Nonoperative Group Research Articles

An analysis of the potential association between obstructive sleep apnea and osteoporosis from the perspective of transcriptomics and NHANES

BackgroundObstructive sleep apnea (OSA) and osteoporosis (OP) are prevalent diseases in the elderly. This study aims to reveal the clinical association between OSA and OP and explore potential crosstalk gene targets.MethodsParticipants diagnosed with OSA in the National Health and Nutrition Examination Survey (NHANES) database (2015–2020) were included, and OP was diagnosed based on bone mineral density (BMD). We explored the association between OSA and OP, and utilized multivariate logistic regression analysis and machine learning algorithms to explore the risk factors for OP in OSA patients. Overlapping genes of comorbidity were explored using differential expression analysis, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis, Least Absolute Shrinkage and Selection Operator (LASSO) regression, and Random Forest (RF) methods.ResultsIn the OSA population, the weighted prevalence of OP was 7.0%. The OP group had more females, lower body mass index (BMI), and more low/middle-income individuals compared to the non-OP group. Female gender and lower BMI were identified as independent risk factors for OP in OSA patients. Gene expression profiling revealed 8 overlapping differentially expressed genes in OP and OSA patients. KCNJ1, NPR3 and WT1-AS were identified as shared diagnostic biomarkers or OSA and OP, all of which are associated with immune cell infiltration.ConclusionThis study pinpointed female gender and lower BMI as OP risk factors in OSA patients, and uncovered three pivotal genes linked to OSA and OP comorbidity, offering fresh perspectives and research targets.

Characteristics and Factors Associated With Nonoperative Management and Hospital Outcomes After Hip Fractures Among Community-Dwelling Older Adults: Retrospective Analysis.

Nonoperative treatment is used at varying rates among older adults with hip fractures despite the high mortality. This retrospective analysis of 7803 patients 65 and older admitted with hip fractures is to estimate the odds of nonoperative treatment and in-hospital mortality after hip fractures among community-dwelling older adults. 13.6% underwent nonoperative treatment. Compared to the group with operative treatment, the nonoperative group had a higher in-hospital mortality rate (6.51% vs. 1.32%, p < .0001). Male sex, nondisplaced fracture, and comorbidities of acute myocardial infarction, congestive heart failure, cerebrovascular disorder, dementia, and liver disease were associated with an increased likelihood of nonoperative treatment. Nonoperative treatment, advanced age, use of osteoporosis pharmacotherapy, multiple medical comorbidities, and hospital-acquired complications were associated with increased in-hospital mortality. Specific characteristics were associated with nonoperative management and in-hospital mortality among older adults with hip fractures. Additional research is necessary to improve the care of this vulnerable population.

Operative versus Nonoperative Treatment of Proximal Hamstring Avulsions

BackgroundOperative treatment is widely used for acute proximal hamstring avulsions, but its effectiveness compared with that of nonoperative treatment has not been shown in randomized trials.MethodsIn this noninferiority trial at 10 centers in Sweden and Norway, we enrolled patients 30 to 70 years of age with a proximal hamstring avulsion in a randomized trial and a parallel observational cohort. Treatments were operative reinsertion of the tendons or nonoperative management. The primary end point was the Perth Hamstring Assessment Tool (PHAT) at 2 years of follow-up. Secondary outcomes included scores on the Lower Extremity Functional Scale (LEFS).ResultsA total of 119 patients were enrolled in the randomized trial and 97 patients in the observational cohort. In the per-protocol analysis of the randomized trial, the mean (±standard deviation) PHAT scores were 79.9±19.5 and 78.5±19.4 in the operative and nonoperative groups, respectively (PHAT scores range from 0 to 100, with higher scores indicating higher function). The prespecified noninferiority limit of 10 points was not crossed (mean difference, −1.2; 95% confidence interval [CI], −8.6 to 6.2; P=0.009 for noninferiority). Analyses of secondary outcomes, including a mean difference in the LEFS score of −1.6 (95% CI, −5.2 to 2.0), aligned with the primary outcome. The observed numbers of adverse events in the randomized trial were nine in the operative group versus three in the nonoperative group (odds ratio, 0.3; 95% CI, 0.1 to 1.2). In the analysis of the observational cohort, the mean PHAT score difference between the nonoperative and operative treatment groups was −2.6 (95% CI, −9.9 to 4.6).ConclusionsIn patients 30 to 70 years of age with proximal hamstring avulsions, nonoperative treatment was noninferior to operative treatment. (Funded by Afa Försäkring and others; ClinicalTrials.gov number, NCT03311997.)

