bluuebunny/crossref_metadata_2025_split huggingface dataset:
Increased litigation burden among tibia, pelvis, and spine fractures
Authors: Working Zachary M. , El Naga Ashraf N. , Slocum Joshua , Tucker Allison , Hoogervorst Paul , Marmor Meir T. 
Published: April 2019

Abstract

Objectives:
To analyze a series of claims from a large national malpractice insurer associated with fracture care to understand what parameters are associated with claims, defense costs, and paid indemnity.

Design:
Review of claims in fracture care settings from a national database; case series.

Setting:
Database draws from insured pool of 400,000 medical malpractice cases from 400 healthcare entities across the country, representing 165,000 physicians; both academic and private.

Patients/Participants:
Fracture care patients bringing legal suit.

Main Outcome Measurements:
Cost of legal proceedings and indemnity, ICD-9 codes, and contributing causes toward claims.

Results:
A total of 756 fracture claims were asserted between 2005 and 2014 regarding fracture care within the database; 70% were brought for inaccurate, missed, or delayed diagnosis, while 22% addressed medical treatment and 8% were for surgical management. Orthopaedics was the primary service in 22%. Total cost (expenses and indemnity) to orthopaedic providers totaled $13.1MM (million). The most common claim against orthopaedics was for fractures of the tibia and fibula (11.4%). Impact factor (IF) analysis (as described by Matsen) of indemnity in these cases reveals 3 fracture regions of highest indemnity burden: fractures of the tibia and fibula (IF: 1.86, 11.4%), pelvis (IF: 1.77, 6.6%), and spine (IF 1.33, 6.6%). Analysis of contributing factors identifies the category of clinical judgement as the most common category (62%). Other common factors include patient noncompliance (31%), communication (28%), technical skill (17%), clinical systems (11%), and documentation (10%). The single most common specific cause of a claim in orthopaedic fracture care was misinterpretation of diagnostic imaging (25%).

Conclusion:
This study is the first of its kind to identify fractures of the tibia and fibula as high risk for litigation against orthopaedic providers and provides general counseling of legal pitfalls in fracture care. Finally, we are able to identify the act of patient assessment as a key issue in over half of all fracture-related claims against orthopaedic providers. Providers in general and specialty settings can use this information to help guide their treatment and care ownership decisions in the care of patients with fractures.

Level of Evidence:
Economic - Level III.
Mortality Rate-Dependent Variations in the Timing and Causes of Death in Extremely Preterm Infants Born at 23–24 Weeks’ Gestation*
Authors: Park Jae Hyun , Chang Yun Sil , Sung Sein , Park Won Soon 
Published: April 2019

Objectives:
To determine mortality rate-dependent variations in the timing and causes of death, and to subsequently identify the clinical factors associated with decreased mortality in extremely preterm infants born at 23–24 weeks’ gestation.

Design:
A retrospective cohort study.

Setting:
Korean Neonatal Network registry that includes all level greater than or equal to 3 neonatal ICUs in Korea.

Patients:
Eligible, actively treated infants born at 23–24 weeks’ gestation (n = 574) from January 2014 to December 2016 were arbitrarily categorized based on institutional mortality rates of less than or equal to 50% (group I, n = 381) and greater than 50% (group II, n = 193). The primary outcome was mortality before discharge and the timing and causes of death according to the mortality rate.

Interventions:
None.

Measurements and Main Results:
The overall mortality rate was significantly lower in group I (40.7%) than in group II (79.3%). Regarding causes of death, mortalities due to cardiorespiratory, infectious, and gastrointestinal causes were significantly lower in group I than in group II. Mortality rates were significantly lower in group I, including all the subgroups that were categorized according to the timing of death, than in group II. The multivariate analyses showed that antenatal corticosteroid use, absence of oligohydramnios, birth weight, and body temperature at admission to the neonatal ICU were significantly associated with reduced mortality.

