Significant Predictors Of Failure Research Articles

74 Construct Validity for the Automatized Sequencing Test (AST) in Hispanic/Latino and Bilingual Youth

Objective:Adequate effort by examinees during neurocognitive testing is a prerequisite to valid interpretation of test results. Utilizing performance validity tests (PVTs) is strongly recommended within pediatric mild Traumatic Brain Injury (mTBI) populations. PVTs have historically been created based on majority-white and monolingual groups; investigating their validity in additional patient populations remains essential. The Automatized Sequencing Task (AST) was developed as a brief validity measure within mTBI youth (Kirkwood, et.al., 2014). This study aimed to examine the clinical utility of the AST among youth identifying as Hispanic/Latino and/or bilingual within a mTBI clinical sample.Participants and Methods:Participants ages 8-17 (N=103, M age=14.08, SD=2.2, 51.5% male, 42.7% Hispanic/Latino, 23.6% bilingual) were drawn from an outpatient mTBI/concussion program within the past 2.6 years. Median time of evaluation since injury was 3.7 weeks. Eligibility criteria included: 1) evaluated for a mTBI (GCS . 13) and 2) 8 through 17 years of age. Language status included English only and English-Spanish bilingual youth. Of the bilingual youth, 95% were considered English dominant. Youth were timed while reciting four well-learned (i.e., automatized) sequences as rapidly as possible: 1) the alphabet, 2) counting from 1-20, 3) the days of the week, and 4) the months of the year. Pass rates for the AST were examined using chi-square tests to compare performance based on ethnic/cultural identity (Hispanic vs Non-Hispanic), language status, age (children 8-12; teens 13-17), and gender.Results:In the clinical sample, 11.7% (n=12) could not complete AST months; 75% of non-completers were Hispanic/Latino. Participants who identified as Hispanic/Latino compared to Non-Hispanic/Latino participants were significantly more likely to fail the 4-item AST, χ2(1) =4.3, p<.05. The odds of failing the 4-item AST was 2.3 times higher if patients identified as Hispanic/Latino. Further, patients identifying as bilingual were even more likely to fail the 4-item AST, χ2(1) =4.5, p<.05. The odds of failing the 4-item AST was 3.0 times higher if patients were bilingual. There were no ethnicity or bilingual group differences in AST failure when examining performance on the 3-item AST. Neither age nor gender were a significant predictor of failure on the 3-item or 4-item AST.Conclusions:Results suggest that the month item on the AST does not function consistently across Hispanic/Latino and bilingual youth. It cannot be presumed to be ‘automatic’ as a significant number of Hispanic/Latino and/or bilingual patients were unable to complete the month item, but with otherwise intact performance on the first three items. Administering only the first three items on the AST appears to be a more culturally sensitive alternative given the increased odds of 4-item failure in Hispanic/Latino and bilingual youth. Additional research is needed to explore the predictive validity of the AST as a PVT in varying ethnic, culturally, linguistically, and socioeconomically diverse mTBI pediatric populations.

The Influence of Patient Sex on Outcomes Following One-Stage and Two-Stage Revision for Periprosthetic Joint Infection in Total Joint Arthroplasty.

Although females have a higher rate of primary total joint arthroplasty (TJA), males have a higher rate of revision. The literature lacks studies examining the relationship between sex and outcomes following single and two-stage exchange for periprosthetic joint infection (PJI). The purpose of this study was to examine if differences exist in outcomes following revision for chronic PJI between sexes. A retrospective review was performed on all patients with an MSIS confirmed PJI who underwent a single or two-stage exchange at our institution from January 2010 to January 2021. Patient demographics, comorbidity characteristics, and outcomes were collected and compared between males and females. The primary outcome variable was disease-free survival at 1 year following definitive revision. Multivariable logistic regression analysis was performed to determine risk factors for failure. Of the 470 patients meeting final eligibility criteria, 250 were male and 226 were female (2 males and 4 females had a joint infection of either the contralateral side or a different joint and were treated as separate records). Of the patients in the cohort, 80% of the males (200/250) and 80% of the females (181/226) were found to be disease-free at 1-year follow-up (p > 0.99). Multivariable logistic regression analysis showed that nicotine use and diabetes, but not sex, were significant predictors of failure. Our study did not find a relationship between sex and outcome of revision for PJI. Further research is required to determine whether differences exist between males and females in the expression of PJI and outcomes following treatment.

Predicting Features of Visceral Stent Failure in Fenestrated Endovascular Aortic Aneurysm Repair.

Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper.

