Retrospective analysis of locked versus non-locked plating of distal fibula fractures.

INTRODUCTION: Unstable distal fibular fractures have traditionally been treated with open reduction internal fixation using a 1/3 tubular non-locked plate (compression plating). Locked plating is a newer technique that has become more popular despite the lack of clinical data supporting improved outcomes. The cost of locked plating is almost four times that of compression plating. We compared rates of reoperation due to implant failure, infection, and symptomatic device between compression and locked plating in open reduction internal fixation of distal fibular fractures METHODS: A retrospective study was performed at a level one trauma center over a ten-year period (2008-2017). Patients who were 18 and older and treated for unstable ankle fractures with locking or non-locking plate were included in this study. Patient charts were reviewed by orthopedic trauma surgeons to identify whether patients were treated with a 1/3 tubular non-locking or pre-contoured locked plate and to determine the cause of reoperation. RESULTS: In total, 442 patients were identified with 203 in the non-locked 1/3 tubular plate group and 239 in the pre-contoured locked plate group. A total of 38 patients (8.6%) underwent device removal with a higher proportion of patients in the non-locked 1/3 tubular plate cohort (11.3% vs. 6.3%, p = 0.059). Statistically significant differences in reasons for reoperation were found for symptomatic implant (78.3% vs. 46.7%, p = 0.045) and infection (8.7% vs 53.3%., p < 0.01). Of patients who had device removal for symptomatic implant in the compression plating cohort, 13 (72.2%) had lateral positioning and 5 (27.8%) had posterior positioning (p < 0.01) whereas there was no statistical difference in plate positioning in the locked cohort. Of all medical comorbidities identified, only diabetes was associated with a higher rate of infection-related reoperations (83.3% vs. 15.6%, p < 0.01). CONCLUSIONS: Both compression and locked plate techniques demonstrated low reoperation rates. Compression plating with 1/3 tubular plates placed laterally more often resulted in reoperation due to symptomatic implant but had fewer complications of infection. Given that the cost is significantly less, 1/3 tubular plating placed posteriorly may be preferred to decrease the risks of symptomatic implant and infection.

Risk of Peri-implant Fracture With Long Versus Short Cephalomedullary Nailing for Geriatric Patients With Intertrochanteric Femur Fracture.

Intramedullary fixation using a short or long cephalomedullary nail (CMN) for treating hip fractures has gained popularity in recent years. We evaluated reoperation rates requiring device removal of short or long CMNs for patients 65 years and older. A retrospective study was performed at a level I trauma center over a 10-year period (2005-2015). Patients 65 years and older who were treated for intertrochanteric hip fractures with CMNs were included. This study included 893 patients (600 patients treated with a short CMN vs 293 treated with a long CMN). Patients in both cohorts were comparable in age, sex, and Injury Severity Score. There was no significant difference in comorbidities between the short and long CMN groups. Hospital length of stay (7.13 vs 6.88 days, P=.407) and intensive care unit length of stay (4.97 vs 4.63 days, P=.732) were not significantly different between the short and long CMN cohorts, respectively. The in-hospital mortality rate also did not vary between the 2 groups (1.3% for short CMN vs 2.7% for long CMN, P=.139). A significantly higher proportion of patients treated with a long CMN were discharged to a skilled nursing facility (63.4% vs 56.1%, P=.042). The overall reoperation rate was also comparable, 4.7% and 3.4% in the short CMN and long CMN groups, respectively (P=.367). No difference was found between the 2 treatment modalities (short or long CMN) for the elderly population. Both implants had similar rates of reoperation and implant failure. There is a cost consideration, with increasing length of the nail corresponding to increased cost. [Orthopedics. 2022;45(5):304-309.].

Hand Injuries of Coal Miners in Southern West Virginia: A Pilot Study on Health-Care Resources in Southern West Virginia.