Conclusions:
The reduced mortality rate among the infants born at 23–24 weeks’ gestation was attributable to decreased mortality ascribed to cardiorespiratory, infectious, and gastrointestinal causes, and it was associated with antenatal steroid use and body temperature at admission to the neonatal ICU.
Nalbuphine Reduces Opioid-Associated Urinary Retention in Pediatric Patients
Authors: Reiter Pamela D. , Clevenger Amy C. 
Published: April 2019

Objectives:
To evaluate the effect of nalbuphine administration on urine output in critically ill children with opioid-associated urinary retention.

Design:
Institutional review board approved, single center, retrospective medical chart review.

Setting:
Large medical-surgical PICU within a free-standing, tertiary care children’s hospital.

Patients:
Patients admitted to the PICU between October 1, 2014, and February 29, 2016, who received IV nalbuphine after meeting criteria for opioid-associated oliguria (defined as urine output below 1 mL/kg/hr and received at least one dose of opioid therapy within the preceding 12 hr).

Interventions:
None.

Measurement and Main Results:
Seventeen patients who received 21 doses of nalbuphine were analyzed. The median age and weight of patients were 6 years (interquartile range, 3–11.5 yr) and 18 kg (interquartile range, 12–35 kg), respectively. Two distinct dosing strategies became evident, specifically 0.05 mg/kg (n = 11 doses) and 0.1 mg/kg (n = 10 doses). Urine output increased significantly from baseline (median, 0 mL/kg/hr; interquartile range, 0–0.53 mL/kg/hr) to 6 hours post nalbuphine administration (median, 1.48 mL/kg/hr; interquartile range, 0–2 mL/kg/hr; p = 0.0002). Patients who received 0.1 mg/kg/dose had a greater urine output response compared with those who received 0.05 mg/kg/dose. Five patients (29%) had a catheter inserted into their bladder after administration of nalbuphine. Pain scores (grouped 6 hr before and after nalbuphine administration and single pain scores documented immediately before and after nalbuphine administration) were unchanged.

Conclusions:
Nalbuphine administration, at a dose of 0.1 mg/kg, improved urine output in a cohort of children with opioid-associated urinary retention. Pain control did not appear influenced by the provision of nalbuphine. Additional studies are needed to determine the influence of nalbuphine on urinary catheter insertion rates and catheter-associated urinary tract infections.
The Fragility of Statistically Significant Findings in Pediatric Critical Care Randomized Controlled Trials*
Authors: Matics Travis J. , Khan Nadia , Jani Priti , Kane Jason M. 
Published: April 2019

Objectives:
The Fragility Index measures the number of events on which the statistical significance of a result depends and has been suggested as an adjunct statistical assessment for interpretation of trial results. This study aimed to assess the robustness of statistically significant results from pediatric critical care randomized controlled trials with dichotomous outcomes.

Data Sources:
A previously published scoping review of pediatric critical care randomized controlled trials (www.PICUtrials.net).

Study Selection:
A total of 342 trials were screened for inclusion. After applying inclusion/exclusion criteria, 43 fulfilled eligibility criteria and were included in the analysis.

Data Extraction:
Calculation of Fragility Index for trials reporting a statistically significant dichotomous outcome, and analysis of the relationship between trial characteristics and Fragility Index.

Data Synthesis:
The median Fragility Index was 2 (interquartile range, 1–6). The median sample size was 98 (interquartile range, 50–148) and sample size demonstrated a strong correlation with the Fragility Index (r = 0.729; n = 43; p < 0.001). The median number of outcome events was 8 (interquartile range, 4–15) and the total number of outcome events also showed a strong correlation with the Fragility Index (r = 0.728; n = 43; p < 0.001).

Conclusions:
Results from pediatric critical care randomized controlled trials with dichotomous outcomes reporting statistically significant findings often hinge on a small number of outcome events. Clinicians should exercise caution when interpreting results of trials with a low Fragility Index.
Clinical Profile and Predictors of Outcome of Pediatric Acute Respiratory Distress Syndrome in a PICU: A Prospective Observational Study*
Authors: Yadav Bharti , Bansal Arun , Jayashree Muralidharan 
Published: April 2019

Objectives:
To study the clinical profile, predictors of mortality, and outcomes of pediatric acute respiratory distress syndrome.