Mid-term survivorship of fixed bearing unicondylar knee arthroplasty with no exclusion of early PFJ arthritis or ACL deficiency: Analysis of clinical and radiological predictors.

Fixed bearing (FB) UKA constituted 63.7% of unicondylar knee arthroplasties in 2020 Australian Registry with the longest UKA survivorship. The significance of patellofemoral joint (PFJ) arthritis, ACL deficiency, post-operative anteromedial pain, radiosclerosis or radiolucency on survivorship of FB UKA is not established. The aim of this study was to analyze the medium-term survivorship of fixed-bearing UKA with no exclusion of PFJ OA and ACL deficiency. Predictors for failure were analyzed. FB UKA performed in 2011-17 were reviewed. Cases with PFJ OA or ACL deficiency were not excluded. The effect on survivorship by ACL deficiency, PFJ arthritis, post-operative anteromedial pain and radiological abnormalities were analyzed. There were 96 UKA with follow-up time of 66 ± 18months (27-98). The mean age was 70 ± 9years, BMI 25.8 ± 2.6kg/m2. Alignment was varus 9° ± 4° pre-operatively and varus 3° ± 3° post-operatively. There were four revisions (4.2%) and 4 deaths (4.2%). Reasons for revisions were loosening (n = 1), persistent pain (n = 2) and lateral compartment disease (n = 1). Estimated survival at 8.3years was 94.7% (95% CI 91.6-97.7). BMI ≥30 was found to be a significant predictor for failure. The incidence of radiographic abnormalities was 75% for PFJ arthritis, 39% for tibial tray overhang, 14% for radiolucency or radiosclerosis, 5% for ACL deficiency and 5% for edge loading respectively but they were not significantly associated with lower survivorship or anteromedial knee pain. The presence of anteromedial pain after surgery in 36.5% was also not significantly associated with survivorship. FB UKA with no exclusion of early PFJ arthritis and ACL deficiency has satisfactory medium-term survivorship. BMI ≥30 could have higher risk of all-cause revision. Tibial tray overhang, non-progressive radiolucency or radiosclerosis do not seem to be associated with anteromedial knee pain or poorer medium term survivorship.

The utility of congenital cardiac status to predict endoscopic third ventriculostomy and ventriculoperitoneal shunt failure in hydrocephalic infants.

The effect of congenital cardiac status on endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) failure in hydrocephalic infants is unknown. Because cardiac status in infants can impact central venous pressure (CVP), it is possible that congenital heart disease (CHD) and congenital cardiac anomalies may render these cerebrospinal fluid diversion interventions more susceptible to failure. Correspondingly, the aim of this study was to determine how CHD and congenital cardiac anomalies may impact the failure of these initial interventions. A retrospective review of the Nationwide Inpatient Sample (NIS) database was conducted. Infants (aged < 1 year) with known congenital cardiac status managed with either ETV or VPS were included. Quantitative data were compared using either parametric or nonparametric methods, and failure rates were modeled using univariable and multivariable regression analyses. A total of 18,763 infants treated with ETV or VPS for hydrocephalus were identified in our search, with ETV used to treat 7657 (41%) patients and VPS used to treat 11,106 (59%). There were 6722 (36%) patients who presented with CHD at admission, and a total of 25 unique congenital cardiac anomalies were detected across the cohort. Overall, the most common anomaly was patent ductus arteriosus (PDA) in 4990 (27%) patients, followed by atrial septal defect (ASD) in 2437 (13%) patients and pulmonary hypertension in 810 (4%) patients. With respect to initial intervention failure, 3869 (21%) patients required repeat surgical intervention during admission. This was significantly more common in the ETV group than the VPS group (36% vs 10%, p < 0.01). In both the ETV and VPS groups, CHD (p < 0.01), including all congenital cardiac anomalies, was an independent and significant predictor of failure. ASD (p < 0.01) and PDA (p < 0.01) both significantly predicted ETV failure, and PDA (p < 0.01) and pulmonary hypertension (p = 0.02) both significantly predicted VPS failure. These results indicate that congenital cardiac status predicts ETV and VPS failure in patients with infantile hydrocephalus. The authors hypothesized that this finding was primarily due to changes in CVP; however, this may not be completely universal across both interventions and all congenital cardiac anomalies. Future studies about optimization of congenital cardiac status with ETV and VPS are required to understand the practical significance of these findings.

