bluuebunny/crossref_metadata_2025_split huggingface dataset:
Days Alive and Out of Hospital
Authors: Jerath Angela , Austin Peter C. , Wijeysundera Duminda N. 
Published: May 2019

Abstract

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Background
Days alive and out of hospital is a potentially useful patient-centered quality measure for perioperative care in adult surgical patients. However, there has been very limited prior validation of this endpoint with respect to its ability to capture differences in patient-level risk factor profiles and longer-term postoperative outcomes. The main objective of this study was assessment of the feasibility and validity of days alive and out of hospital as a patient-centered outcome for perioperative medicine.

Methods
The authors evaluated 540,072 adults undergoing 1 of 12 major elective noncardiac surgical procedures between 2006 to 2014. Primary outcome was days alive and out of hospital at 30 days, secondary outcomes were days alive and out of hospital at 90 days and 180 days. Unadjusted and risk-adjusted adjusted analyses were used to determine the association of days alive and out of hospital with patient-, surgery-, and hospital-level characteristics. Patients with days alive and out of hospital at 30 days values less than the tenth percentile were also classified as having poor days alive and out of hospital at 30 days. The authors then determined the association of poor days alive and out of hospital at 30 days with in-hospital complications, poor days alive and out of hospital at 90 days (less than the tenth percentile), and poor days alive and out of hospital at 180 days (less than the tenth percentile).

Results
Overall median (interquartile range) days alive and out of hospital at 30, 90, and 180 days were 26 (24 to 27), 86 (84 to 87), and 176 (173 to 177) days, respectively. Median days alive and out of hospital at 30 days was highest for hysterectomy and endovascular aortic aneurysm repair (27 days) and lowest for upper gastrointestinal surgery (22 days). Days alive and out of hospital at 30 days was associated with clinically sensible patient-level factors (comorbidities, advanced age, postoperative complications), but not measured hospital-level factors (academic status, bed size). Of patients with good days alive and out of hospital at 30 days, 477,163 of 486,087 (98%) and 470,093 of 486,087 (97%) remained within this group (greater than the tenth percentile) at days alive and out of hospital at 90 and 180 days.

Conclusions
Days alive and out of hospital is a feasibly measured patient-centered outcome that is associated with clinically sensible patient characteristics, surgical complexity, in-hospital complications, and longer-term outcomes. Days alive and out of hospital forms a novel patient-centered outcome for future clinical trials and observational studies for adult surgical patients.
Atrophy of Diaphragm and Pectoral Muscles in Critically Ill Patients
Authors: Vivier Emmanuel , Roussey Aurore , Doroszewski Fanny , Rosselli Sylvène , Pommier Christian , Carteaux Guillaume , Mekontso Dessap Armand 
Published: May 2019

Abstract

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Background
Muscle atrophy occurs early during critical illnesses. Although diffuse, this atrophy may specifically affect the diaphragm under artificial inactivity accompanying invasive mechanical ventilation. The primary objective of this study was to highlight diaphragm atrophy during the first 5 days of critical illness. Monitoring of pectoral thickness (a nonpostural muscle with mainly phasic function) served as a control.

Methods
Diaphragm and pectoral thicknesses were measured by ultrasound within the first 24 h of admission in 97 critically ill patients, including 62 on mechanical ventilation. Thirty-five patients were reexamined at day 5.

Results
Baseline median (interquartile) values of diaphragm and pectoral thicknesses at day 1 were 2.4 (2.0, 2.9) and 5.9 (4.7, 7.2) mm, respectively (n = 97). Higher values of diaphragm thickness at baseline were positively associated with male sex, chronic obstructive pulmonary disease, and diabetes. Diaphragm and pectoral atrophies (defined as a decrease of 10% or more between day 1 and day 5) were detected in 48% (17 of 35) and 29% (10 of 34) respectively, and were uncorrelated with each other. Diaphragm atrophy was significantly more frequent in patients with septic shock and in those with mechanical ventilation, as compared with their respective counterparts (71% [10 of 14] vs. 33% [7 of 21], P = 0.027 and 71% [17 of 28] vs. 0% [0 of 7], P = 0.004, respectively), whereas pectoral atrophy was more common in patients treated with steroids as compared with their counterparts (58% [7 of 12] vs. 14% [3 of 22], P = 0.006). A statistically significant association between diaphragm atrophy and outcome was not found. Pectoral atrophy seemed associated with less successful weaning from mechanical ventilation at day 14 (12% [1 of 8] vs. 58% [11 of 19], P = 0.043).