Continuous Glucose Monitoring Captures Glycemic Variability After Roux-en-Y Gastric Bypass in Patients with and Without Type 2 Diabetes Mellitus: A Prospective Cohort Study.

To evaluate glycemic variability (GV) using continuous glucose monitoring (CGM) in individuals with and without type 2 diabetes mellitus (T2DM) undergoing Roux-en-Y gastric bypass (RYGB). This prospective cohort study compared the CGM data of fourteen patients with T2DM (n = 7) and without T2DM (n = 7) undergoing RYGB. After 6months, these patients were compared to a non-operative control group (n = 7) matched by BMI, sex, and age to the T2DM group. Fourteen patients underwent RYGB, with a mean BMI of 46.9 ± 5.3kg/m2 and an average age of 47.9 ± 8.9years; 85% were female. After 6months post-surgery, the total weight loss (TWL) was 27.1 ± 6.3%, with no significant differences between the groups. Patients without diabetes had lower mean interstitial glucose levels (81 vs. 94 and 98mg/dl, p < 0.01) and lower glucose management indicator (GMI) (5.2 vs. 5.6 and 5.65%, p = 0.01) compared to the control and T2DM groups, respectively. The coefficient of variation (CV) significantly increased only in patients with diabetes (17% vs. 26.7%, p < 0.01). Both groups with (0% vs. 2%, p = 0.03) and without (3% vs. 22%, p = 0.03) T2DM experienced an increased time below range with low glucose (54-69mg/dL). However, patients without T2DM had significantly less time in rage (70-180mg/dL) (97% vs. 78%, p = 0.04). Significant differences in CGM metrics among RYGB patients suggest an increase in glycemic variability after surgery, with a longer duration of hypoglycemia, especially in patients without T2DM.

Quantitative measurements of dual-energy CT parameters in the diagnosis of osteoporosis - a highly sensitive and specific technique: An observational study.

With the aging of the population in our society, osteoporosis (OP) has become one of the chronic diseases that seriously threaten the physical health of the elderly, leading to a heavy burden on healthcare. In recent years, with the continuous development of dual-energy CT (DECT) technology, quantitative measurements of DECT parameters, which is highly sensitive to OP, provides accurate results, is convenient and cost-effective, and is expected to be widely used in bone density testing. This study was aimed to explore the value of quantitative measurements of DECT parameters in diagnosing OP, in order to better guide clinical judgments and treatment. A total of 187 patients who underwent dual-energy X-ray and DECT examinations at Tianjin hospital between January 2022 and June 2023 were included as participants in this study. The bone mineral density (BMD) values of the lumbar spine (L1-L4) were determined using dual-energy X-ray absorptiometry. Simultaneously, CT scans of the lumbar spine (L1-L4) were conducted to measure the CT values of contrast media (CM), mixed-energy image CT values (regular CT value [rCT]), calcium concentration (CaD), as well as fat fraction (FF). Pearson correlation analysis was used to examine the relationship between the quantitative measurements of L1 to L4 vertebral bodies obtained from DECT and BMD. The values of CM, rCT, and CaD in the OP group were all lower than those in the non-OP group with statistical significance (P < .001). Conversely, the fat fraction parameter value in the OP group was significantly higher in contrast with the non-OP group (P = .004); there was a positive correlation between CM, rCT, CaD, and BMD values (R = 0.579, P < .001; R = 0.604, P < .001; R = 0.563, P < .001); CM, rCT, and CaD had high diagnostic value for OP, as evidenced by AUCs of 0.935 (95% CI: 0.900-0.971), 0.956 (95% CI: 0.925-0.987), and 0.926 (95% CI: 0.858-0.954), respectively, all with P values < .001. Quantitative measurement of DECT parameters showed a high sensitivity as well as a high specificity in the diagnosis of OP. It is also highly feasible and holds significant clinical diagnostic value, making it a suitable candidate for widespread application.