Comparison Between Intramedullary Nailing and Plating in Diaphyseal Tibial Fractures with Intact Fibula: Randomized Controlled Trial

Aim: To compare between intramedullary nailing and plating in diaphyseal tibial fractures with intact fibula Study design: Randomized controlled trial Place and duration: This study was conducted at Pakistan Institute of Medical Sciences Islamabad, Pakistan from February 2020 to February 2021. Methodology: During these two years of study period, 1470 limb fracture patients were treated at our institute from which 114 were qualified to participate in this study. A total of 73 patients who were eligible for the experiment were enrolled, and a total of 69 of them were monitored for at least a year. Plating fractures and intramedullary nailing are both common surgical methods that may be used in the treatment of fractures in the femur. Patients' reports of pain or discomfort in the limb were significant predictors of failure in both therapies. We monitored the factors including the length of surgery, the quantity of blood lost, and the time it took to accomplish union. Results: Intramedullary nailing resulted in a single nonunion (P = 0.285) and one patient developed a late, deep infection in the screw position (P = 0.478), which was cured by screw removal. Although the intramedullary group required more procedures to accomplish union, the tibial fractures in both groups were healed in around 4 months (dynamization was done in 4 patients, representing 12.1% of the total, P = 0.047). Two patients in the intramedullary group (6.1%) and four patients in the plate group (11.1%) had implants removed during the follow-up period, which was not statistically significant (P = 0.675). A statistically significant difference between the two groups was found only when it came to the number of patients reporting limb pain and the number of people reporting knee discomfort (P = 0.001). The plate group included 29 patients with no complaints, whereas the intramedullary group had 18 patients (54.4%) with no complaints and 13 patients (39.5%) with knee discomfort. Conclusion: Both methods are suitable treatments for closed noncomminuted solitary tibial fractures, as per the findings of this study; moreover, patients who receive intramedullary nails are more likely to require additional operations to achieve union and to complain of discomfort in their limbs or knees. Keywords: tibial fracture, nailing, bone plates, intramedullary

Labor Contracts, Wages and SME Failure

Although employment protection and employee remuneration has been shown to affect many aspects of a firm’s performance, evidence of their ability to explain firm failure is very limited. This paper examines the effect of different types of labor contracts and wages on the probability of corporate failure between 2012 and 2019 using a sample of 29,596 Belgian SMEs. Using discrete time hazard regression models, we find that the use of contract types with lower employment protection and paying lower wages are significant predictors of failure.

Medial Calcar Comminution and Intramedullary Nail Failure in Unstable Geriatric Trochanteric Hip Fractures.

Background and Objectives: An increasing global burden of geriatric hip fractures is anticipated. The appropriate treatment for fractures is of ongoing interest and becoming more relevant with an aging population and finite health resources. Trochanteric fractures constitute approximately half of all hip fractures with the medial calcar critical to fracture stability. In the management of unstable trochanteric fractures, it is assumed that intramedullary nails and longer implants will lead to less failure. However, the lack of power, inclusion of older generation femoral nails, and a variable definition of stability complicate interpretation of the literature. Materials and Methods: Between January 2012 and December 2017, a retrospective analysis of operatively treated geriatric trochanteric hip fracture patients were examined at a Level 1 Trauma Centre. The treatment was with a long and short version of one type of trochanteric nail. Unstable trochanteric fractures with medial calcar comminution were examined (AO31A2.3, 2.3 & 3.3). The length of the medial calcar loss, nail length, demographics, fracture morphology, and relevant technical factors were examined in univariate and multivariate analysis using competing risk regression analysis. The primary outcome was failure of fixation with post-operative death the competing event and powered to previously reported failure rates. Results: Unstable patterns with medial calcar comminution loss constituted 617 (56%) of operatively treated trochanteric fractures. Failure occurred in 16 (2.6%) at a median post-operative time of 111 days (40–413). In univariate and multivariate analysis, only younger age was a significant predictor of failure (years; SHR: 0.91, CI 95%: 0.86–0.96, p < 0.001). Nail length, medial calcar loss, varus reduction, and other technical factors did not influence nail failure. Conclusions: In a cohort of unstable geriatric trochanteric hip fractures with medial calcar insufficiency, only younger patient age was predictive of nail failure. Neither the length of the medial calcar fragment or nail was predictive of failure.