INTRODUCTION: Distance and other factors may play a significant role in both the implementation of care and the number of secondary health outcomes. The distance from an injury site can play a substantial impact on the mortality of different injuries and access to health-related services. Within this study, we sought to understand the effect of the site to treating center distance and access to relevant health-care services on effect and secondary injuries of coal mining-related injuries. METHODS: We evaluated patient demographics, coal mining locations, and patient outcomes. This study is a retrospective review of patients with coal mining hand injuries included in our Level 1 trauma database as well as the amount of health-related resources defined by WV GIS Health Care (Hospitals). The sample consists of coal mine workers. All patients had to meet the study criteria and were admitted during the study period of January 1, 2005, through March 31, 2015. We then were able to locate the coal mines where these coal miners were injured based on information from their medical records and the availability of health-care resources (hospitals) around the zones of injury, as well as health-related resources from the WV GIS database. The sample size was n = 104. Data were collected in an Excel spreadsheet. Stata 11.2 was used to conduct a multinomial logistic regression. A hub analysis was performed to understand the overall distance associated with the injury site and care using Arch GIS 10.6. A hotspot analysis was also performed in order to understand the differences of different zones of concern of injury sites in Southern West Virginia, from January 1, 2005, to March 31, 2015. RESULTS: Variables collected are as follows: a total number of coal miners were 104, with an average age of miners being similar in age demographics at 19-62. Coal mines are registered on the map with relevance to injury based on location; severity scale is presented. The most common injuries were fractures at 42.3% (47/104) followed by amputations at 26.9% (28/104). The index finger had an overall higher rate of injury at 28.8% (30/104). To understand the overall impact of specific injuries of coal miners based on the location, we peered into the number of injuries sustained at particular sites over the 10 years. Within this, the attached group, the average distance per injury to a medical center that was able to assist with hand injuries, was 46.1 miles. The shortest distance was within one mile of the center, and the most prolonged distance was 83.3 miles. The highest concentration of coal mining injuries were over 5 miles away from any health care organizations. The at-risk area of coal mining injuries was identified at (P = 0.001) and outside of health-care resources that can be seen within the hotspot analysis tested within this analysis. CONCLUSION: Specific injuries appear to be more at risk on different portions of the hand, as described in our initial data analysis. We also found that particular coal mines seem to harbor more coal mining hand injuries. Rural health care has the challenge of injuries occurring at extended distances and requires that treatment becomes as efficient as possible to maximize the chances of a full recovery. AIM AND OBJECTIVES: The objective of this study is to understand if the distance between the location of injury and trauma center plays a role in the outcome of coal mines related to hand injuries treated at Charleston Area Medical Center.

Humeral Shaft Fracture Healing Rates in Older Patients.

Nonoperative treatment has become the standard of care for the majority of humeral shaft fractures. Published studies have mainly come from trauma centers with a young cohort of patients. The purpose of this study was to determine the nonunion rate of humeral shaft fractures in patients older than 55 years. A retrospective study was performed on a group of orthopedic trauma group treated at a level I trauma center during a 10-year period (2007-2017). Patients 55 years or older and treated for a humeral shaft fracture nonoperatively, with or without manipulation, were identified. Nonunion was defined by no bridging callus radiographically or by gross motion at the fracture at least 12 weeks from injury. There were 31 patients identified with humeral shaft fractures who met the inclusion criteria. The cohort included 21 (67.7%) females and 10 (32.3%) males with a mean age of 72.5 years (range, 55-92 years). Twenty-one fractures went on to union, and there were 10 nonunions, with no significant differences in the demographics or comorbidities. There was no correlation between AO/OTA fracture classification or fracture location and union status. There was a tendency toward higher risk of nonunion in proximal third humeral shaft fractures (45%) compared with middle (26%) and distal third (20%) humeral shaft fractures, although this was not statistically significant. The overall nonunion rate for humeral shaft fractures was 32% for patients older than 55 years. The authors found a significant correlation between age and union rate: as age increased, union rate decreased (R=-0.9, P=.045). The incidence of humeral shaft nonunion in patients older than 55 years was significantly higher than that of younger adults. To the authors' knowledge, this study is the first to report a significant correlation between nonunion and increased age. [Orthopedics. 2020;43(3);168-172.].

The impact of burnout syndrome on practitioners working within rural healthcare systems.