Conclusions
Ultrasound enables identification of specific early diaphragm atrophy that affects the majority of mechanically ventilated patients and septic shock patients. Diaphragm atrophy and pectoral muscle atrophy seem to be two unrelated processes.
Measuring Childbirth Outcomes Using Administrative and Birth Certificate Data
Authors: Glance Laurent G. , Hasley Steve , Glantz J. Christopher , Stevens Timothy P. , Faden Eric , Kreso Melissa A. , Pyne Sonia G. , Wissler Richard N. , Fichter Jennifer , Gloff Marjorie S. , Dick Andrew W. 
Published: May 2019

Abstract

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Background
The number of pregnancy-related deaths and severe maternal complications continues to rise in the United States, and the quality of obstetrical care across U.S. hospitals is uneven. Providing hospitals with performance feedback may help reduce the rates of severe complications in mothers and their newborns. The aim of this study was to develop a risk-adjusted composite measure of severe maternal morbidity and severe newborn morbidity based on administrative and birth certificate data.

Methods
This study was conducted using linked administrative data and birth certificate data from California. Hierarchical logistic regression prediction models for severe maternal morbidity and severe newborn morbidity were developed using 2011 data and validated using 2012 data. The composite metric was calculated using the geometric mean of the risk-standardized rates of severe maternal morbidity and severe newborn morbidity.

Results
The study was based on 883,121 obstetric deliveries in 2011 and 2012. The rates of severe maternal morbidity and severe newborn morbidity were 1.53% and 3.67%, respectively. Both the severe maternal morbidity model and the severe newborn models exhibited acceptable levels of discrimination and calibration. Hospital risk-adjusted rates of severe maternal morbidity were poorly correlated with hospital rates of severe newborn morbidity (intraclass correlation coefficient, 0.016). Hospital rankings based on the composite measure exhibited moderate levels of agreement with hospital rankings based either on the maternal measure or the newborn measure (κ statistic 0.49 and 0.60, respectively.) However, 10% of hospitals classified as average using the composite measure had below-average maternal outcomes, and 20% of hospitals classified as average using the composite measure had below-average newborn outcomes.

Conclusions
Maternal and newborn outcomes should be jointly reported because hospital rates of maternal morbidity and newborn morbidity are poorly correlated. This can be done using a childbirth composite measure alongside separate measures of maternal and newborn outcomes.
Opioid use after ankle fracture surgery: current trends in the United States
Authors: Chen Michael J. , Zhang Steven , DeBaun Malcolm , Fogel Nathaniel , Bishop Julius A. , Gardner Michael J. 
Published: May 2019

Background:
The United States opioid epidemic has been declared a national public health emergency. While opioids are frequently prescribed after ankle fracture surgery, the percentage of patients actually requiring them is unknown. Here we compare the annual percentage of patients using an opioid prescription after ankle fracture surgery over the last decade.

Methods:
We retrospectively queried a large private-payer database from 2007-2015 and identified 20,992 opioid-naive patients undergoing ankle fracture surgery. We then measured the annual prevalence of opioid prescriptions over time separated into the immediate postoperative period (between 0 and 6 mo from surgery) and the prolonged period (between 6 and 12 mo from surgery). Linear regression with beta coefficients was calculated.

Results:
The prevalence of patients filling opioid prescriptions between 0 and 6 mo after surgery declined from 28.5% to 21.2% during the study period. The prevalence of patients filling opioid prescriptions between 6 and 12 mo after surgery declined from 2.9% to 2.3% during the study period.