Low Implant Failure Rate of Percutaneous Fixation for Spinal Metastases: A Multicenter Retrospective Study

To evaluate incidence and types of implant failure observed in a series of patients with spinal metastases (SM) treated with minimally invasive stabilization surgery without fusion. In this multicenter, retrospective, observational study, we reviewed the files of patients >18 years old who underwent surgery for SM using percutaneous spinal stabilization without fusion with a minimum 3-month follow-up. The following variables were included: demographics, clinical findings, prior radiation history, SM location, epidural spinal cord compression scale, Spinal Instability Neoplastic Scale, neurological examination, and surgery-related data. Primary outcome measure was implant failure rate, as observed in patients' last computed tomography scan. Multivariable analysis was performed to identify baseline factors and factors associated with implant failure. Analysis included 72 patients. Mean age of patients was 62 years, 39 patients were men, and 75% of patients had an intermediate Spinal Instability Neoplastic Scale score. Tumor separation surgery was performed in 48.6% of patients. Short instrumentation was indicated in 54.2% of patients. Three patients (4.2%) experienced implant failure (2 screw loosening, 1 screw cut-out); none of them required revision surgery. In 73.6% of cases, survival was >6 months. No significant predictors of failure were identified in the multivariate analysis. A low implant failure rate was observed over the short and medium term, even when short instrumentations without fusion were performed. These findings suggest that minimally invasive stabilization surgery without fusion may be an effective and safe way to treat complicated SM.

Stereotactic Ablative Radiotherapy (SABR) For Oligometastases: Risk Stratification Using Positional Uncertainty

Compared to conventional RT, SABR/SBRT is more resource intensive, demands for a smaller margin of error, and has higher potential for causing significant toxicities. We hypothesize that SABR can be stratified into low, intermediate, and high-risk categories of toxicity considering the site and the surrounding organs at risk (OAR). We also aim to identify potential predictors of high risk SABR. We obtained radiation plan data for 40 randomly selected patients previously treated on a prospective phase 2 trial for oligometastases at our institution. Parameters were collected from each plan: i) prescription dose in EQD210 ii) Dmax of nearest OAR in EQD2 (α/β = 2–3, with 2 for spinal cord), iii) PTV volume, iv) number of OARs within a 5 cm radius, and v) distance of the closest OAR to PTV. Simulation was done to mimic potential positional errors at treatment using the open source DICOMautomaton platform. Positional shifts of 2mm were applied to each plan to move the center of mass of each OAR towards the PTV. Dosimetric analyses were then performed on the perturbed plans to identify potential OAR overdosing or plan “failures”. “High-risk” plans were defined as failure in OARs for which toxicities can lead to potentially catastrophic side effects (spinal cord, proximal bronchial tree, and bowel). Failures in other OARs for which toxicities are likely not catastrophic (e.g. chest wall) were categorized as “intermediate-risk”. Plans which did not fail despite shifts were categorized as “low-risk”. Predictors of failure and high-risk plans were identified using logistic regression. We identified 51 PTV’s with 47 isocenters. Analysis was performed per isocenter. Median dose was 35 Gy (range 24–60 Gy) in 2-8 fractions, with median EQD210 of 49.6 Gy (range 44–126 Gy10). The number of plans with OAR’s that failed was 29/47 (61.7%). Number of plans that were classified as low, intermediate, and high risk were 18 (38%), 17 (36%), and 12 (26%), respectively. On univariate analysis, the site category, number of OARs within 5 cm, and distance of closest OAR were significant predictors of failure. On multivariable analysis (MVA), only distance of the closest OAR was significant, with OR 0.58 (95% CI 0.36 – 0.95, p = 0.03). For predictors of high-risk plans, the number of OARs within 5 cm (OR 1.76, 95% CI 1.15-2.7, p = 0.01), and the Dmax of the closest OAR in EQD22-3 (OR 0.97, 95% CI 0.94 – 0.99, p = 0.02) were significant on MVA. It is feasible to group SABR cases into high, intermediate, and low potential risk of predicted toxicity using positional shifts based on risk of exceeding OAR tolerance. If validated with clinical toxicity rates, these findings can be used to generate a clinical risk prediction model for high risk SABR, and could be used to triage cases for subspecialized or generalized radiation oncology, and for level of plan reviewer in an adaptive setting. Further work is required to identify a priori indicators of risk group.

Clinical Outcomes of Immature Teeth Treated with Regenerative Endodontic Procedures—A San Antonio Study

