bluuebunny/crossref_metadata_2025_split huggingface dataset:
Primary and periprosthetic distal femur fractures in older adults: No difference in 12-month mortality and patient reported outcomes
Authors: Mather Anne M. , Edwards BBiomed (Honours); Elton , Hau F.R.A.C.S; Raphael , Ekegren F.R.A.C.S; Christina L. 
Published: June 2023

Abstract

Objectives:
To compare fracture incidence, mortality and patient reported health outcomes at six and 12 months post-injury between primary and periprosthetic distal femur fractures in older adults.

Methods:
A registry-based cohort study was carried out including all adults aged 70 years or older registered by the Victorian Orthopaedic Trauma Outcomes Registry who experienced a primary or periprosthetic distal femur fracture between 2007 and 2017. Outcomes included mortality and health status (EQ-5D-3L) collected six and 12 months post-injury. All distal femur fractures were confirmed by radiological review. Multivariable logistic regression was conducted to report associations between fracture type, and mortality and health status.

Results:
A final cohort of 292 participants was identified. Overall mortality for the cohort was 29.8% and no significant differences were found in mortality rate or EQ-5D-3L outcomes between fracture types (i.e. primary vs. periprosthetic). A large proportion of participants reported problems across all EQ-5D-3L domains at six and 12 months post-injury, with slightly worse outcomes in the primary fracture group.

Conclusions:
This study reports high mortality and poor 12-month outcomes in an older adult cohort with both periprosthetic and primary distal femur fractures. Given these poor outcomes, fracture prevention and a greater focus on long-term rehabilitation is needed in this cohort. Additionally, the involvement of an ortho-geriatrician should be considered as a routine component of care.
Patterns of Misdiagnosis and Discordance in Detecting Osteoporosis
Authors: Aynaszyan Stephan , Devia Luis G. , Parry Matthew W. , Badve Siddharth , DelSole Edward M. 
Published: June 2023

Study Design:
This was a retrospective chart review.

Objective:
This study aims to identify the prevalence of osteoporosis (OP) by lumbar computed tomography (CT) Hounsfield units (HUs) in patients who have normal or osteopenic bone determined by dual-energy x-ray absorptiometry (DEXA).

Summary of Background Data:
OP is a critical issue in the postmenopausal and aging population. Bone mineral density assessment by DEXA has been described as insensitive for diagnosing OP in the lumbar spine. Improving the detection of OP can bring more patients to treatment and reduce the risks associated with low bone mineral density.

Patients and Methods:
We retrospectively reviewed all patients with DEXA scans and noncontrast CTs of the lumbar spine over a 15-year period. Patients were diagnosed as non-OP if they had a normal DEXA T-score (≥ −1) or osteopenic DEXA T-score (between −1.1 and −2.4). Patients in this cohort were considered osteoporotic by CT if L1-HU ≤110. Demographics and lumbar HUs were compared between these stratified groups.

Results:
A total of 74 patients were included for analysis. All patients were demographically, similar, and the average patient age was 70 years. The prevalence of OP determined by CT L1-HU ≤110 was 46% (normal DEXA: 9%, osteopenic DEXA: 63%). A significant number of males in our study were considered osteoporotic by L1-HU ≤110 (74%, P = 0.03). All individual axial and sagittal lumbar HU measurements including L1–L5 average lumbar HUs were statistically significant among non-OP and OP groups except for the lower lumbar levels (P > 0.05 for L4 axial HUs, and L4–L5 sagittal HUs).

Conclusions:
The prevalence of OP in patients with normal or osteopenic T-scores is high. Among those with osteopenia by DEXA, more than 50% may lack appropriate medical treatment. The DEXA scan may be particularly insensitive to male bone quality making the CT HU the diagnostic method of choice for detecting OP.

Level of Evidence:
Level III.
Cost-utility Analysis of Anterior Cervical Discectomy and Fusion for Cervical Spondylosis Patients Comparing Polyetheretherketone Versus Tricortical Iliac Crest Bone Graft
Authors: Hajeeyeh Muhammadakbar , Wilartratsami Sirichai , Phisalprapa Pochamana , Piyapromdee Urawit , Sornsa-Ard Tuanrit , Kositamongkol Chayanis , Vamvanij Visit , Luksanapruksa Panya 
Published: June 2023

Study design:
Prospective cohort study.

Objectives:
To perform a cost-utility analysis and to investigate the clinical outcomes and patient’s quality of life after anterior cervical discectomy and fusion (ACDF) to treat cervical spondylosis compared between fusion with polyetheretherketone (PEEK) and fusion with tricortical iliac bone graft (IBG) in Thailand.