INTRODUCTION: Burnout syndrome (BOS) affects up to 50% of healthcare practitioners. Limited data exist on BOS in paramedics/firstresponders, or others whose practice involves trauma. We sought to assess the impact of BOS in practitioners of rural healthcare systems involved in the provision of trauma care within West Virginia. METHODS: A 3-part survey was distributed at two regional trauma conferences in 2018. The survey consisted of 1) Demographic/occupational items, 2) The Mini Z Burnout Survey, and 3) elements measuring the impact, and supportive infrastructure to prevent and/or manage BOS. RESULTS: Response rate was 74.7% (127/170 attendees). Respondents included emergency medical services (EMS) (44.9%), nurses (37.8%), and physicians (9.4%). Overall, 31% reported BOS - physicians (45.5%), EMS (35.1%), and nurses (25.0%). Most agreed that BOS impacts the health of medical professionals (99.2%) and presents a barrier to patient care (97.6%). Those with BOS reported higher stress (p < 0.001), chaos at work (p < 0.001), and excessive documentation time at home (p < 0.001). Fewer respondents with BOS reported job satisfaction (p < 0.001), control over workload (p = 0.001), sufficient time for documentation (p ≤0.001), value alignment with institutional leadership (p = 0.001), and team efficiency (p = 0.004). Unique factors for BOS in EMS included: lack of control over workload (p = 0.032), poor value alignment with employer (p = 0.002), lack of efficient teamwork (p = 0.006), and excessive time documenting at home (p = 0.003). CONCLUSIONS: Burnout syndrome impacts rural healthcare practitioners, regardless of discipline. These data highlight a need to address the entire team and implement occupation-specific approaches for prevention and treatment. Further prospective study of these findings is warranted.

Farming Related Trauma Injuries in Southern West Virginia With a Focus on Risks, Injury Trends, and Associated Co-morbidities.

Background The implementation of safety policies in farming-related injuries in West Virginia has been lacking. Farming-related injuries have resulted in massive injuries that have resulted in life long injuries and death. Therefore, this study aims to review 12 years of our level 1 trauma data and describe the incidence rate and patterns of priority-related farming injuries in West Virginia, as well as the specific co-morbidities and related injuries that might be more susceptible to damage. Methods We examined 82 cases of farm-related injuries that required trauma-priority related intervention from 2005 -2016. We harvested data from the Charleston Area Medical Center Trauma registry to investigate associated injuries. We defined farm equipment as any mechanical or automated tool used on a farm for related farm upkeep or farm-related activity. Multinomial logistic regression was used to understand the overall impact on the differing effects of years of injuries. Results The total number of farming-related injury cases was 82. The most statistically suggestive finding was those that had a positive narcotics urine test at (p= 0.062) (-.3230-12.82). Those with a history of CHF (congestive heart failure) also had a significant statistical relationship at (p=0.001) (-5.477-1.394). Alcohol use disorder was also a significant statistical relationship (p=0.012) (-5.127--.6728). The most common injuries were concussions at 18 % ( 15/82) followed by rib fractures at 17 % ( 14/82). Conclusion Farming-related injuries appear to have increased risks on specific body and organ systems, as described in our initial data analysis. Specific co-morbidities also have been documented to show a higher risk of injury and would need further investigation. Specific years show a higher prevalence of farming injuries compared to other years. Further research is needed to explore these underlying findings.

Whole exome sequencing of patients who resolved Crohn's disease and complex regional pain syndrome following treatment for paratuberculosis.

BACKGROUND: A whole exome sequencing study was performed on an extended family including a patient with Crohn's disease (CD) and a patient with complex regional pain syndrome (CRPS). The patient with CD and the patient with CRPS have experienced resolution of their disease following treatment for paratuberculosis. The study was performed in order to determine if there is an unusual mutation in this extended family that would explain the susceptibility to mycobacterial infection among many of the members. RESULTS: We identified sets of rare single nucleotide polymorphisms (SNPs) that were shared among affected family members, including variants in two genes, IL15RA and CASP10, which have established roles in the immune response. In addition, the CD and CRPS patients were found to have heterozygous mutations in MBL2 and DDX58, mutations that have been associated with susceptibility to tuberculosis. CONCLUSIONS: The IL15RA and CASP10 variants may contribute to the disease symptoms exhibited in this family. The finding of SNPs associated with immune function supports a complementary role of infection and genetics in these diseases.

The Consensus from the Mycobacterium avium ssp. paratuberculosis (MAP) Conference 2017.

On March 24 and 25, 2017 researchers and clinicians from around the world met at Temple University in Philadelphia to discuss the current knowledge of Mycobacterium avium ssp. paratuberculosis (MAP) and its relationship to human disease. The conference was held because of shared concern that MAP is a zoonotic bacterium that poses a threat not only to animal health but also human health. In order to further study this problem, the conferees discussed ways to improve MAP diagnostic tests and discussed potential future anti-MAP clinical trials. The conference proceedings may be viewed on the www.Humanpara.org website. A summary of the salient work in this field is followed by recommendations from a majority of the conferees.

Resolution of Crohn's disease and complex regional pain syndrome following treatment of paratuberculosis.