Clinical efficacy of different therapeutic strategies in patients with spontaneous rupture of the esophagus: a multicenter retrospective cohort study.

The therapeutic strategy for patients with spontaneous rupture of the esophagus includes surgical repair, endoscopic therapy, supportive care, and others. However, no evidence exists to direct clinical decision-making regarding the choice of operative and nonoperative management. The aim of this study was to determine the clinical efficacy of different therapeutic strategies in both general and stratified patients. This study retrospectively analyzed a consecutive cohort of 101 patients at nine tertiary referral hospital centers in China. Patients were divided into operative and nonoperative groups based on the initial treatment. Short-term outcomes, including 90-day mortality, length of hospital stay, and postoperative leakage were compared. Subgroup analysis was performed based on treatment timing and Pittsburgh perforation severity score (PSS). Of 101 patients, 60 (58.4%) underwent operative management. A significant difference of 90-day mortality between operative and nonoperative groups was observed (15.0% vs. 34.1%, P=0.031). Operative management tend to yield similar therapeutic benefits in timely (OR, 0.250; 95% CI, 0.05-1.14, P=0.073) and delayed (OR, 0.42; 95% CI, 0.12-1.47, P=0.175) treatment groups. Based on PSS stratification, operative management significantly decreased the risk of 90-day mortality (OR, 0.211; 95% CI, 0.064-0.701; P=0.011) for patients in low- and moderate-risk groups but may be detrimental for patients in high-risk group (OR, 1.333; 95% CI, 0.233-7.626; P=0.746). Operative management might be superior to nonoperative management for low- and moderate-risk patients with spontaneous rupture of the esophagus. However, for patients at high risks, operative management might not provide additional benefits compared with nonoperative management. Further research involving larger sample sizes is required for accurate patient stratification and conclusive evidence-based guideline.

Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures.

Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores. Multicenter, prospective, observational. Seven Level 1 Trauma Centers in the United States. Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018. DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups. Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001). Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Poster 212: Ischial Tuberosity Avulsion Fractures: Treatment and Return to Sport in Athletes with Displaced Fragments

Objectives: Ischial tuberosity avulsion fractures are relatively rare injuries that typically occur in young athletes during activity. Some of these patients may experience significant morbidity, often through chronic pain and changes in sports participation. The influence of fragment displacement on optimal treatment and proper return to sport protocol has not been well investigated. This study sought to evaluate the relationship between displacement and both choice of treatment and time to return to sport. Methods: Retrospective analysis of ischial tuberosity avulsion fractures in pediatric patients between 2010-2021 at Boston Children’s Hospital was completed. Information regarding demographics, treatment, and recovery were extracted from individual patient charts. Plain radiographs and magnetic resonance imaging (MRI) were analyzed in order to measure fragment displacement at the ischial apophysis. Treatment protocol, return to sport (RTS) time, and complications were analyzed. Results: Eighty-eight patients with a diagnosis of an ischial tuberosity avulsion fracture were identified. Of these, 64 (73%) were treated non-operatively, 8 (9%) were treated acute operatively (within 6 weeks), and 16 (18%) were treated chronic operatively (&gt;6 weeks). Imaging for measurement of fragment displacement was available for 86 (98%) of patients. The median displacement was 0.2cm for the non-operative group, 2.2cm for the acute operative group, and 1.5 for the chronic operative group. Of the 86 patients with available imaging, 67 (78%) had a RTS time. The median RTS was 3.6 months in the non-operative group, 5.5 months in the acute operative group, and 13.3 months in the chronic operative group. Conclusions: In this retrospective cohort study, nearly all fractures with displacement &gt;= 1.0cm were surgically treated, either acutely or at a delayed time point. All patients that underwent acute operation had displacement &gt; 1.0cm, while 87% of those undergoing delayed operation had displacements &gt; 1.0cm. Those treated non-operatively returned to sport about 1 month earlier than those undergoing acute operation, and several months prior to those who underwent delayed surgical intervention. This data suggests that patients with displacement less than 1.0cm may be successfully treated through non-operative treatment and those with displacement greater than this should undergo operative treatment in the acute period to optimize outcome and return to sport.