Summary of Background Data:
ACDF is one of the standard treatments for cervical spondylosis. The fusion material options include PEEK and tricortical IBG. No previous studies have compared the cost-utility between these 2 fusion material options.

Patients and Methods:
Patients with cervical spondylosis who were scheduled for ACDF at Siriraj Hospital (Bangkok, Thailand) during 2019–2020 were prospectively enrolled. Patients were allocated to the PEEK or IBG fusion material group according to the patient’s choice of fusion material. EuroQol-5 dimensions 5 levels and relevant costs were collected during the operative and postoperative periods. A cost-utility analysis was performed using a societal perspective. All costs were converted to 2020 United States dollars (USD), and a 3% discount rate was used. The outcome was expressed as the incremental cost-effectiveness ratio.

Results:
Thirty-six patients (18 ACDF-PEEK and 18 ACDF-IBG) were enrolled. Except for Nurick grading, there was no significant difference in patient baseline characteristics between groups. The average utility at 1 year after ACDF-PEEK and ACDF-IBG were 0.939 ± 0.061 and 0.798 ± 0.081, respectively (P < 0.001). The total lifetime cost of ACDF-PEEK and ACDF-IBG was 83,572 USD and 73,329 USD, respectively. The incremental cost-effectiveness ratio of ACDF-PEEK when compared with that of ACDF-IBG showed a gain of 4468.52 USD/quality-adjusted life-years, which is considered cost-effective at the Thailand willingness-to-pay threshold of 5115 USD/quality-adjusted life-year gained.

Conclusions:
ACDF-PEEK was found to be more cost-effective than ACDF-IBG for treating cervical spondylosis in Thailand.

Level of Evidence:
Level II.
Oxycodone, Morphine, and Fentanyl in Patients With Chronic Pain: Proposal of Dose-Specific Concentration Ranges
Authors: Thaulow Cecilie Hasselø , Helland Arne , Kongsgaard Ulf Erik , Høiseth Gudrun 
Published: June 2023

Background:
Interpreting opioid concentrations is challenging because of the lack of reference ranges. Therefore, the authors aimed to propose dose-specific concentration ranges in serum for oxycodone, morphine, and fentanyl in patients with chronic pain, based on concentration measurements from a large number of patients and supported by theoretical pharmacokinetic calculations and previously published concentrations.

Methods:
The opioid concentrations in patients undergoing therapeutic drug monitoring (TDM) for various indications (TDM group) and patients with cancer (cancer group) were investigated. Patients were divided based on the daily opioid doses, and the 10th and 90th percentiles of the concentrations in each dose interval were evaluated. In addition, the expected average serum concentrations were calculated for each dose interval based on published pharmacokinetic data, and a targeted literature search for previously reported dose-specific concentrations was performed.

Results:
The opioid concentrations in 1054 patient samples were included: 1004 in the TDM group and 50 in the cancer group. In total, 607 oxycodone, 246 morphine, and 248 fentanyl samples were evaluated. The authors proposed dose-specific concentration ranges based mainly on 10th–90th percentiles of the concentrations measured in patient samples, whereas the calculated average concentrations and previously published concentrations were used to adjust the ranges. In general, results from calculations and concentrations retrieved from previous literature were within the 10th–90th percentiles of concentrations from patient samples. However, the lowest calculated average concentrations of fentanyl and morphine were below the 10th percentiles of patient samples in all dose groups.

Conclusions:
The proposed dose-specific ranges may be useful for interpreting steady-state opioid serum concentrations in clinical and forensic settings.
Pharmacokinetic/Pharmacodynamic Target Attainment of Tigecycline in Patients with Hepatic Impairment in a Real-World Setting
Authors: Yang Xiaoxuan , Jin Lu , Luo Xuemei , An Shurun , Wang Min , Zhu Huaijun , Zhou Yujie , Liu Hang 
Published: June 2023

Background:
This study aimed to investigate the pharmacokinetic/pharmacodynamic (PK/PD) target attainment of various tigecycline dosing regimens in real-world patients with impaired liver function.

Methods:
The clinical data and serum concentrations of tigecycline were extracted from the patients' electronic medical records. Patients were classified into Child-Pugh A, Child-Pugh B, and Child-Pugh C groups, according to the severity of liver impairment. Furthermore, the minimum inhibition concentration (MIC) distribution and PK/PD targets of tigecycline from the literature were used to obtain a proportion of PK/PD targets attainment of various tigecycline dosing regimens at different infected sites.