Conclusions:
The percentage of patients utilizing opioid prescriptions after ankle fracture surgery is much lower than expected, suggesting that routine prescriptions given after ankle fracture surgery and other smaller orthopaedic procedures are not likely to be contributing to the epidemic.
Rates and treatments of CrossFit-related injuries at a single hospital system
Authors: Everhart Joshua S. , Kirven James C. , France Thomas J. , Hidden Krystin , Vasileff William Kelton 
Published: May 2019

Background:
CrossFit is a new sport with rapidly growing participation rates that utilizes movements from other sports including gymnastics, Olympic weightlifting, and power lifting. We hypothesized that there would be high rates of nonoperative treatment, that treatment patterns would vary by anatomic site of injury, and that rates of surgical treatment would be higher with increasing age and have no association with patient sex among CrossFit athletes.

Methods:
Hospital system-wide electronic medical records from 2010 to 02/2017 were queried for reference to CrossFit or a related term within the clinical notes. For musculoskeletal (MSK) injuries, use of physical therapy, injection, advanced diagnostic imaging (CT or MRI), and surgery were documented.

Results:
Nine hundred and eighty-two CrossFit-related injuries were identified (91.1% MSK injuries, 8.9% non-MSK conditions) (mean age 36.4 yr SD 11.0, 50.3% male) with a >30% yearly increase in cases throughout the study period. Physical therapy was utilized for 76.0% of MSK injuries, 15.8% received an injection, 37.5% underwent advanced imaging, and 15.8% underwent surgery. The most common MSK injury sites were knee, shoulder, and spine. Male sex and later year of injury were independent risk factors for surgery; compared to other MSK injuries, knee injuries had higher surgery risk and spine had a lower risk.

Conclusions:
CrossFit injury volumes at our center have steadily increased as participation rates have increased. Physical therapy was frequently utilized. Surgery rates for MSK injuries varied considerably by anatomic region. Men were more likely to require surgery. The percentage of injuries requiring surgery increased throughout the study period.
Characterization of compliance to weight-bearing protocols and patient weight-bearing behavior during the recovery period in lower extremity fractures: a pilot study
Authors: Lajevardi-Khosh Arad , Stuart Ami , Ackerman Matt , Rothberg David , Kubiak Erik , Petelenz Tomasz , Hitchcock Robert 
Published: May 2019

Background:
To promote fracture healing and limit complications, clinicians typically instruct patients with lower extremity fracture to be nonweight or partial-weight bearing or to bear weight as tolerated during the recovery period. Although this practice represents the standard of care, continuous patient compliance to weight-bearing protocols and actual patient weight-bearing progression remain unknown. This study aimed to characterize patient compliance towards weight-bearing protocols and weight-bearing progression during recovery.

Methods:
Eleven patients with lower extremity fracture consented to participate in this observational study. Postoperatively, patients were instructed to follow weight-bearing protocols based upon the treating clinicians’ recommendation. Patients were fitted with an underfoot load monitor integrated into the sole of a walking boot. Continuous load data from each patient were used to quantify the number of days patients were compliant with the weight-bearing protocol.

Results:
Overall, patients were unable to comply to nonweight-bearing and partial-weight-bearing protocols. Patients performed nonweight bearing and partial weight bearing only 24% and 12% of the time, respectively. Patients were most compliant (72%) to the weight bearing as tolerated protocol. Additionally, weight-bearing progressions either consistently increased (46%), remained relatively constant (27%), or remained constant initially and then suddenly increased (27%).

Conclusions:
Continuous compliance data from this study indicate that patients do not comply with weight-bearing protocols. Additionally, the variety of weight-bearing progressions, with limited complications, may suggest that patients are able to self-regulate their weight bearing without compromising healing outcomes.
Surgical Site Infections in Elderly Fragility Hip Fractures Patients Undergoing Warfarin Treatment
Authors: Frenkel Rutenberg Tal , Vitenberg Maria , Yahav Dafna , Spectre Galia , Velkes Steven 
Published: May 2019

Objectives:
Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients.

