and middle-income countries. The average age was 33 ± 14 years, with 83% men and 17% women. Sixty percent of SIGN nails used in these 14 studies were used in femur fracture fixation, 38% in tibial shaft fractures, and the remaining 2% for humeral shaft fractures. Approximately 23% of patients had follow-up data recorded. All studies that measured clinical outcome indicated that >90% achieved full weight-bearing status, favorable range of motion (knee range of motion >90 degrees according to the SIGN database), and radiographic or clinical union depending on the specific variable(s) measured in each study. The overall complication rate was 5.2% (4.4%–6.4%). Malalignment (>5 degrees of angulation in any plane) was the most common complication (7.6%), followed by delayed/nonunion (6.9%), infection (5.9%), and hardware failure, (3.2%).

Conclusions:
Overall, the use of SIGN nails in fixing femoral, tibial, and humeral shaft fractures demonstrates good results with a high rate of return to full weight-bearing and radiographic/clinical union. The most common complications when using the SIGN nail are malalignment, delayed/nonunion, infection, and hardware failure.

Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Impact of Direct Oral Anticoagulants in Patients With Hip Fractures
Authors: Bruckbauer Martin , Prexl Oliver , Voelckel Wolfgang , Ziegler Bernhard , Grottke Oliver , Maegele Marc , Schöchl Herbert 
Published: October 2018

Objective:
To assess the impact of direct oral anticoagulant (DOAC) intake compared with Coumadin (COU) in patients suffering hip fractures (HFs).

Design:
Retrospective cohort analysis.

Setting:
Level 1 Trauma Center.

Intervention:
Timing of surgical hip fixation.

Patients:
Three-hundred twenty patients 65 years of age or older with isolated HF were enrolled into the study: 207 (64.7%) without any antithrombotic therapy (no-ATT), 59 (18.4%) on COU, and 54 (16.9%) on DOACs.

Main Outcome Measurements:
Time to surgery, blood loss, mortality, hospital length of stay, red blood cell transfusion, use of reversal agents, and Charlson Comorbidity Index.

Results:
Patients on COU and DOACs had a higher Charlson Comorbidity Index compared with the no-ATT group (P < 0.0001). Despite the fact that significantly more patients received reversal agents in the COU group compared with DOAC medication (P < 0.0001), percentage of transfused patients were similar (54.2% vs. 53.7%). Time to surgery was significantly shorter in the no-ATT group when compared with DOAC patients (12–29.5 hours, respectively). No difference in postoperative hemorrhage, intensive care unit length of stay, and mortality was observed between groups.

Conclusions:
DOAC medication in HF patients caused long elapse time until surgical repair. We found no evidence of higher bleeding rates in HF patients on DOACs compared with COUs. Earlier HF fixation might be indicated in DOAC patients.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Self-Reported Recovery Likelihood Predicts Higher Physician Ratings: A Survey of Patients After Orthopaedic Surgery
Authors: Rascoe Alexander S. , Treiman Scott , Gunasekar Ashwath , Vallier Heather A. 
Published: October 2018

Objectives:
What are the differences between elective and trauma patient satisfaction and do patient and diagnosis factors predict physician scores?

Design:
Prospective cohort study.

Setting:
Urban Level 1 Trauma center.

Patients/Participants:
Three hundred twenty-three trauma patients and 433 elective orthopaedic patients treated at our center by the same surgeons.

Intervention:
Trauma patients treated surgery for one or more fractures; elective patients treated with hip, knee, or shoulder arthroplasty, or rotator cuff repair.

Main Outcome Measurements:
Telephone survey regarding patient experience and satisfaction with their care. The survey included questions from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, and responses were rated on a 1–5 point Likert scale (5 best).

Results:
Elective surgery patients had mean age of 56.4 years, and trauma patients were mean 50.3 years of age. Trauma patients rated their likelihood to make a full recovery lower than elective patients (median, interquartile range), 5.0 (1.0) versus 4.0 (2.0) (P < 0.001). After multivariate binary logistic regression, patients who rated the hospital higher (≥4 vs. ≤3) were more likely (odds ratio = 10.0, 95% confidence interval, 6.4–15.8) to score physicians better. Similarly, patients who scored their overall likelihood of recovering ≥4 compared with ≤3 were more likely (odds ratio = 3.6, 95% confidence interval, 2.9–5.6) to rate their physicians more positively.