Results:
The pharmacokinetic parameters revealed significantly higher values in moderate and severe liver failure (groups Child-Pugh B and Child-Pugh C) than those in mild impairment (Child-Pugh A). Considering the target area under the time–concentration curve (AUC0-24)/MIC ≥4.5 for patients with pulmonary infection, most patients with high-dose (100 mg, every 12 hours) or standard-dose (50 mg, every 12 hours) for tigecycline achieved the target in groups Child-Pugh A, B, and C. Considering the target AUC0-24/MIC ≥6.96 for patients with intra-abdominal infection, when MIC ≤1 mg/L, more than 80% of the patients achieved the target. For an MIC of 2–4 mg/L, only patients with high-dose tigecycline in groups Child-Pugh B and C attained the treatment target. Patients experienced a reduction in fibrinogen values after treatment with tigecycline. In group Child-Pugh C, all 6 patients developed hypofibrinogenemia.

Conclusions:
Severe hepatic impairment may attain higher PK/PD targets, but carries a high risk of adverse reactions.
The experience of neoadjuvant chemotherapy versus upfront surgery in resectable pancreatic cancer. a cross sectional study
Authors: Su Yung-Yeh , Chao Ying-Jui , Wang Chih-Jung , Liao Ting-Kai , Su Ping-Jui , Huang Chien-Jui , Chiang Nai-Jung , Yu Yu-Ting , Tsai Hong-Ming , Chen Li-Tzong , Shan Yan-Shen 
Published: June 2023

Background:
Upfront resection (UR) followed by adjuvant chemotherapy remains the standard treatment for resectable pancreatic cancer. There is increasing evidence suggesting favorable outcomes toward neoadjuvant chemotherapy followed by surgery (NAC).

Methods:
All clinical staging with resectable pancreatic cancer patients treated at a tertiary medical center from 2013 to 2020 were identified. The baseline characteristics, treatment course, surgery outcome, and survival results of UR or NAC were compared.

Results:
Finally, in 159 resectable patients, 46 patients (29%) underwent NAC and 113 patients (71%) received UR. In NAC, 11 patients (24%) did not receive resection, 4 (36.4%) for comorbidity, 2 (18.2%) for patient refusal and 2 (18.2%) for disease progression. In UR, 13 patients (12%) were unresectable intraoperatively; 6 (46.2%) for locally advanced and 5 (38.5%) for distant metastasis. Overall, 97% of patients in NAC and 58% of patients in UR completed adjuvant chemotherapy. As of data cut-off, 24 patients (69%) in NAC and 42 patients (29%) in UR were still tumor free. The median recurrence-free survival (RFS) in NAC, UR with adjuvant chemotherapy and without adjuvant chemotherapy were 31.3 months (95% CI, 14.4 - not estimable), 10.6 months (95% CI, 9.0–14.3) and 8.5 months (95% CI, 5.8–11.8), P=0.036; and the median overall survival (OS) in each group were not reached (95% CI, 29.7 - not estimable), 25.9 months (95% CI, 21.1–40.5) and 21.7 months (12.0–32.8), P=0.0053. Based on initial clinical staging, the median OS of NAC was not significantly different from UR with a tumor ≤2 cm, P=0.29. NAC patients had a higher R0 resection rate (83% vs. 53%), lower recurrence rate (31% vs. 71%), and harvested median number LN (23 vs. 15).

Conclusion:
Our study demonstrates that NAC is superior to UR in resectable pancreatic cancer with better survival.
Effect of early achievement of energy target by different nutritional support strategies on nosocomial infections in patients undergoing major abdominal surgery: a secondary analysis of 2 randomized clinical trials
Authors: Gao Xuejin , Zhang Li , Zhang Yupeng , Zhou Da , Gao Tingting , Liu Yuxiu , Jin Gang , Wang Kunhua , Zhou Yanbing , Chi Qiang , Yang Hua , Li Mengbin , Yu Jianchun , Qin Huanlong , Tang Yun , Wu Xiaoting , Li Guoli , Wang Xinying 
Published: June 2023

Background:
The effect of early achievement of energy targets using different nutritional support strategies in patients undergoing major abdominal surgery is unclear. This study determined the impact of early achievement of energy targets on the incidence of nosocomial infections in patients undergoing major abdominal surgery.

Methods:
This was a secondary analysis of two open-label randomized clinical trials. Patients from the general surgery department of 11 academic hospitals in China undergoing major abdominal surgery and at nutritional risk (Nutritional risk screening 2002≥3) were divided into two groups based on whether they met the 70% energy targets, the early achievement of energy target (521 EAET) and non-achievement of energy target (114 NAET) groups. The primary outcome was the incidence of nosocomial infections between postoperative day 3 and discharge, and the secondary outcomes were actual energy and protein intake, postoperative noninfectious complications, intensive care unit admission, mechanical ventilation, and hospital stay.