Design:
A prospective observational study.

Setting:
PICU, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Patients:
All children (age > 1 mo to < 14 yr) admitted in PICU with a diagnosis of pediatric acute respiratory distress syndrome (as per Pediatric Acute Lung Injury Consensus Conference definition) from August 1, 2015, to November 2016.

Interventions:
None.

Measurements and Main Results:
Out of 1,215 children admitted to PICU, 124 (11.4%) had pediatric acute respiratory distress syndrome. Fifty-six children (45.2%) died. Median age was 2.75 years (1.0–6.0 yr) and 66.9% were male. Most common primary etiologies were pneumonia, severe sepsis, and scrub typhus. Ninety-seven children (78.2%) were invasively ventilated. On multiple logistic regressions, Lung Injury Score (p = 0.004), pneumothorax (p = 0.012), acute kidney injury at enrollment (p = 0.033), Fio
2-D1 (p = 0.018), and Pao
2/Fio
2 ratio-D7 (p = 0.020) were independent predictors of mortality. Positive fluid balance (a cut-off value > 102.5 mL/kg; p = 0.016) was associated with higher mortality at 48 hours. Noninvasive oxygenation variables like oxygenation saturation index and saturation-Fio
2 ratio were comparable to previously used invasive variables (oxygenation index and Pao
2/Fio
2 ratio) in monitoring the course of pediatric acute respiratory distress syndrome.

Conclusions:
Pediatric acute respiratory distress syndrome contributes to a significant burden in the PICU of a developing country and is associated with significantly higher mortality. Infection remains the most common etiology. Higher severity of illness scores at admission, development of pneumothorax, and a positive fluid balance at 48 hours predicted poor outcome.
Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale*
Authors: Kirschen Matthew P. , Snyder Megan , Smith Katherine , Lourie Kristen , Agarwal Kenya , DiDonato Pamela , Doll Ashlee , Zhang Bingqing , Mensinger Janell , Ichord Rebecca , Shea Judy A. , Berg Robert A. , Nadkarni Vinay , Topjian Alexis 
Published: April 2019

Objectives:
Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU.

Design:
Prospective observation study.

Setting:
Large academic PICU.

Patients/Subjects:
All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate.

Interventions:
None.

Measurements and Main Results:
PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss’ Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05).

Conclusions:
A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.
Infections on Extracorporeal Life Support in Adults and Children—A Survey of International Practice on Prevention, Diagnosis, and Treatment*
Authors: Farrell Deborah , MacLaren Graeme , Schlapbach Luregn J. 
Published: April 2019

Objectives:
To assess nosocomial infection management practices in pediatric and adult patients supported with extracorporeal life support.

Design:
A 23-question online survey was developed to assess practices related to infection prevention, surveillance, diagnosis, and treatment in patients managed on extracorporeal life support. The survey was distributed internationally to intensivists via online newsletters and e-mail from June to December 2017.

Setting:
Extracorporeal life support centers.

Subjects:
Intensivists working in extracorporeal life support centers.

Interventions:
None.

Results:
We analyzed 147 responses from 25 countries. Most centers have bundles implemented as standard of care to prevent against ventilator-associated pneumonia (77%) and central catheter–associated bloodstream infections (91%). Prophylactic antibiotics beyond cannulation are at least occasionally used by 61% of respondents. Daily C-reactive protein (35%) and white cell count (80%) are the most commonly used surveillance biomarkers, and 25% of respondents reported collecting daily surveillance cultures. Participants responded that new onset of hemodynamic instability and rising C-reactive protein (49%) or rising procalcitonin (30%) are the most common triggers to commence antibiotics.