Conclusions:
Patient perceptions including their likelihood to make a full recovery and their overall impression of the hospital predicted higher physician scores. We conclude that these physician scores are subject to patient perception biases and are not independent of the overall care experience. We recommend HCAHPS and physician ratings' web sites include internal controls, such as the patient perception of overall likelihood to recover, to aid in interpreting survey results.
Intraoperative Assessment of Coronal Alignment in Distal Femur Fracture Fixation: Technical Trick
Authors: Scott Brandon R. , Wright Raymond D. , Moghadamian Eric S. 
Published: October 2018

Summary:
Supracondylar femur fractures represent a challenging and common injury treated by many orthopedic surgeons. An array of surgical fixation options has been developed to help the treating surgeon restore normal anatomic alignment of these fractures, and lateral precontoured condylar femoral locking plates have become a common implant for most surgeons in treating these fractures. Although these precontoured plates provide significant benefit to the treating physician in regards to gaining appropriate bony fixation, common technical errors that may lead to malalignment when using these plates have been described. Avoiding these errors will help improve patient outcomes. Here, we describe a novel, inexpensive, and universally available technique that may aid the treating surgeon in restoring coronal alignment when treating distal femur fractures.
Reverse Shoulder Arthroplasty in Acute Fractures of the Proximal Humerus: Does Tuberosity Healing Improve Clinical Outcomes?
Authors: Reuther Falk , Petermann Martin , Stangl Richard 
Published: October 2018

Objective:
To evaluate the clinical outcomes of reverse shoulder arthroplasty (RSA) in elderly patients with proximal humeral fractures and assess the role of tuberosity healing on the outcome.

Design:
Case series.

Setting:
Multicenter clinical study of Level-2 trauma centers.

Patients/Participants:
We included 81 patients with a mean age of 78.5 ± 6.5 years (range, 58.5–90.9 years) and a nonreconstructable proximal humeral fracture.

Intervention:
Modular reverse fracture shoulder arthroplasty.

Main Outcome Measurements:
We determined range of motion, constant score, and the American Shoulder and Elbow Surgeons Shoulder Score as clinical outcomes and evaluated tuberosity healing at 6 weeks, 6 months, 1 year, and 2 years.

Results:
Tuberosities healed in most patients; 37 patients had completely healed tuberosities, and 33 patients had partially healed tuberosities, whereas 11 patients had unhealed tuberosities. However, no significant differences were found in the functional outcomes among the 3 groups (P > 0.05).

Conclusions:
Our results with a modular reverse prosthesis confirmed similar constant scores, American Shoulder and Elbow Surgeons Shoulder Scores, and tuberosity healing rates as reported in the current clinical evidence for RSA. We could not confirm that tuberosity healing improved functional outcomes; however, it should be noted that tuberosity healing was assessed using standard radiographs. Nevertheless, our study strengthens the consensus that RSA can be recommended for well-selected elderly patients with complex displaced proximal humeral fractures.

Level of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The Effects of Storage Age of Blood in Massively Transfused Burn Patients: A Secondary Analysis of the Randomized Transfusion Requirement in Burn Care Evaluation Study
Authors: Cartotto Robert , Taylor Sandra L. , Holmes James H. , Peck Michael , Cochran Amalia , King Booker T. , Bhavsar Daval , Tredget Edward E. , Mozingo David , Greenhalgh David , Pollock Brad H. , Palmieri Tina L. 
Published: October 2018

Objectives:
Major trials examining storage age of blood transfused to critically ill patients administered relatively few blood transfusions. We sought to determine if the storage age of blood affects outcomes when very large amounts of blood are transfused.

Design:
A secondary analysis of the multicenter randomized Transfusion Requirement in Burn Care Evaluation study which compared restrictive and liberal transfusion strategies.

Setting:
Eighteen tertiary-care burn centers.

Patients:
Transfusion Requirement in Burn Care Evaluation evaluated 345 adults with burns greater than or equal to 20% of the body surface area. We included only the 303 patients that received blood transfusions.

Interventions:
The storage ages of all transfused red cell units were collected during Transfusion Requirement in Burn Care Evaluation. A priori measures of storage age were the the mean storage age of all transfused blood and the proportion of all transfused blood considered very old (stored ≥ 35 d).

Measurements and Main Results:
The primary outcome was the severity of multiple organ dysfunction. Secondary outcomes included time to wound healing, the duration of mechanical ventilation, and in-hospital mortality. There were 6,786 red cell transfusions with a mean (± sd) storage age of 25.6 ± 10.2 days. Participants received a mean of 23.4 ± 31.2 blood transfusions (range, 1–219) and a mean of 5.3 ± 10.7 units of very old blood. Neither mean storage age nor proportion of very old blood had any influence on multiple organ dysfunction severity, time to wound healing, or mortality. Duration of ventilation was significantly predicted by both mean blood storage age and the proportion of very old blood, but this was of questionable clinical relevance given extreme variability in duration of ventilation (adjusted r
2 ≤ 0.01).