Results:
Overall, 635 patients (mean [standard deviation, SD]) age, 59.5 [11.3] years) were included. The EAET group received more mean energy between days 3 and 7 than the NAET group (22.7±5.0 kcal/kg/d vs. 15.1±4.8 kcal/kg/d; P<0.001). The EAET group had significantly fewer nosocomial infections than the NAET group (46/521[8.8%] versus 21/114[18.4%]; risk difference, 9.6%; 95% confidence interval [CI], 2.1%-17.1%; P=0.004). A significant difference was found in the mean (SD) number of noninfectious complications between the EAET and NAET groups (121/521[23.2%] vs. 38/114[33.3%]; risk difference, 10.1%; 95%CI, 0.7%-19.5%; P=0.024). The nutritional status of the EAET group was significantly improved at discharge compared with the NAET group (P<0.001), and other indicators were comparable between groups.

Conclusion:
Early achievement of energy targets was associated with fewer nosocomial infections and improved clinical outcomes, regardless of the nutritional support strategy (early enteral nutrition alone or combined with early supplemental parenteral nutrition).
Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas: an international multicenter cohort study
Authors: Choi Munseok , Wang Shin-E , Park Joon Seong , Kim Hyung Sun , Choi Sung Hoon , Lee Jin Ho , Chong Jae Uk , Nagakawa Yuichi , Wada Keita , Nakamura Yoshiharu , Sunagawa Hiroki , Dasari Bobby VM , Peng Cheng-Ming , Seng Lee Lip , Wolters Heiner , Gurbadam Unenbat , Park Byoung UK , Winslow Emily , Fishbein Thomas , Hawksworth Jason , Radkani Pejman , Kang Chang Moo 
Published: June 2023

Background:
Adjuvant therapy prolongs survival in patients with pancreatic ductal adenocarcinoma (PDAC). However, no clear guidelines are available regarding the oncologic effects of AT in resected invasive intraductal papillary mucinous neoplasms (IPMN). The aim was to investigate the potential role of AT in patients with resected invasive IPMN.

Materials and Methods:
From 2001 to 2020, 332 patients with invasive pancreatic IPMN were retrospectively reviewed in 15 centers in eight countries. Propensity score-matched and stage-matched survival analyses were conducted.

Results:
A total of 289 patients were enrolled in the study after exclusion (neoadjuvant therapy, unresectable disease, uncertain AT status, and stage IV). A total of 170 patients were enrolled in a 1:1 propensity score-matched analysis according to the covariates. In the overall cohort, disease-free survival was significantly better in the surgery alone (SA) group than in the AT group (P=0.003), but overall survival (OS) was not (P=0.579). There were no significant differences in OS in the stage-matched analysis between the SA and AT groups (stage I, P=0.402; stage II, P=0.179). AT did not show a survival benefit in the subgroup analysis according to nodal metastasis (N0, P=0.481; N+, P=0.705). In multivariate analysis, node metastasis (hazard ratio [HR], 4.083; 95% confidence interval [CI], 2.408−6.772, P<0.001), and CA 19-9 ≥100 (HR, 2.058; 95% CI, 1.247−3.395, P=0.005) were identified as adverse prognostic factors in resected invasive IPMN.

Conclusion:
The current AT strategy may not be recommended to be performed with resected invasive IPMN in stage I and II groups, unlike PDAC. Further investigations of the potential role of AT in invasive IPMN are recommended.
Closing the Gap in Direct Admissions: A Quality Improvement Project
Authors: McKenna Amanda L. , Carter Laurel E. , Kase Adam M. , McCain Josiah D. , Fitzgerald Patrick J. , Kesler Alex M. , Varma Suneel , Cowdell J. Colt 
Published: June 2023

Background and Objectives:
Direct admissions (DAs) are nonemergent admissions to the inpatient unit that bypass the emergency department. Our institution lacked a standardized DA process, which resulted in postponement of prompt patient care. The purpose of the present study was to review and modify the existing DA process and to decrease the time between patient arrival for DA and placement of initial clinician orders.

Methods:
A team was assembled and tasked with using quality improvement tools (eg, Define-Measure-Analyze-Improve-Control, fishbone diagrams, process mapping) to streamline the DA process to decrease average time between patient arrival for DA and initial clinician orders, from 84.4 minutes in July 2018 to 60 minutes or less by June 2019, without negatively affecting patient admission loyalty questionnaire scores.

Results:
In a standardized and streamlined DA process, average time between patient arrival and provider order placement decreased to less than 60 minutes. This reduction was achieved without substantially affecting patient loyalty questionnaire scores.