IntroductionFactors that influence clinical outcomes for regenerative endodontic procedures (REPs) are unknown. This retrospective study aimed to assess tooth healing, root development, pulp vitality, and esthetics post-REPs and categorize them into clinician- and patient-centered outcomes. Furthermore, this study identified significant predictors affecting such outcomes. MethodsImmature permanent teeth diagnosed with pulp necrosis treated with REPs between 2008 and 2018 with a minimum of 1-year follow-up were included. Outcomes included success and survival rates, changes in root development using 2-dimensional radiographic root area (RRA) and 3-dimensional measurements, pulp vitality, and tooth discoloration. Predictor variables of success included age, sex, etiology of pulp necrosis (PN), type of medicament, sodium hypochlorite (NaOCl) concentration, type of biomaterial used over the blood clot, and preoperative apical diagnosis. Statistical analyses included Cox proportional hazard analyses and generalized regression models. ResultsFifty-one teeth with an average of 2.1 years of follow-up satisfied the criteria. The survival rate was 92%. The success rate was 84.3% with age, etiology of PN, type of medicament, and NaOCl concentration being significant predictors of failure. Root development occurred in 91.4% of cases with age, sex, etiology of PN, type of medicament, NaOCl concentration, and apical diagnosis being significant predictors for RRA change. Positive pulp sensibility responses were associated with greater RRA change, and, finally, the type of biomaterial was a significant predictor for tooth discoloration after treatment. Conclusions: REPs provide a high survival rate. Patient and clinical factors may affect outcomes, and this knowledge may help to define the criteria for optimal treatment planning of REPs.

Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA II): a study in a Southeast Asian population.

Intertrochanteric hip fractures pose a significant health problem. The proximal femur nail anti-rotation (PFNA IIDePuySynthes) is the most commonly used implant for intramedullary nailing of unstable intertrochanteric fractures at our institution. We aim to identify the risk factors predisposing to mechanical failure of intertrochanteric hip fractures fixation with PFNAII in our Southeast Asian population. We retrospectively reviewed 295 consecutive patients who underwent PFNA fixation for intertrochanteric fractures of the proximal femur between January 2014 and June 2018 at our institution. Exclusion criteria included a follow-up period of less than 4months and patients with polytrauma. 204 patients were eligible for analysis, of which 22 had mechanical failure of PFNAII. We compared these patients with respect to their demographics, medical co-morbidities, quality of reduction according to the Baumgartner scale, calcar restoration, blade position according to Cleveland Zones, the stability of fracture according to OTA/AO classification, neck-shaft-angle, tip-apex distance, as well as neck of femur bone mineral density T-score. Patients were followed up for a minimum of 4months and until fracture union or complication had occurred. Logistic regression analysis was performed to determine the odds ratio for mechanical failure for selected variables. Good quality of reduction reduced risk of mechanical failure whilst posterior blade position in lateral hip X-ray predicted it, with odds ratios of 0.147 (95% confidence interval, 0.030-0.733; p = 0.019) and12.12 (95% confidence interval, 1.583-92.825; p = 0.016) respectively. On univariate analysis, the mechanical failure group were older, had poorer calcar restoration, more unstable fracture patterns, more varus neck-shaft angle, and trochanteric starting points that were lateral to or on the tip of the greater trochanter. However, these were not significant in multivariate analysis. Tip apex distance, the severity of osteoporosis, presence of diabetes, chronic kidney disease and serum vitamin D levels were not significant predictors of failure. To avoid mechanical failure, one should aim to achieve a good quality of reduction and centre blade position on lateral hip X-ray. Tip apex distance did not predict mechanical failure in our study.

Local control and toxicity outcomes of stereotactic radiosurgery for spinal metastases of gastrointestinal origin.

Colorectal cancer (CRC) and other gastrointestinal (GI) cancers are believed to have greater radioresistance than other histologies. The authors report local control and toxicity outcomes of stereotactic radiosurgery (SRS) to spinal metastases from GI primary cancers. A retrospective single-center review was conducted of patients with spinal metastases from GI primary cancers treated with SRS from 2004 to 2017. Patient demographics and lesion characteristics were summarized using medians, interquartile ranges (IQRs), and proportions. Local failure (LF) was estimated using the cumulative incidence function adjusted for the competing risk of death and compared using Gray's test for equality. Multivariable analyses were conducted using Cox proportional hazard models, adjusting for death as a competing risk, on a per-lesion basis. Patients were stratified in the Cox model to account for repeated measures for clustered outcomes. Median survival was calculated using the Kaplan-Meier method. A total of 74 patients with 114 spine lesions were included in our analysis. The median age of the cohort was 62 years (IQR 53-70 years). Histologies included CRC (46%), hepatocellular carcinoma (19%), neuroendocrine carcinoma (13%), pancreatic carcinoma (12%), and other (10%). The 1- and 2-year cumulative incidence rates of LF were 24% (95% confidence interval [CI] 16%-33%) and 32% (95% CI 23%-42%), respectively. Univariable analysis revealed that older age (p = 0.015), right-sided primary CRCs (p = 0.038), and single fraction equivalent dose (SFED; α/β = 10) < 20 Gy (p = 0.004) were associated with higher rates of LF. The 1-year cumulative incidence rates of LF for SFED < 20 Gy10 versus SFED ≥ 20 Gy10 were 35% and 7%, respectively. After controlling for gross tumor volume and prior radiation therapy to the lesion, SFED < 20 Gy10 remained independently associated with worse LF (hazard ratio 2.92, 95% CI 1.24-6.89, p = 0.014). Toxicities were minimal, with pain flare observed in 6 patients (8%) and 15 vertebral compression fractures (13%). Spinal metastases from GI primary cancers have high rates of LF with SRS at a lower dose. This study found that SRS dose is a significant predictor of failure and that prescribed SFED ≥ 20 Gy10 (biological equivalent dose ≥ 60 Gy10) is associated with superior local control.