The Management and Outcomes in Blunt Splenic Injury: A Comparison Between a Rural and Urban Trauma Center

Introduction: The management of blunt splenic trauma (BST) has evolved over the last 20 years, with nonoperative management in hemodynamically stable patients prevailing as the standard of care. Nonoperative management includes angioembolization of the splenic artery. Although non-operative management has increased in use, there is limited standardization of practices for the management of blunt splenic trauma. The objective was to compare outcomes for BST and the use of angioembolization between a Level 1 urban trauma center, Ascension St. John Hospital, Detroit MI (ASJH) and a Level 2 rural trauma center, Munson Medical Center, Traverse City MI (MMC). Methods: Our study used registry data comprising all patients from 1/2015-12/2021 who presented to ASJH and MMC with BST. Patients were divided into operative intervention versus non-operative management groups. Data collected included timing of intervention, length of stay, severity scores, blood product requirements and concomitant injuries. The management and outcomes between the two institutions were compared. Data were analyzed using Student’s t-test, the χ2 test, the Mann-Whitney U test and logistic regression. Results: Data were collected on 93 patients from ASJH and 189 patients from MMC. Splenic injury grade was scored from one to five, with 60.0% of patients scoring grade three or higher and 62.1% of patients having active blush identified on imaging. Eighty-four patients (28.4%) had operative intervention and 24 patients (8.5%) underwent angioembolization. ASJH had an angioembolization rate of 15.1% vs 5.3% at MMC (p=0.006). When comparing the two hospitals, patient groups were different in terms of race (p=0.001), fresh frozen plasma administered (p=0.046) and presenting systolic blood pressure (p=0.001). In patients with active blush, after adjusting for hemoglobin on arrival, ASJH patients were 3.8 times more likely to have angioembolization than patients at Munson (p=0.02). TRISS and race dropped out of the model. Conclusions: There is a significant difference in the rate of non-operative management between the hospitals. Higher rates of angioembolization at an urban center may reflect a difference in resource distribution between urban and rural centers.

Gastroesophageal signet ring cell carcinoma morbidity and mortality: A retrospective review.

Upper gastrointestinal (GI) signet ring cell carcinomas (SRCC) confer a poor prognosis. The benefit of operative intervention for this patient group is controversial in terms of overall survival. To investigate factors relating to survival in patients with upper GI SRCC. A retrospective, tertiary, single-centre review of patients who were diagnosed with oesophageal, gastroesophageal junction and gastric SRCC was performed. The primary outcome was to compare mortality of patients who underwent operative management with those who had nonoperative management. Secondary outcomes included assessing the relationship between demographic and histopathological factors, and survival. One hundred and thirty-one patients were included. The one-year survival for the operative group was 81% and for the nonoperative group was 19.1%. The five-year survival in the operative group was 28.6% vs 1.5% in the nonoperative group. The difference in overall survival between groups was statistically significant (HR 0.19, 95%CI (0.13-0.30), P < 0.001). There was no difference in survival when adjusting for age, smoking status or gender. On multivariate analysis, patients who underwent surgical management, those with a lower stage of disease, and those with a lower Charlson Comorbidity Index (CCI) had significantly improved survival. Well-selected patients with upper GI SRCC appear to have reasonable medium-term survival following surgery. Offering surgery to a carefully selected patient group may improve the outcome for this disease.

Follow-up study of gallbladder stones in 44 children.

Cholesterol stones affect a certain subpopulation of children. Concerns have been raised on the impact of gallbladder surgery on the growth of children and adolescents. To study the population characteristics, clinical features, treatment, and prognosis of gallstones in children. The clinical data of 44 children with gallstones admitted to The First Affiliated Hospital of Naval Medical University from August 2009 to August 2021 were collected, the children were followed up by telephone to monitor their prognoses. The follow-up ended in August 2023. The shortest follow-up time was 2 years and 6 months, whereas the longest was 13 years and 11 months. The population characteristics, general clinical characteristics, and treatments were retrospectively analyzed. The children were divided according to whether they underwent surgical gallbladder removal into an operation group (n = 28) and a non-operation group (n = 16), The effects of surgical gallbladder resection on the growth and development of children were analyzed. The male-female ratio in the population was 6:5 and 84.09% of the children had onset in adolescence. Furthermore, 29.55% of the children were overweight or obese. The study identified 26 cases with metabolic abnormalities, 9 with hemolytic anemia, and 4 with choledochal cyst. Of the population, 68.18% had recurrent symptomatic cholecystolithiasis. Surgical treatment accounted for 63.64%, with laparoscopic cholecystectomy accounting for 71.43% of surgical treatment. No significant differences were observed in symptoms and complications between the surgery and non-surgery groups. Furthermore, no significant differences were found between the two groups in the attainment of genetic height target and the rightward shift of height curve during follow-up. The sex characteristics of gallstones in children were not observed. Most gallstones occurred in adolescents and rarely in young children. A considerable proportion of children have inborn causes, which are often concurrent with metabolic abnormalities and hemolytic anemia. Most children had recurrent symptomatic gallstones. Surgical treatment, especially laparoscopic cholecystectomy, is still the main treatment for gallstones in children. Surgical treatment did not affect the growth and development of children who underwent gallstone removal.