Conclusion:
By using a quality improvement methodology, we developed a standardized DA process that resulted in prompt care for patients without decreasing admission loyalty scores.
Improving Waste Segregation in the Operating Room to Decrease Overhead Cost
Authors: Plezia Daniel , Sabol Valerie K. , Nelson Christoffer , Simmons Virginia C. 
Published: June 2023

Background and Objectives:
Operating rooms (ORs) disproportionally contribute 20% to 33% of hospital waste nationwide and therefore have a major impact on hospital waste management. Seventy percent of general OR waste is incorrectly eliminated as clinical waste, which compounds unnecessary financial burden and produces negative environmental impact. The primary purpose of this quality improvement (QI) project was to evaluate the effectiveness of waste segregation education for OR anesthesia staff on improving waste segregation compliance in the OR.

Methods:
A waste segregation QI project was implemented at a 19-OR hospital. Sharps bins in each OR were monitored for weight in pounds and 6 ORs were monitored for percent compliance both pre- and post-institution of a waste segregation education. In addition, a waste segregation knowledge assessment, waste segregation barriers assessment, and a demographic survey were administered to anesthesia staff. Twenty-two certified registered nurse anesthetists (CRNAs), 13 anesthesiologists, and 4 anesthesia technicians responded to the initial surveys and assessments while 30 of these original 39 participants (77%) responded following the educational intervention. A cost analysis was calculated pre- and post-implementation by multiplying total weight of the sharps bins by the price per pound of sharps.

Results:
Twenty-three percent of participants reported having formal waste segregation training. Survey responses revealed that the greatest barrier to waste segregation involved bin location (56.4%), followed by lack of time to segregate (25.6%), lack of knowledge of what content goes in the bin (25.6%), and lack of incentive (25.6%). A waste segregation knowledge assessment showed improvement from pre- (M = 9.18, SD = 1.66) to post-implementation (M = 9.90, SD = 1.64). Pre-implementation sharps bin compliance was 50.70% while post-implementation bin compliance improved to 58.44%. A 27.64% decrease in sharps disposal cost occurred following implementation, which is estimated to produce a $2964 cost savings per year.

Conclusions:
Waste segregation education for anesthesia staff increased their waste management knowledge, improved sharps waste bin compliance, and produced an overall cost savings.
Myocardial Scar Detection Using High-Resolution Free-Breathing 3D Dark-Blood and Standard Breath-Holding 2D Bright-Blood Late Gadolinium Enhancement MRI: A Comparison of Observer Confidence
Authors: Nies Hedwig M.J.M. , Martens Bibi , Gommers Suzanne , Bijvoet Geertruida P. , Wildberger Joachim E. , ter Bekke Rachel M.A. , Holtackers Robert J. , Mihl Casper 
Published: June 2023

Abstract:

Objective:
To compare observer confidence for myocardial scar detection using 3 different late gadolinium enhancement (LGE) data sets by 2 observers with different levels of experience.

Materials and Methods:
Forty-one consecutive patients, who were referred for 3D dark-blood LGE MRI before implantable cardioverter-defibrillator implantation or ablation therapy and who underwent 2D bright-blood LGE MRI within a time frame of 3 months, were prospectively included. From all 3D dark-blood LGE data sets, a stack of 2D short-axis slices was reconstructed. All acquired LGE data sets were anonymized and randomized and evaluated by 2 independent observers with different levels of experience in cardiovascular imaging (beginner and expert). Confidence in detection of ischemic scar, nonischemic scar, papillary muscle scar, and right ventricular scar for each LGE data set was scored using a using a 3-point Likert scale (1 = low, 2 = medium, or 3 = high). Observer confidence scores were compared using the Friedman omnibus test and Wilcoxon signed-rank post hoc test.

Results:
For the beginner observer, a significant difference in confidence regarding ischemic scar detection was observed in favor of reconstructed 2D dark-blood LGE compared with standard 2D bright-blood LGE (p = 0.030) while for the expert observer, no significant difference was found (p = 0.166). Similarly, for right ventricular scar detection, a significant difference in confidence was observed in favor of reconstructed 2D dark-blood LGE compared with standard 2D bright-blood LGE (p = 0.006) while for the expert observer, no significant difference was found (p = 0.662). Although not significantly different for other areas of interest, 3D dark-blood LGE and its derived 2D dark-blood LGE data set showed a tendency to score higher for all areas of interest at both experience levels.

Conclusions:
The combination of dark-blood LGE contrast and high isotropic voxels may contribute to increased observer confidence in myocardial scar detection, independent of observer's experience level but in particular for beginner observers.