A cohort of family members with various chronic diseases including Crohn's disease, asthma, complex regional pain syndrome, hypothyroidism, type 1 diabetes mellitus, and lymphangiomatosis and/or evidence of infection by Mycobacterium avium subsp. paratuberculosis (MAP) are described in this series of case reports. MAP was cultured from the blood of three members affected by the first five diseases and there was accompanying elevated anti-MAP IgG in two members. The patient affected by the sixth disease has a markedly elevated anti-MAP titer. The two patients affected by the first four diseases have been treated with a combination of anti-MAP antibiotics and ultraviolet blood irradiation therapy with resolution of the disease symptomatology and inability to culture MAP in post treatment blood samples. These case reports of patients with MAP infections provide supportive evidence of a pathogenic role of MAP in humans.

Long-term Comparative Outcomes of Carotid Artery Stenting Following Previous Carotid Endarterectomy vs De Novo Lesions.

PURPOSE: To report the long-term outcomes of patients who underwent carotid artery stenting (CAS) for de novo carotid stenosis vs patients treated for restenosis after carotid endarterectomy (CEA). METHODS: A retrospective review was conducted of all 385 patients (mean age 68.6±9.6 years; 231 men) who underwent 435 CAS procedures at a large tertiary care center between January 1999 and December 2013. For analysis, patients were stratified based on their lesion type [de novo (dn) vs post-CEA restenosis (res)] and subclassified by symptoms status [symptomatic (Sx) or asymptomatic (Asx)], creating 4 groups: (1) CAS-dn Asx, (2) CAS-dn Sx, (3) CAS-res Asx, and (4) CAS-res Sx. For the CAS-res group, the mean elapsed time from CEA to CAS was 72.4±63.6 months. Outcomes included target vessel reintervention (TVR) and in-stent restenosis (ISR), the latter defined by a carotid duplex ultrasound velocity >275 cm/s. RESULTS: The main indication for initial carotid angiography with possible revascularization was severe carotid stenosis (≥70%-99% on duplex) in both CAS-dn and CAS-res groups (83.6% vs 83.7%, p=0.999). There were no significant differences in the percentage of patients with postintervention residual stenosis (<30%; 100% each arm) or complications between CAS-res vs CAS-dn: in-hospital stroke (1.4% vs 1.8%, respectively), myocardial infarction (0.9% vs 0%), or death (0.9% vs 0%). Mean follow-up was 62.4±45.6 months (median 53.5, range 1-180). Average clinical/TVR follow-up was greater for the CAS-res group (71.9±48.6 months) compared with 53.3±40.5 months for the CAS-dn group (p<0.001). Across the 4 study groups, there were no differences in freedom from ISR (p=0.174) or TVR (p=0.856). Multivariate analysis found peripheral vascular disease (PVD) as the sole ISR independent predictor [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.03 to 3.62, p=0.041], while significant predictors for TVR were age <65 years at the time of the procedure (HR 2.55, 95% CI 1.05 to 6.18, p=0.039) and PVD (HR 2.46, 95% CI 1.03 to 5.87, p=0.043). CONCLUSION: The current study suggests that CAS is a feasible and durable therapeutic option for recurrent restenosis after CEA. Long-term outcomes were similar for patients treated for de novo lesions or post-CEA restenosis. Age and PVD appear to influence long-term CAS durability.

Appropriate use of D-dimer testing can minimize over-utilization of venous duplex ultrasound in a contemporary high-volume hospital.

BACKGROUND: The sensitivity of d-dimer (DD) in detecting deep venous thrombosis (DVT) is remarkably high; however, many institutions send patients immediately for a venous duplex ultrasound (VDU). This study was designed to examine the appropriate utilization of DD and VDU in a high-volume hospital. METHODS: A retrospective study was conducted on consecutive patients who presented to a high-volume emergency department (ED) with lower extremity limb swelling/pain over a 30-day period, who were sent for VDU during an evaluation for DVT. VDU data were merged with electronic DD laboratory results. The enzyme-linked immunosorbent assay method was used to provide DD values and thresholds. Values above 0.60 mg/fibrinogen equivalent unit (FEU) were considered abnormal. RESULTS: We reviewed the medical records of 517 ED patients in the month of June 2013. After applying the Wells criteria, 157 patients (30.4%) were excluded because of a history of DVT or pulmonary embolism, having been screened for shortness of breath, or sent for surveillance-leaving 360 for analysis. The average age was 59.3 ± 16.5 years with more women (210, 58.3%) and the majority reported limb pain or swelling (73.9%). DD was performed on 51 patients with an average value of 3.6 ± 5.4 mg/FEU, of which 43 (84.3%) were positive. DD identified all positive and negative DVT patients (100% sensitivity and negative predictive value), but also included 40 false positives (16.7% specificity). On the other hand, 309 patients were sent directly to VDU without DD; of those, 43 (13.9%) were positive for DVT. However, 266 (86.1%) patients were negative for DVT by VDU without DD and these were deemed improper by our current study protocol. Potential charge savings were calculated as VDU for all (360 × $1000 = $360,000), DD for all (360 × $145 = $52,200), and VDU for both true and false positives (estimated to be about 25% of the cases; 90 × $1000 = $90,000); this equals a charge savings of $217,800 and would avoid unnecessary VDUs. CONCLUSIONS: Based on the results of our study, we suggest that the DD test be utilized during the initial work-up for patients with limb swelling/pain in the emergency room. Appropriate utilization of DD, as well as other clinical criteria, may limit the over-utilization and added cost of VDU, without a negative impact on patient care. The results of DD tests should be utilized to limit the number of patients sent for VDU to only those patients with a positive DD or other significant underlying concerns.