Failure in Revision Dacryocystorhinostomy: A Study of Surgical Technique and Etiology.

The aim of this study is to assess the etiologic factors of primary dacryocystorhinostomy (DCR) failure according to DCR techniques and also to determine risk factors for the prediction of failure in revision external DCR. Retrospective review was performed in patients who underwent revision external DCR for previous DCR failure between 2008 and 2018. All patients underwent full ophthalmic and intranasal examination, lacrimal probing, and irrigation. Patients were classified into following groups according to previous DCR type: external, endoscopic endonasal, and transcanalicular laser DCR. Potential etiologic factors were compared between 3 groups. Multivariate analysis was performed to identify risk factors for failure in revision external DCR. About 115 eyes from 109 patients constituted the external (50.4%), endonasal (31.3%), and laser (18.3%) DCR groups. Among 27 (23.5%) patients with intranasal pathologies, septal deviation (33.3%) is the most common finding. The commonest cause of failure was inadequate ostium size in external (37.9%), endonasal (36.1%), and laser (66.7%) DCR groups. Inadequate ostium size and cicatricial lacrimal ostium scarring were observed significantly more common in the laser (P = 0.047) and external DCR group (P = 0.043), respectively. The success rate for revision external DCR was 85.2%. Canalicular or common canalicular obstruction (P = 0.032), intranasal pathology (P = 0.003), and bilateral obstruction (P = 0.025) demonstrated a significant independent association with failure in revision external DCR. Inadequate ostium size was the most common cause of failure in primary external, endonasal, and laser DCR. Canalicular or common canalicular obstruction, intranasal pathology, and bilateral lacrimal obstruction were significant predictors of failure in revision external DCR.

Role of pelvicalyceal anatomy in the outcomes of retrograde intrarenal surgery (RIRS) for lower pole stones: outcomes with a systematic review of literature

Controversies exist on the influence of lower pole anatomy (infundibular pelvic angle, IPA; infundibular length, IL; and infundibular width, IW) for success and outcomes related to the treatment of stones in the lower pole. We wanted to look at the role of lower pole anatomy to study clinical outcomes in patients treated for isolated lower pole stones (LPS) using retrograde intra renal surgery (RIRS), and also perform a review to look at the published literature on the influence of pelvicalyceal anatomy on success with RIRS. Data were prospectively collected (June 2013–June 2016) for all patients who underwent RIRS for LPS, and the imaging was then retrospectively reviewed to calculate the IPA, IL and IW using the Elbahnasy method. A systematic review was also conducted for all English language articles between January 2000 and April 2018, reporting on the impact of pelvicaliceal anatomy on RIRS. A total of 108 patients with LPS were included with a male to female ratio of 2:3 and a mean age of 54.7 years. The mean lower pole stone size was 9.3 mm (range 3–29 mm) and 102/108 (94.4%) patients were stone free (SF) at the end of their procedure. While steep IPA (< 30°), operative time duration and larger stone size were significant predictors of failure, the placement of ureteric access sheath, IW and IL did not influence treatment outcomes. Six studies (460 patients) met the inclusion criteria for our review. The IPA, IW, IL for failure ranged from 26° to 38°, 5.5–7 mm and 24–34 mm, respectively. The SFR ranged from 78 to 88% with a metaanalysis showing IPA as the most important predictor of treatment outcomes for LPS. Infundibular pelvic angle seems to be the most important predictor for the treatment of LPS using RIRS. Pelvicalyceal anatomy in conjunction with stone size and hardness seem to dictate the success, and decisions on the type of surgical interventions should reflect this.