Conclusion:
There is considerable variability surrounding practices on prevention and diagnosis of infection in patients treated with extracorporeal life support. In view of the impact of infections acquired during extracorporeal life support, further research to inform recommendations on prevention, diagnosis, and management of infection on extracorporeal life support is urgently needed.
Gastric Residual Volume Measurement in U.K. PICUs: A Survey of Practice*
Authors: Tume Lyvonne N. , Arch Barbara , Woolfall Kerry , Latten Lynne , Deja Elizabeth , Roper Louise , Pathan Nazima , Eccleson Helen , Hickey Helen , Brown Michaela , Beissel Anne , Andrzejewska Izabela , Gale Chris , Valla Frédéric V. , Dorling Jon 
Published: April 2019

Objectives:
Despite little evidence, the practice of routine measurement of gastric residual volume to guide both the initiation and delivery of enteral feeding in PICUs is widespread internationally. In light of increased scrutiny of the evidence surrounding this practice, and as part of a trial feasibility study, we aimed to determine enteral feeding and gastric residual volume measurement practices in U.K. PICUs.

Design:
An online survey to 27 U.K. PICUs.

Setting:
U.K. PICUs.

Subjects:
A clinical nurse, senior doctor, and dietician were invited to collaboratively complete one survey per PICU and send a copy of their unit guidelines on enteral feeding and gastric residual volume.

Interventions:
None.

Measurement and Main Results:
Twenty-four of 27 units (89%) approached completed the survey. Twenty-three units (95.8%; 23/24) had written feeding guidelines, and 19 units (19/23; 83%) sent their guidelines for review. More units fed continuously (15/24; 62%) than intermittently (9/24; 37%) via the gastric route as their primary feeding method. All but one PICU routinely measured gastric residual volume, regardless of the method of feeding. Eighteen units had an agreed definition of feed tolerance, and all these included gastric residual volume. Gastric residual volume thresholds for feed tolerance were either volume based (mL/kg body weight) (11/21; 52%) or a percentage of the volume of feed administered (6/21; 29%). Yet only a third of units provided guidance about the technique of gastric residual volume measurement.

Conclusions:
Routine gastric residual volume measurement is part of standard practice in U.K. PICUs, with little guidance provided about the technique which may impact the accuracy of gastric residual volume. All PICUs that defined feed tolerance included gastric residual volume in the definition. This is important to know when proposing a standard practice arm of any future trial of no-routine gastric residual volume measurement in critically ill children.
A Single-Arm, Multicenter Validation Study of Prostate Cancer Localization and Aggressiveness With a Quantitative Multiparametric Magnetic Resonance Imaging Approach
Authors: Maas Marnix C. , Litjens Geert J.S. , Wright Alan J. , Attenberger Ulrike I. , Haider Masoom A. , Helbich Thomas H. , Kiefer Berthold , Macura Katarzyna J. , Margolis Daniel J.A. , Padhani Anwar R. , Selnæs Kirsten M. , Villeirs Geert M. , Fütterer Jurgen J. , Scheenen Tom W.J. 
Published: April 2019

Objectives
The aims of this study were to assess the discriminative performance of quantitative multiparametric magnetic resonance imaging (mpMRI) between prostate cancer and noncancer tissues and between tumor grade groups (GGs) in a multicenter, single-vendor study, and to investigate to what extent site-specific differences affect variations in mpMRI parameters.

Materials and Methods
Fifty patients with biopsy-proven prostate cancer from 5 institutions underwent a standardized preoperative mpMRI protocol. Based on the evaluation of whole-mount histopathology sections, regions of interest were placed on axial T2-weighed MRI scans in cancer and noncancer peripheral zone (PZ) and transition zone (TZ) tissue. Regions of interest were transferred to functional parameter maps, and quantitative parameters were extracted. Across-center variations in noncancer tissues, differences between tissues, and the relation to cancer grade groups were assessed using linear mixed-effects models and receiver operating characteristic analyses.