Design:
Retrospective cohort study.

Setting:
Level-1 trauma center.

Patients:
Individuals 65 years of age and older with fragility hip fractures.

Intervention:
Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered.

Main Outcome Measures:
Postoperative SSIs.

Results:
Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm3 and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm3 for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ.

Conclusions:
Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
The Effect of Dexmedetomidine Added to Preemptive Ropivacaine Infiltration on Postoperative Pain After Lumbar Fusion Surgery
Authors: Li Jing , Yang Jun-Song , Dong Bu-Huai , Ye Jiu-Min 
Published: May 2019

Study Design.
A prospective and controlled study of dexmedetomidine added to preemptive ropivacaine infiltration in lumbar fusion surgery.

Objective.
Assessment of dexmedetomidine added to preemptive ropivacaine infiltration for the relief of postoperative pain after lumbar fusion surgery.

Summary of Background Data.
Single local anesthetic preemptive wound infiltration for the relief of postoperative pain does not translate into major or consistent clinical benefits after lumbar fusion surgery. Dexmedetomidine added to local anesthetics prolonged the duration of blockade and enhanced the analgesic in peripheral nerve block. The effect of dexmedetomidine added to preemptive ropivacaine infiltration in lumbar fusion surgery for the relief of postoperative pain has yet not been studied.

Methods.
Fifty-seven patients with elective posterior lumbar fusion were randomly divided into two groups. Five minutes before incision, the skin and subcutaneous tissues were injected with 20 mL 0.5% ropivacaine in group R (n = 28) and 20 mL 0.5% ropivacaine and 1 ug/kg of dexmedetomidine in group RD (n = 29) in two divided doses (i.e., 10 mL per side of the incision line). After the operation, all patients received intravenous morphine for analgesia. The total morphine consumption, the time of first analgesic demand, numbers of PCA analgesia, Visual Analog Scale, and postoperative adverse effects were collected.

Results.
In group RD, cumulative morphine dose and numbers of PCA analgesia in group RD were significantly reduced, the time of first analgesic demand was significantly delayed compared to the group R. Visual Analog Scale in group RD showed a marked reduction at 8 hours, 12 hours, 16 hours after operation and less patients in group RD experienced postoperative nausea or vomiting compared to the group R.

Conclusion.
The addition of dexmedetomidine to preemptive ropivacaine wound infiltration provided a superior analgesic effect, reduced postoperative morphine consumption, and prolonged the time of the first analgesic demand with no serious side effects.

Level of Evidence: 2
Early Enteral Nutrition in Patients Undergoing Sustained Neuromuscular Blockade: A Propensity-Matched Analysis Using a Nationwide Inpatient Database*
Authors: Ohbe Hiroyuki , Jo Taisuke , Matsui Hiroki , Fushimi Kiyohide , Yasunaga Hideo 
Published: May 2019

Objectives:Whether enteral nutrition should be postponed in patients undergoing sustained treatment with neuromuscular blocking agents remains unclear. We evaluated the association between enteral nutrition initiated within 2 days of sustained neuromuscular blocking agent treatment and in-hospital mortality.Design:Retrospective administrative database study from July 2010 to March 2016.Setting:More than 1,200 acute care hospitals covering approximately 90% of all tertiary-care emergency hospitals in Japan.Patients:Mechanically ventilated patients, who had undergone sustained treatment with neuromuscular blocking agents in an ICU, were retrospectively reviewed. We defined patients who received sustained treatment with neuromuscular blocking agents as those who received either rocuronium at greater than or equal to 250 mg/d or vecuronium at greater than or equal to 50 mg/d for at least 2 consecutive days.Interventions:Enteral nutrition started within 2 days from the initiation of neuromuscular blocking agents (defined as early enteral nutrition).Measurements and Main Results:We identified 2,340 eligible patients during the 69-month study period. Of these, 378 patients (16%) had received early enteral nutrition. One-to-three propensity score matching created 374–1,122 pairs. The in-hospital mortality rate was significantly lower in the early than late enteral nutrition group (risk difference, –6.3%; 95% CI, –11.7% to –0.9%). There was no significant difference in the rate of hospital pneumonia between the two groups (risk difference, 2.8%; 95% CI, –2.7% to 8.3%). Length of hospital stay among survivors was significantly shorter in the early compared with the late enteral nutrition group (risk difference, –11.4 d; 95% CI, –19.1 to –3.7 d). There was no significant difference between the two groups in length of ICU stay or length of mechanical ventilation among survivors.Conclusions:According to this retrospective database study, early enteral nutrition may be associated with lower in-hospital mortality with no increase in-hospital pneumonia in patients undergoing sustained treatment with neuromuscular blocking agents.
Necrotic Keratinocytes Are Common in Psoriasis and Have a Predilection to the Upper Epidermis: A Quantitative and Comparative Analysis
Authors: Cloutier Jeffrey M. , Hsi Andy , Camacho Christine , Lazova Rossitza 
Published: May 2019