Survival of maxillary and mandibular bonded retainers 10 to 15\xa0years after orthodontic treatment: a retrospective observational study

BackgroundThe long-term evidence regarding failures of fixed retainers is limited and the aim of this cohort study was to assess the long-term risk of failure of one type of maxillary and two types of mandibular fixed lingual retainers.Trial designRetrospective cohort study.MethodsEighty-eight patients in retention 10–15 years after orthodontic treatment were included. The type of failure; number of failures per tooth, per patient, and retainer; and adverse effects were assessed by (1) a questionnaire, (2) clinical examination, and (3) screening patients’ clinical charts. Descriptive statistics were calculated and a Cox regression was used to assess possible predictors for mandibular retainer survival.Results and conclusionsIn the mandible, 47 (53.4%) .016″ × .022″ braided stainless steel retainers (SS) were bonded to all six anterior teeth, and 41 (46.6%) .027″ β-titanium (TMA) retainers were bonded to the canines only. From the SS retainers 40.4% and of the TMA retainers 61% had no failures during the whole observation period. SS failures per retainer were 2.17 (3.15) vs. 0.66 (1.03) for TMA. The type of retainer was the only significant predictor for failure. In the maxilla, 82 (93.2%) .016″ × .022″ braided SS retainers were bonded to all four incisors and six retainers (6.8%) to all six anterior teeth. The latter group was not further analyzed due to the small sample size. From the retainers bonded to all four incisors, 74.4% had no failure during the whole observation period. SS average number of failures per retainer bonded to the four incisors was 1.14 (SD 2.93). Overall, detachments were the most frequent type of first failure followed by composite damage. From the original mandibular retainers 98.9% and of the original maxillary retainers 97.6% were still in situ 10–15 years after debonding. No adverse torque changes were observed.LimitationsPotential effects of selection bias, information bias, and attrition bias as well as possible confounding factors cannot be fully excluded in this study.

Incidence and Predictors of Hardware Failure After Instrumentation for Spine Metastasis: A Single-Institutional Series

We report a retrospective analysis of hardware failure in patients requiring instrumentation for spinal metastasis. In a retrospective study at a single institution, we identified 58 patients who underwent spinal instrumentation for metastasis from 2012 to 2018. Hardware failure was defined as screw pullout/loosening, cage migration, progressive kyphosis, or an otherwise-noticeable instrumentation deficit detectable on imaging. Risk factors for hardware failure with a P < 0.05 in in univariate were included in multivariate logistic regression models controlled for age, sex, and previously identified risk factors for hardware failure. In total, 58 patients required instrumentation for metastatic spine disease. Median age was 60.2 years (interquartile range 49.0-66.3), 38 patients (65.5%) were male, and median follow-up was 8.1 months (interquartile range 3.1-20.7). Eight patients (13.8%) developed signs of hardware failure during follow-up, of whom 2 patients (3.4%) underwent operative revision. In univariate analysis, Eastern Cooperative Oncology Group performance status >2 (P= 0.049) and multiple myeloma lesions (P= 0.010) were significant predictors of failure. Both factors maintained significance in a multivariate logistic regression model controlled for age, sex, history of spine radiation, and number of fused levels with P= 0.047; odds ratio 12.7 (95% confidence interval 1.03-156.4) for Eastern Cooperative Oncology Group performance status over 2 and P= 0.012; odds ratio 31.5 (95% confidence interval 2.2-460.0) for multiple myeloma lesions. The rate of hardware failure in this cohort was 13.8%, although operative revision rate was 3.4%. Spinal instrumentation in patients with poor preoperative functional status or multiple myeloma may be more likely to develop instrumentation failure.

Excision and Primary Anastomosis for Short Bulbar Strictures: Is It Safe to Change from the Transecting towards the Nontransecting Technique?

Objective To explore whether it is safe to change from transecting excision and primary anastomosis (tEPA) towards nontransecting excision and primary anastomosis (ntEPA) in the treatment of short bulbar urethral strictures and to evaluate whether surgical outcomes are not negatively affected after introduction of ntEPA. Materials and Methods Two-hundred patients with short bulbar strictures were treated by tEPA (n=112) or ntEPA (n=88) between 2001 and 2017 in a single institution. Failure rate and other surgical outcomes (complications, operation time, hospital stay, catheterization time, and extravasation at first cystography) were calculated for both groups. Potentially predictive factors for failure (including ntEPA) were analyzed using Cox regression analysis. Results Median follow-up for the entire cohort was 76 months, 118 months, and 32 months for, respectively, tEPA and ntEPA (p<0.001). Nineteen (9.5%) patients suffered a failure, 13 (11.6%) with tEPA and 6 (6.8%) with ntEPA (p=0.333). High-grade (grade ≥3) complication rate was low (1%) and not higher with ntEPA. Median operation time, hospital stay, and catheterization time with tEPA and ntEPA were, respectively, 98 and 87 minutes, 3 and 2 days, and 14 and 9 days. None of these outcomes were negatively affected by the use of ntEPA. Diabetes and previous urethroplasty were significant predictors for failure (Hazard ratio resp. 0.165 and 0.355), whereas ntEPA was not. Conclusions Introduction of ntEPA did not negatively affect short-term failure rate, high-grade complication rate, operation time, catheterization time, and hospital stay in the treatment of short bulbar strictures. Diabetes and previous urethroplasty are predictive factors for failure.