Predictors of psychosocial functioning in people diagnosed with schizophrenia spectrum disorders that committed violent offences and in those that did not: Results of the Recoviwel study

Psychosocial functioning represents a core treatment target of Schizophrenia Spectrum Disorders (SSD), and several clinical and cognitive factors contribute to its impairment. However, determinants of psychosocial functioning in people living with SSD that committed violent offences remain to be more thoroughly explored. This study aims to separately assess and compare predictors of psychosocial functioning in people with SSD that did and that did not commit violent offences considering several clinical, cognitive and violence-related parameters. Fifty inmates convicted for violent crimes in a forensic psychiatry setting diagnosed with SSD (OP group) and fifty participants matched for age, gender, education, and diagnosis (Non-OP group) were included in the study. A higher risk of violent relapse as measured by HCR-20 clinical subscale scores (p < 0.002) and greater global clinical severity as measured by CGI-S scores (p = 0.023) emerged as individual predictors of worse psychosocial functioning, as measured by PSP scores, in the OP group. Greater global clinical severity (p < 0.001), worse performance in the processing speed domain as measured by the BACS Symbol Coding (p = 0.002) and TMT-A tests (p = 0.016) and higher levels of non-planning impulsivity as measured by BIS-11 scores (p < 0.001) emerged as individual predictors of worse psychosocial functioning in the Non-OP group. These results confirm that clinical severity impacts psychosocial functioning in all individuals diagnosed with SSD and suggest that while cognitive impairment clearly represents a determinant of worse functional outcomes in most patients, the risk of violent relapse is a specific predictor of worse psychosocial functioning in people with SSD that committed criminal offences.

Comparison of Operative and Nonoperative Management of Elderly Fragility Pelvic Ring Fractures.

To compare outcomes of nonoperative and percutaneous fixation of geriatric fragility lateral compression 1 (LC1) pelvic ring fractures. Retrospective. Two level 1 trauma centers. Included were patients who were 60 years or older with an isolated LC1 pelvic ring fracture managed nonoperatively or those who failed mobilization and were managed operatively with percutaneous sacral fixation. Patients with high-energy mechanisms of injury or polytrauma were excluded. The primary outcome was pain as measured by using the visual analog scale (VAS) after treatment. Secondary outcomes included length of stay, discharge disposition, mortality, readmission rates, and complications. In total, 231 patients were included with a mean age of 79.5 years (range 60-100). One hundred eighty-five (80.0%) patients were female. Sixty-two (26.8%) patients received percutaneous sacral fixation after failed mobilization, and 169 (73.2%) were managed nonoperatively. In the operative group, the median time to surgery was hospital day 4. Nonoperative patients were older (81.5 ± 10.0 years vs. 74.2 ± 9.4 years, P < 0.01) and had a shorter hospital length of stay (4.8 ± 6.2 days) than the operative group (10.6 ± 9.5 days, P < 0.01). Patients in the operative group had more pain (VAS 7.9 ± 3.0) than those in the nonoperative group (VAS 6.6 ± 3.0) ( P = 0.01) on admission but had similar pain control postoperatively (VAS 4.4 ± 3.0) compared with the nonoperative group (VAS 4.5 ± 3.6) on the equivalent hospital day ( P = 0.91). Thus, patients in the operative group experienced more improvement in pain (VAS 3.3 ± 2.7) compared with the nonoperative group (VAS 1.9 ± 3.9) after treatment ( P = 0.02). Ninety-day mortality ( P = 0.21) and readmission rates ( P = 0.27) were similar for both groups. Two patients in the operative cohort sustained nerve injuries, whereas 1 patient in the nonoperative group had a nonunion and underwent surgery. Patients who undergo percutaneous surgical fixation for low-energy LC1 injuries have similar discharge disposition, mortality, complication rates, and readmission rates compared with patients treated nonoperatively. Percutaneous surgical fixation may provide significant pain relief for patients who failed conservative management. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reverse Shoulder Arthroplasty versus Non-Operative Treatment of Three-Part and Four-Part Proximal Humerus Fractures in the Elderly Patient: A Pooled Analysis and Systematic Review.