Background:The most salient histopathological features of psoriasis are epidermal hyperplasia, hypogranulosis, parakeratosis, dilated capillaries in dermal papillae, and intraepidermal and intracorneal neutrophils. Several additional “nonclassic” features of psoriasis have recently been reported, including necrotic keratinocytes (NK). To determine the diagnostic utility of NK, we characterized NK in a large cohort of psoriasis cases compared with psoriasiform spongiotic dermatitis (PSD) and normal skin.Methods:NK were quantified in 101 cases of psoriasis, 20 cases of PSD, and 20 cases of normal skin. The location of NK within the lower, middle, or upper thirds of the epidermis was recorded.Results:NK were identified in 77/101 (76%) of psoriasis cases. By comparison, NK were seen in 8/20 (40%) cases of PSD and 4/20 (20%) cases of normal skin. The linear concentration of NK was significantly higher in psoriasis (0.36 NK/mm) compared with PSD (0.12 NK/mm) and normal skin (0.03 NK/mm) (P= 0.0009). NK were preferentially located in the upper (58%) and middle (31%) epidermis in psoriasis.Conclusions:NK are a common feature of psoriasis and have a predilection to the upper layers of epidermis. Superficial NK may provide additional diagnostic support for psoriasis in challenging or borderline cases.
Triage to Observation
Authors: Williams Julie , Aurora Taruna , Baker Kathy , Thompson Julie , Smallheer Benjamin 
Published: May 2019

Objective:
The objective of this study was to evaluate the impact of a rapid admission protocol for chest pain patients presenting to the emergency department (ED) on ED length-of-stay (LOS). In this study, ED LOS was defined as the time from triage check-in until the time the patient physically leaves the ED. The purpose of this quality improvement study was to decrease ED crowding.

Methods:
This is a single-center prospective cohort study performed as a quality improvement initiative. This study implemented a rapid admission protocol for patients who were at moderate risk for a major adverse cardiac event based on the HEART score. When a patient presented to the ED through triage with a chief complaint of chest pain, this protocol allowed the provider-in-triage (PIT) to identify eligible patients for potential rapid admission to the hospital’s clinical decision unit (CDU). The PIT would complete a rapid medical screening examination, initiate the patient’s workup, and call the CDU providers to further evaluate the patient. By identifying these patients early, the lengthy ED chest pain workup contributing to longer ED LOS could then be completed in the CDU.

Results:
The total number of patients seen in the ED over the study period was 34,251. The total number of patients admitted to the CDU during the study period was 1,442. The PIT identified 13 patients for rapid admission to the CDU during the study period. These patients had a statistically significant reduction in ED LOS (P < 0.001). ED LOS was also adjusted to identify delays in patient movement resulting in a statistically significant difference (P < 0.001).

Conclusion:
Implementation of a rapid admission protocol for chest pain patients at moderate risk for a major adverse cardiac event resulted in a reduction in ED LOS. Adjusted ED LOS was also significant, highlighting a delay in patient movement from the ED to the CDU indicating continued barriers affecting ED holding times.