Mildly reduced preoperative ejection fraction increases the risk of stroke in older adults undergoing coronary artery bypass grafting.

INTRODUCTION: Current guidelines based on clinical trials may have inadvertently excluded a representative cohort of older adults. As a result, little is known about the predictors of stroke among elderly patients undergoing coronary artery bypass surgery (CABG). The purpose of this study was to determine how a lower than normal ejection fraction (EF) predicted post surgery stroke among elderly patients undergoing CABG when compared with younger populations. METHODS: Retrospective cross-sectional cohort analysis. setting: Charleston Area Medical Center, a tertiary medical center. PARTICIPANTS: 8661 consecutive CABG cases between 2003 and 2009. measurements: PARTICIPANTS were divided into three different age groups: < 65 years old (Group 1), between 65 and 79 years old (Group 2), and > or = 80 years old (Group 3). We calculated the rate of overall neurological complications after CABG for patients with ejection fraction values: < 40%, between 40% and 59%, and > or = 60. RESULT: Group 3 (age > = 80) with EF < = 39 had the highest odds of developing post CABG stroke (Odds Ratio (OR): 5.6) followed by Group 3 (age > = 80) with EF 40-59 (OR: 3.9). In addition, Group 2 (age 65-79) with EF < = 39 had the next highest odds of developing post CABG stroke (OR: 2.3) followed by Group 2 (age 65-79) with EF 40-59 (OR: 1.9). CONCLUSION: Contrary to current guidelines, in our study population, mildly affected EF increased the overall risk of neurological complications among elderly patients undergoing CABG.

The investigation of missing paternal information in birth certificates and low birth weight.

OBJECTIVE: To determine if missing paternal information in birth certificates is associated with an increased risk of low birth weight (LBW). METHODS: This was a retrospective single cohort analysis including all live births at our institution between April 1999 and May 2002. We created two study groups, one with father's information complete (FIC) and one with father's information missing (FIM). We utilised a three-tier approach (univariate analysis, multivariate analysis and propensity matching) to determine if FIM was related to LBW. RESULTS: Univariate analysis showed a significant difference in LBW rates between the FIM and FIC groups (14.6 vs. 9.1%, p < 0.001). However, this difference was not observed in the multivariate (odds ratio = 1, p = 0.858, ns) or propensity matching analysis (13.9 vs. 13.8%, p = 0.954, ns). CONCLUSION: After controlling for LBW risk factors, FIM was not an independent predictor of LBW.

Effect of neurology consults on outcomes for patients suffering transient ischemic attacks after coronary artery bypass grafting.

Stroke patients appear to have lower morbidity and mortality rates and better outcomes when neurologists serve as the primary admitting physician. The effect of neurological consultations on coronary artery bypass graft (CABG) patients who have suffered a postoperative transient ischemic attack (TIA) has not yet been determined. The authors evaluated whether neurology consultations improved outcomes. A retrospective analysis was conducted of CABG patients from a high-volume tertiary care center. Primary end points included 30-day mortality, discharge disposition, length of stay, and 1-year incidence of stroke. Post-CABG TIA patients receiving a neurological consult (N = 127) were compared with propensity-matched controls. Thirty-day mortality was identical (3.1%), with nonsignificant difference in long-term incidence of stroke. There were no differences in home discharges or length of stay. Including a neurologist in the treating team for patients suffering TIAs after CABG appears not to reduce post-operative incidence of morbidity and mortality, reduce length of stay, or improve patient disposition at discharge.