Background: The treatment of complex proximal humerus fractures in elderly patients is not yet fully elucidated. Of all treatment options, reverse shoulder arthroplasty (RSA) and non-operative treatment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus NOT. Methods: Studies comparing complex proximal humerus fractures in patients aged >65 years treated either with RSA or NOT were included for systematic review and direct comparison via pooled analysis of patient-rated outcome and range of motion. Indirect comparison of case series and non-comparative studies on either treatment was performed separately. Results: Three comparative studies including 77 patients treated with RSA and 81 treated non-operatively were analysed. The RSA group scored better for both the Constant-Murley score (mean difference 6 points) and DASH score (mean difference 8 points). No differences were detected in ASES, PENN score, pain scores, or range of motion between treatment groups. The most common complications for RSA were infection (3%), nerve injury (2%), and dislocation (2%). Reoperation was required in 5%. In the NOT group, common complications included malunion (42%), osteonecrosis (25%), and non-union (3%); no reoperation was required. Patient satisfaction was equal in both groups. Conclusions: The functional outcomes and range of motion after RSA seemed satisfactory and potentially superior to NOT in elderly patients. Patient satisfaction was comparable despite a high malunion and osteonecrosis rate in the non-operative treatment group, which did not require re-interventions.

Pure varus posteromedial rotatory instability of the elbow: Radiographic findings, treatment, and outcomes

IntroductionAlthough varus posteromedial rotatory instability (VPMRI) is a subtle elbow injury that involves anteromedial coronoid facet (AMCF) fracture and ligamentous injuries, treatment options and outcomes of VPMRI remains controversial. The aim of this study was to investigate radiographic findings, treatments, and outcomes of a large series of VPMRI. MethodsWe retrospectively reviewed 91 pure VPMRI cases with AMCF fracture (O'Driscoll classification anteromedial type) which were treated at 6 hospitals. Clinical and radiographic outcomes were investigated with a mean follow-up period of 46.8 months using the Mayo elbow performance score (MEPS), and the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score, and serial plain radiographs. ResultsIn AMCF fracture, there were 4 cases of subtype 1, 67 cases of subtype 2, and 20 cases of subtype 3. On MRI, complete tears of lateral collateral ligament and medial collateral ligament were observed in 83.1 % (59/71 cases) and 33.8 % (24/71 cases). Operative treatment was performed in 68 cases (74.7 %) including both side fixation in 40 cases (58.8 %), medial side fixation only in 17 cases (25.0 %), and lateral side fixation only in 11 cases (16.2 %). Nonoperative treatment was performed in 23 cases (25.3 %). The mean final MEPS and Quick-DASH scores were 93.7 and 7.9. The overall complication and reoperation rates were 22.0 % and 15.4 %. No significant differences regarding final clinical scores and range of motions were observed between the operative group and the nonoperative group, but significant differences were observed regarding number (p = 0.019) and displacement (p = 0.002) of coronoid fragment, and complication rate (p < 0.001) between the two groups. ConclusionDepending on the pattern of coronoid fragment and the degree of ligamentous injuries, operative treatment of unstable VPMRI using various fixation techniques including coronoid fixation and ligament repair yielded satisfactory final clinical outcomes. However, surgeons should be aware of the high complication and reoperation rates after operative treatment. Stable VPMRI with AMCF fracture involving minimal displacement or small number of fragments can be treated nonoperatively.

The Potential Value of Mean Platelet Volume and Platelet Distribution Width as Inflammatory Indicators in Surgical Necrotizing Enterocolitis.