Results
Variations in quantitative parameters were low across institutes (mean [maximum] proportion of total variance in PZ and TZ, 4% [14%] and 8% [46%], respectively). Cancer and noncancer tissues were best separated using the diffusion-weighted imaging-derived apparent diffusion coefficient, both in PZ and TZ (mean [95% confidence interval] areas under the receiver operating characteristic curve [AUCs]; 0.93 [0.89–0.96] and 0.86 [0.75–0.94]), followed by MR spectroscopic imaging and dynamic contrast-enhanced-derived parameters. Parameters from all imaging methods correlated significantly with tumor grade group in PZ tumors. In discriminating GG1 PZ tumors from higher GGs, the highest AUC was obtained with apparent diffusion coefficient (0.74 [0.57–0.90], P < 0.001). The best separation of GG1–2 from GG3–5 PZ tumors was with a logistic regression model of a combination of functional parameters (mean AUC, 0.89 [0.78–0.98]).

Conclusions
Standardized data acquisition and postprocessing protocols in prostate mpMRI at 3 T produce equivalent quantitative results across patients from multiple institutions and achieve similar discrimination between cancer and noncancer tissues and cancer grade groups as in previously reported single-center studies.
Gender and Age Estimation Using the Morphometric Analysis of Odontoid Process: Is There a Relationship With Dental Maturation?
Authors: Magat Guldane , Ozcan Sevgi 
Published: April 2019

Objective:
The purposes of this study were to show that differences in odontoid process related to age and gender using cone beam volumetric tomography, develop regression formulae based on metric data for gender and age estimation in a Turkish population and investigate whether there is a relationship between the odontoid process and dental maturation for usefulness in forensic and bioarchaeological studies.

Material and Method:
The study sample included a total of 77 subjects in the age group of 8–22 years. The anterior–posterior and transverse diameters of the odontoid process were measured. Regression formulae were performed for age and gender estimation. The dental maturation levels were determined according to Demirjian's method.

Result:
The mean values of anterior–posterior diameters were significantly larger than those of transverse diameters (P < 0.05). Those values were statistically higher for men than for women (P < 0.05). The lowest correlations were observed for the all measurements of the odontoid process in all cases. There were no significant correlations between the dental maturation levels and all measurements of the odontoid process.

Conclusion:
The findings of the present study state that measurements of the odontoid process can be utilized for age and gender estimation in the Turkish population.
A National Analysis of Short-term Outcomes and Long-term Survival Following Thoracoscopic Versus Open Lobectomy for Clinical Stage II Non-Small-Cell Lung Cancer
Authors: Yang Chi-Fu Jeffrey , Kumar Arvind , Deng John Z. , Raman Vignesh , Lui Natalie S. , D’Amico Thomas A. , Berry Mark F. 
Published: April 2019

Objective:
To compare outcomes after open versus thoracoscopic (VATS) lobectomy for clinical stage II (cN1) non-small-cell lung cancer (NSCLC).

Background:
There have been no published studies evaluating the impact of a VATS approach to lobectomy for N1 NSCLC on short-term outcomes and survival.

Methods:
Outcomes of patients with clinical T1-2, N1, M0 NSCLC who underwent lobectomy without induction therapy in the National Cancer Data Base (2010–2012) were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis.

Results:
Median follow-up of 1559 lobectomies (1204 open and 355 VATS) was 43.2 months. The VATS approach was associated with a shorter median hospitalization (5 vs 6 d, P < 0.001) than the open approach. There were no significant differences between the VATS and open approach with regard to nodal upstaging (12.0% vs 10.5%, P = 0.41), 30-day mortality (2.3% vs 3.1%, P = 0.31), and overall survival (5-yr survival: 48.6% vs 48.7%, P = 0.76; multivariable-adjusted HR for VATS approach: 1.08, 95% CI: 0.90–1.30, P = 0.39). A propensity score-matched analysis of 334 open and 334 VATS patients who were well matched by 14 common prognostic covariates, including tumor size, and comorbidities, continued to show no significant differences in nodal upstaging, 30-day mortality, and 5-year survival between the VATS and open groups.

Conclusion:
In this national analysis, VATS lobectomy was used in the minority of N1 NSCLC cases but was associated with shorter hospitalization and similar nodal upstaging rates, 30-day mortality, and long-term survival when compared to open lobectomy. These findings suggest thoracoscopic techniques are feasible for the treatment of stage II (cN1) NSCLC.