Identification of risk factors for failure in patients with skin and soft tissue infections

PurposeThe purpose was to determine significant predictors of treatment failure of skin and soft tissue infections (SSTI) in the inpatient and outpatient setting. MethodsA retrospective chart review of patients treated between January 1, 2005 to July 1, 2016 with ICD-9 or ICD-10 code of cellulitis or abscess. The primary outcome was failure defined as an additional prescription or subsequent hospital admission within 30 days of treatment. Risk factors for failure were identified through multivariate logistic regression. ResultsA total of 541 patients were included. Seventeen percent failed treatment. In the outpatient group, 24% failed treatment compared to 9% for inpatients. Overweight/obesity (body mass index (BMI) > 25 kg/m2) was identified in 80%, with 15% having a BMI >40 kg/m2. BMI, heart failure, and outpatient treatment were determined to be significant predictors of failure. The unit odds ratio for failure with BMI was 1.04 (95% [Cl] = 1.01 to 1.1, p = 0.0042). Heart failure increased odds by 2.48 (95% [Cl] = 1.3 to 4.7, p = 0.0056). Outpatients were more likely to fail with an odds ratio of 3.36. ConclusionPatients with an elevated BMI and heart failure were found to have increased odds of failure with treatment for SSTIs. However, inpatients had considerably less risk of failure than outpatients. These risk factors are important to note when making the decision whether to admit a patient who presents with SSTI in the emergency department. Thoughtful strategies are needed with this at-risk population to prevent subsequent admission.

Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis.

Can live birth be accurately predicted following surgical resection of moderate-severe (Stage III-IV) endometriosis? Live births can accurately be predicted with the endometriosis fertility index (EFI), with adnexal function being the most important factor to predict non-assisted reproductive technology (non-ART) fertility or the requirement for ART (www.endometriosisefi.com). Fertility prognosis is important to many women with severe endometriosis. Controversy persists regarding optimal post-operative management to achieve pregnancy and the counselling of patients regarding duration of conventional treatments before undergoing ART. The EFI is reported to correlate with expectant management pregnancy rate, although external validation has been performed without specifically addressing fertility in women with moderate and severe endometriosis. Retrospective cohort study of 279 women from September 2001 to June 2016. We included women undergoing laparoscopic resection of Stage III-IV endometriosis who attempted pregnancy post-operatively. The EFI was calculated based on detailed operative reports and surgical images. Fertility outcomes were obtained by direct patient contact. Kaplan-Meier model, log rank test and Cox regression were used for analyses. The follow-up rate was 84% with a mean duration of 4.1 years. A total of 147 women (63%) had a live birth following surgery, 94 of them (64%) without ART. The EFI was highly associated with live births (P < 0.001): for women with an EFI of 0-2 the estimated cumulative non-ART live birth rate at five years was 0% and steadily increased up to 91% with an EFI of 9-10, while the proportion of women who attempted ART and had a live birth, steadily increased from 38 to 71% among the same EFI strata (P = 0.1). A low least function score was the most significant predictor of failure (P = 0.003), followed by having had a previous resection (P = 0.019) or incomplete resection (P = 0.028), being older than 40 compared to <35 years of age (P = 0.027), and having leiomyomas (P = 0.037). The main limitation of this study is its retrospective design. Imprecision was higher with low EFI due to smaller sample size in this subgroup. Finally, the EFI is somewhat subjective and could be prone to intra- and inter-observer variations. Women with a high EFI score have excellent fertility prognosis and may be advised to try to become pregnant with timed intercourse compared to women with a low score, for which prompt referral to ART seems more reasonable. Other prognostic factors can be used to guide the management of women with an intermediate EFI score. These data follow women over many years post-resection and represent longitudinal fertility data rarely demonstrated in such a cohort. The location and impact of lesions on the ability of the adnexa to function seems crucial for the fertility prognosis and should be further investigated. This study was funded by the GRACE Research funds. S.M.-L. is the recipient of a Training Award from the Fonds de Recherche Quebec-Sante. D.A. is the primary author of the Endometriosis Fertility Index. All authors have no conflicts of interest to declare. N/A.