This study aims to investigate the potential significance of mean platelet volume (MPV) and platelet distribution width (PDW) in predicting surgical neonatal necrotizing enterocolitis (NEC) and establish the correlation between MPV/PDW levels and the severity/prognosis of NEC. A retrospective study was conducted on a cohort of 372 patients diagnosed with NEC. The patients were categorized into two groups based on whether they underwent surgical therapy. Univariate /multivariate analysis were employed to compare the MPV and PDW between the two groups. Moreover, patients in surgical group were categorized into multiple subgroups based on intraoperative findings and postoperative prognosis, and the levels of MPV and PDW were compared among these subgroups. Of the 372 patients, the operative group exhibited significantly higher levels of MPV and PDW than the nonoperative group (P < 0.05). Logistic regression analysis revealed that MPV (OR = 4.895, P < 0.001) and PDW (OR = 1.476, P < 0.001) independently associated with surgical NEC. The analysis of the receiver operating characteristic (ROC) curve revealed that the area under the curve (AUC) was 0.706 for MPV alone, with a cut-off value of 11.8 fL. Similarly, the AUC was 0.728 for PDW alone, with a cut-off value of 16%. However, when MPV and PDW were combined, the AUC increased to 0.906 for predicting surgical NEC. In accordance with the intraoperative findings, the levels of MPV and PDW were found to be higher in the large area necrosis group than in the partial or mild necrosis group (P < 0.01). Furthermore, the MPV and PDW values in the death group were significantly greater than those in the survival group (P =0.040, P =0.008). MPV and PDW may serve as potentially valuable indicators for determining the need for surgical intervention and predicting the prognosis of patients with NEC.

What Affects Healing Rates in Patients Treated for Medication-Related Osteonecrosis of the Jaw? The Role of Operative Therapy and Other Clinical Factors

BackgroundIn the therapy of medication-related osteonecrosis of the jaw (MRONJ), the healing rate, effectiveness of operative therapy, and factors associated with healing remain unclear. PurposeThis study aimed to estimate MRONJ therapy healing rates and identify associated prognostic factors. Study design, setting, sampleA 25-center prospective cohort study was conducted on 291 patients with MRONJ treated with a common therapeutic protocol during 2013–2016. Patients unable to continue examinations or treatment were excluded. Predictor variableThe primary predictor variable was MRONJ therapy grouped into two categories: operative and nonoperative. Secondarily, the prognostic factors categorized as demographic, medical, clinical, and perioperative were evaluated. Main outcome variablesThe primary outcome variable was treatment duration, defined as the time (in months) between the initiation of therapy and when the site was healed or the date of the final visit or loss to follow-up. CovariatesNot applicable. AnalysesDescriptive statistics and 3-year cumulative healing rates were calculated. The association between clinical factors and time to healing were analyzed using bivariate and multivariate analyses and propensity score analysis. P < .05 was considered significant. ResultsWe analyzed data from 291 subjects with 76 (26.1%) and 215 (73.9%) subjects in the operative and nonoperative therapy groups, respectively. The healing rates for operative and nonoperative therapies were 95.8% and 70.7%, respectively (hazard ratio [HR] = 1.6, 95% confidence interval [CI] = 1.1–2.2, P-value [P] < .01). The healing rates in patients for whom anti-resorptive agent (ARA) treatment was discontinued and continued were 87.2% and 37.4%, respectively (HR = 1.8, 95% CI = 1.1–3.0, P = .02). In a multiple regression analysis using ARA indication, the therapy method showed a significant association in the MRONJ malignancy group (HR = 2.75, 95% CI = 1.46–5.17, P < .01). Conclusions and RelevanceOperative therapy and ARA discontinuation were associated with better healing rates in MRONJ therapy. However, the choice of therapy for MRONJ should be based on a comprehensive consideration of the patient’s condition. ARA discontinuation should be considered an adjunctive measure because of the possibility of adverse events such as fragility fractures and skeletal related events.

Pre- and postoperative levels of serum brain-derived neurotrophic factor in neonates with congenital heart defects.