Conclusions:
Despite massive blood transfusion, including very old blood, the duration of red cell storage did not influence outcome in burn patients. Provision of the oldest blood first by Blood Banks is rational, even for massive transfusion.
Incidence and Prevalence of Delirium Subtypes in an Adult ICU: A Systematic Review and Meta-Analysis*
Authors: Krewulak Karla D. , Stelfox Henry T. , Leigh Jeanna Parsons , Ely E. Wesley , Fiest Kirsten M. 
Published: October 2018

Objectives:
Use systematic review and meta-analytic methodology to estimate the pooled incidence, prevalence, and proportion of delirium cases for each delirium subtype (hypoactive, hyperactive, and mixed) in an adult ICU population.

Data Sources:
We conducted a search of the MEDLINE, EMBASE, CINAHL, SCOPUS, Web of Science, and PsycINFO databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards from database inception until October 22, 2017, with no restrictions.

Study Selection:
We included original research conducted in adults admitted to any medical, surgical, or speciality ICU that reported incidence or prevalence estimates of delirium according to delirium subtype.

Data Extraction:
Data were extracted on sample size, population demographics, condition information, and reported delirium estimates.

Data Synthesis:
Forty-eight studies (27,342 patients; 4,550 with delirium) with an overall pooled prevalence of 31% (95% CI, 24–41; I

2
= 99%) met inclusion criteria. The pooled incidence (n = 18 studies) of delirium subtypes were hyperactive (4% [95% CI, 2–6]; I
2 = 92%]), hypoactive (11% [95% CI, 8–17; I
2 = 97%]), and mixed (7% [95% CI, 4–11; I
2 = 97%]). The pooled prevalence (n = 31 studies) of delirium subtypes were hyperactive (4% [95% CI, 3–6; I
2 = 94%]), hypoactive (17% [95% CI, 13–22; I
2 = 97%]), and mixed (10% [95% CI, 6–16; I
2 = 99%]). The pooled prevalence of hypoactive delirium in study populations with a similarly high severity of illness or mechanically ventilated was higher (severity of illness: 29% [95% CI, 18–46%; I

2
= 95%], 100% mechanically ventilated: 35% [95% CI, 23–55%; I

2
= 93%]) compared with the pooled prevalence of hypoactive delirium.

Conclusions:
Despite significant heterogeneity between studies, these data show the majority of delirious ICU patients to have hypoactive delirium, a finding with potential monitoring, management, and prognostic implications. The prevalence of hypoactive delirium varies between-study populations and is higher in patients with greater severity of illness.
Renal Klotho is Reduced in Septic Patients and Pretreatment With Recombinant Klotho Attenuates Organ Injury in Lipopolysaccharide-Challenged Mice
Authors: Jou-Valencia Daniela , Molema Grietje , Popa Eliane , Aslan Adnan , van Dijk Fransien , Mencke Rik , Hillebrands Jan-Luuk , Heeringa Peter , Hoenderop Joost G. , Zijlstra Jan G. , van Meurs Matijs , Moser Jill 
Published: October 2018

Objectives:
To determine the applicability of recombinant Klotho to prevent inflammation and organ injury in sepsis in man and mice.

Design:
Prospective, clinical laboratory study using “warm” human postmortem sepsis-acute kidney injury biopsies. Laboratory study using a mouse model of endotoxemia.

Setting:
Research laboratory at a university teaching hospital.

Subjects:
Adult patients who died of sepsis in the ICU and control patients undergoing total nephrectomy secondary to renal cancer; male C57BL/6 and Klotho haploinsufficient mice.

Interventions:
Lipopolysaccharide (0.05 mg/kg) injection and kill after 4, 8, and 24 hours. Mice received recombinant Klotho (0.05 mg/kg) 30 minutes prior to lipopolysaccharide (1 mg/kg) injection. Mice treated with saline were included as controls.

Measurements and Main Results:
Quantitative reverse transcription polymerase chain reaction and immunohistochemical staining were used to quantify Klotho messenger RNA and protein expression in the kidney of sepsis-acute kidney injury patients and the kidney and brain of mice. The messenger RNA and protein expression of damage markers, inflammatory cytokine, chemokines, and endothelial adhesion molecules were also determined in mice. Renal neutrophil influx was quantified. We found significantly lower renal Klotho messenger RNA and protein levels in sepsis-acute kidney injury biopsies than in control subjects. These findings were recapitulated in the kidney and brain of lipopolysaccharide-challenged mice. Decreased Klotho expression paralleled an increase in kidney damage markers neutrophil gelatinase-associated lipocalin and kidney injury molecule-1. Administration of recombinant Klotho prior to lipopolysaccharide injection attenuated organ damage, inflammation and endothelial activation in the kidney and brain of mice. Furthermore, less neutrophils infiltrated into the kidneys of recombinant Klotho mice compared with lipopolysaccharide only treated mice.