The objectives of this study were to assess the preoperative and postoperative serum brain- derived neurotrophic factor (BDNF) levels in neonates undergoing surgery for congenital heart defects (CHD). Also to explore the relationship between changes in BDNF levels and the impact of perioperative factors including intraoperative body temperature, aortic cross-clamp time, perfusion time, operation time, inotropic score, vasoactive inotropic score and lactate levels. Forty-four patients with CHD and 36 healthy neonates were included in the study. Blood samples for serum BDNF levels were collected three times: preoperatively, and at 24 and 72 hours postoperatively from each patient in the operated group. Additionally, samples were collected once from each individual in the non-operated case group and the control group. Serum BDNF levels were analyzed using the Elabscience ELISA (Enzyme-Linked Immunosorbent Assay) commercial kit. Cranial ultrasonography (USG) was performed on all infants with CHD. Following cardiac surgery, patients underwent second and third cranial USG examinations at 24 and 72 hours postoperatively, respectively. Forty-four consecutive patients with CHD were divided into two groups as follows: the operated group (n=30) and the non-operated group (n=14). Although there were no differences in the baseline serum BDNF levels between the case and control groups, the preoperative serum BDNF levels were significantly lower in the patients operated compared to the non-operated patients. The serum BDNF levels at the 24th hour postoperatively were higher than the preoperative levels. However, no significant correlation was found between the serum BDNF levels at 24 and 72 hours postoperatively as well as the cranial USG findings at corresponding times. Serum BDNF levels were initially lower in neonates with CHD who underwent surgery, but increased during the early postoperative period. These results suggest that serum BDNF levels are influenced by CHD and the postoperative period.

Palliative Intervention for Malignant Bowel Obstruction Comes at a Cost: A National Inpatient Study.

Background: Malignant bowel obstruction (MBO) due to peritoneal carcinomatosis (PC) is associated with poor outcomes. Optimal management for palliation remains unclear. This study aims to characterize nonoperative, procedural, and operative management strategies for MBO and evaluate its association with mortality and cost.Materials and Methods: ICD-10 coding identified patient admissions from the 2018 to 2019 National Inpatient Sample (NIS) for MBO with PC from gastrointestinal or ovarian primary cancers. Management was categorized as nonoperative, procedural, or surgical. Multivariate analysis was used to associate treatment with mortality and cost.Results: 356,316 patient admissions were identified, with a mean age of 63 years. Gender, race, and insurance status were similar among groups. Length of stay (LOS) was longest in the surgical group (surgical: 17 days; procedural: 14 days; nonoperative: 7 days; P = .001). In comparison to nonoperative, procedural and surgical patients had statistically higher hospital charges, post-discharge medical needs, palliative care consults, and admission to rehab centers. Mortality was 7% in nonoperative, 9% in procedural, and 8% in surgical (P = .007) groups. In adjusted analyses, older age, palliative care consult, and non-Medicare payer status were associated with higher mortality. Compared to nonoperative, procedural and surgical groups resulted in increased costs (procedural: $17K more; surgical: $30K more).Conclusions: Admissions for procedural and surgical treatment of MBO are associated with increased LOS, hospital costs, and discharge needs. Optimal management remains challenging. Clinicians must examine all options prior to recommending palliative interventions given a trend towards higher resource utilization and mortality.

A systematic review and meta-analysis of operative versus non-operative management for first time traumatic anterior shoulder dislocation in young adults

Background The most appropriate management following primary traumatic anterior shoulder dislocation in young adults is unclear. This systematic review and meta-analysis evaluated operative versus non-operative management. The primary outcome measure was re-dislocation rate, in contrast to the often reported ‘recurrent instability’, which includes subjective instability. Methods Our review was prospectively registered with PROSPERO (CRD42022322600) and reported as per PRISMA guidelines. Selection criteria included mean age of participants between 15 and 25 and minimum follow-up of 1 year. Results 21 studies meet the inclusion criteria with 5142 patients included. The mean age of patients was 23, with 87% male. There was a median of 54 patients per study and a mean follow up of 46 months per study. The mean re-dislocation rate was 16.08% in the operative group and 24.84% in the non-operative group. In the subgroup meta-analysis, including only RCTs, comparing arthroscopic stabilisation vs non-operative there was an odds ratio of 0.09, strongly favouring intervention. Discussion This systematic review found the literature available supports surgical intervention in patients under the age of 25, in order to reduce re-dislocation. However, there is a lack of cost-effectiveness data to support these findings, and this should be an area of future research.