Conclusions:
Renal Klotho expression in human sepsis-acute kidney injury and in mouse models of sepsis was significantly decreased and correlated with renal damage. Recombinant Klotho intervention diminished organ damage, inflammation, and endothelial activation in the kidney and brain of lipopolysaccharide-challenged mice. Systemic Klotho replacement may potentially be an organ-protective therapy for septic patients to halt acute, inflammatory organ injury.
Meaning of Intracranial Pressure-to-Blood Pressure Fisher-Transformed Pearson Correlation–Derived Optimal Cerebral Perfusion Pressure: Testing Empiric Utility in a Mechanistic Model
Authors: Akhondi-Asl Alireza , Vonberg Frederick W. , Au Cheuk C. , Tasker Robert C. 
Published: October 2018

Objectives:
Time-averaged intracranial pressure-to-blood pressure Fisher-transformed Pearson correlation (PRx) is used to assess cerebral autoregulation and derive optimal cerebral perfusion pressure. Empirically, impaired cerebral autoregulation is considered present when PRx is positive; greater difference between time series median cerebral perfusion pressure and optimal cerebral perfusion pressure (Δ
CPP) is associated with worse outcomes. Our aims are to better understand: 1) the potential strategies for targeting optimal cerebral perfusion pressure; 2) the relationship between cerebral autoregulation and PRx; and 3) the determinants of greater Δ
CPP.

Design:
Mechanistic simulation using a lumped compartmental model of blood pressure, intracranial pressure, cerebral autoregulation, cerebral blood volume, Paco
2, and cerebral blood flow.

Setting:
University critical care integrative modeling and precision physiology research group.

Subjects:
None, in silico studies.

Interventions:
Simulations in blood pressure, intracranial pressure, Paco
2, and impairment of cerebral autoregulation, with examination of “output” cerebral perfusion pressure versus PRx-plots, optimal cerebral perfusion pressure, and Δ
CPP.

Measurements and Main Results:
In regard to targeting optimal cerebral perfusion pressure, a shift in mean blood pressure or mean intracranial pressure with no change in mean blood pressure, with intact cerebral autoregulation, impacts optimal cerebral perfusion pressure. Second, a positive PRx occurs even with intact cerebral autoregulation. In relation to Δ
CPP, for a given input blood pressure profile, with constant intracranial pressure, altering the degree of impairment in cerebral autoregulation or the level of Paco
2 maintains differences to within ±5 mm Hg. Change in intracranial pressure due to either an intermittently prolonged pattern of raised intracranial pressure or terminal escalation shows Δ
CPP greater than 10 mm Hg and less than –10 mm Hg, respectively.

Conclusions:
These mechanistic simulations provide insight into the empiric basis of optimal cerebral perfusion pressure and the significance of PRx and Δ
CPP. PRx and optimal cerebral perfusion pressure deviations do not directly reflect changes in cerebral autoregulation but are, in general, related to the presence of complex states involving well-described clinical progressions with raised intracranial pressure.
Minimal Impact of Implemented Early Warning Score and Best Practice Alert for Patient Deterioration*
Authors: Bedoya Armando D. , Clement Meredith E. , Phelan Matthew , Steorts Rebecca C. , O’Brien Cara , Goldstein Benjamin A. 
Published: October 2018

Objectives:
Previous studies have looked at National Early Warning Score performance in predicting in-hospital deterioration and death, but data are lacking with respect to patient outcomes following implementation of National Early Warning Score. We sought to determine the effectiveness of National Early Warning Score implementation on predicting and preventing patient deterioration in a clinical setting.

Design:
Retrospective cohort study.

Setting:
Tertiary care academic facility and a community hospital.

Patients:
Patients 18 years old or older hospitalized from March 1, 2014, to February 28, 2015, during preimplementation of National Early Warning Score to August 1, 2015, to July 31, 2016, after National Early Warning Score was implemented.

Interventions:
Implementation of National Early Warning Score within the electronic health record and associated best practice alert.

Measurements and Main Results:
In this study of 85,322 patients (42,402 patients pre-National Early Warning Score and 42,920 patients post-National Early Warning Score implementation), the primary outcome of rate of ICU transfer or death did not change after National Early Warning Score implementation, with adjusted hazard ratio of 0.94 (0.84–1.05) and 0.90 (0.77–1.05) at our academic and community hospital, respectively. In total, 175,357 best practice advisories fired during the study period, with the best practice advisory performing better at the community hospital than the academic at predicting an event within 12 hours 7.4% versus 2.2% of the time, respectively. Retraining National Early Warning Score with newly generated hospital-specific coefficients improved model performance.

Conclusions:
At both our academic and community hospital, National Early Warning Score had poor performance characteristics and was generally ignored by frontline nursing staff. As a result, National Early Warning Score implementation had no appreciable impact on defined clinical outcomes. Refitting of the model using site-specific data improved performance and supports validating predictive models on local data.