Expedited surgery does not increase transfusion rates for patients with geriatric hip fracture taking factor Xa inhibitors.

Objectives: Geriatric patients who sustain hip fractures and are taking factor Xa inhibitors (Xa-I) experience surgical delay. Our institution developed a pharmacokinetic protocol to formally guide and expedite surgical timing for these patients. The protocol is based on the patient's renal function and timing of last Xa-I dose. For patients with impaired renal function, longer wait times are recommended. The purpose of this study was to determine the effects of this protocol for patients with geriatric hip fracture taking Xa-I. Design: Retrospective cohort study. Setting: Level 1 trauma center. Patients/Participants: A total of 164 patients aged 65 and older who were taking Xa-I before admission and underwent hip fracture surgery; 68 patients in the Standard group (2014-2018) and 96 patients in the Expedited group (2020-2022, after protocol implementation). Intervention: Hip fracture surgery. Main Outcome Measurements: Time to surgery (TTS), transfusion rate, blood loss, 90-day complication rates. Results: The median TTS was significantly shorter in the Expedited group (28.6 hours, interquartile range 21.3 hours) than in the Standard group (44.8 hours, interquartile range 21.1 hours) (P < .001). There were no differences in overall transfusion rates. Multivariable regression analysis demonstrated that time to surgery was not predictive of transfusion rate in all patients (OR 1.00, 95% CI 0.99-1.02, P = .652). There were no differences in blood loss or rates of 90-day complications. Conclusion: Geriatric patients with hip fractures and taking factor Xa inhibitors may warrant earlier surgery without an increased risk of transfusion or bleeding. Level of Evidence: Therapeutic Level III.

Optimizing the Entry Point for Reconstruction Nailing of the Femur.

INTRODUCTION: Varus after antegrade medullary nailing of the proximal femur is associated with worse outcomes. Anecdotally, a more medialized "trochiformis" entry is beneficial to avoid varus with valgus-bend (greater trochanteric entry) femoral nails. However, the optimal entry point remains unknown. The purpose of this study was to define the optimal entry point for reconstruction nailing. METHODS: Using standing alignment radiographs from 51 patients, we templated the ideal entry point for straight and valgus-bend nails from three major manufacturers using TraumaCad software. We measured the distance from the tip of the trochanter to the ideal entry site for each nail. We compared piriformis (PF) with trochanteric (GT) entry for each company and across manufacturers. RESULTS: The mean greater trochanter offset from the femoral axis was 15.2 mm. The mean PF entry was 5.9 to 6.7 mm medial to the mean GT entry for each company's nail and was statistically distinct. No differences were observed in GT and PF entry points across manufacturers. Only 2 of 153 ideal GT entry points were lateral to the tip of the trochanter. An increased neck-shaft angle (NSA) and increased GT offset were correlated with a more medial ideal entry point. DISCUSSION: The ideal entry point for GT nails is similar across manufacturers and is medial to the tip of the greater trochanter; however, PF and GT entry sites remain distinct. During preoperative planning and when executing femoral nailing intraoperatively, it may also be important to consider the NSA and GT offset of a patient before committing to a certain entry point.

Thermal Degradation Characteristics of Styrene-Butadiene-Styrene Copolymer Asphalt Binder Filled with an Inorganic Flame-Retarding Agent.

Asphalt binder is a complex mixture of dark brown polymers composed of hydrocarbons with generally poor fire resistance. To improve its flame retardancy when used in tunnel asphalt pavements, a new inorganic flame-retardant filler (FR) containing magnesium hydroxide, aluminum hydroxide, inorganic phosphate, and melamine salt was explored. Thereafter, limiting oxygen index (LOI) and smoke suppression tests for the flame-retarded asphalt binder (FRA) mastics mixed with FR and styrene-butadiene-styrene (SBS) copolymer asphalt binder were conducted. Thermogravimetric (TG) and differential scanning calorimetry (DSC) curves for the FRA were correspondingly generated. Based on the TG data, the reaction function g(α), apparent activation energy Ea, and pre-exponential factor A were quantitatively evaluated using kinetic analysis. In addition, a Fourier transform infrared spectrometry (FTIR) test was utilized to assess the effects of the presence of FR on the chemical composition of the asphalt binder. Dynamic shear rheometer (DSR) tests were also performed to evaluate the rheological behavior of FRA. Results show that the presence of the FR significantly reduced the LOI and improved the smoke suppression during combustion of the asphalt binder mastics. The presence of FR was found to increase the Ea and the complexity of the combustion reaction, thereby improving the flame retardancy of the asphalt binder. FTIR analysis indicated that the presence of FR did not induce any strong chemical reactions to significantly impact or alter the functional groups of the asphalt binder. Furthermore, it was also observed that the rutting parameter and critical failure temperature of FRA increased with the addition of FR due to the stiffening effect of the solid FR particles.

COVID-19 Shelter-In-Place Orders Associated With Delayed Presentation and Deep Venous Thrombosis in Geriatric Hip Fractures.

Geriatric hip fractures benefit from timely surgery. At the onset of the corona-virus disease 2019 (COVID-19) pandemic, shelter-in-place (SIP) orders were mandated in high-risk cities. The authors hypothesized that geriatric patients with hip fractures were more likely to present to the hospital greater than 24 hours after injury during SIP orders. They retrospectively reviewed patients 65 years or older who presented with hip fractures between March 20, 2020, and May 24, 2020 (SIP group), and between March 20, 2019, and May 24, 2019 (historical group). Primary outcomes were incidence of presentation greater than 24 hours after injury and mean number of days between injury and presentation. Secondary outcomes were incidence of preoperative deep venous thrombosis (DVT) and 30- and 90-day mortality rates. Thirty-three patients comprised the SIP group, and 50 patients comprised the historical group. There were no significant differences in their demographics or medical comorbidities. The SIP group was more likely to present greater than 24 hours after injury (P=.05) and presented a greater number of days after injury (P=.02). There was a significant difference in the incidence of preoperative DVT (P=.03). There were no significant differences in 30- and 90-day mortality rates. Geriatric patients who sustained hip fractures during SIP restrictions for COVID-19 were more likely to present greater than 24 hours after injury, have a greater number of days between injury and presentation, and be diagnosed with a preoperative DVT. [Orthopedics. 2021;44(4):223-228.].

Posterior Lateral Meniscal Root Tears Increase Strain on the Reconstructed Anterior Cruciate Ligament: A Cadaveric Study.

PURPOSE: To quantify the amount of strain across an anterior cruciate ligament reconstruction (ACLR) before and after a lateral meniscus (LM) posterior root complex tear and determine whether a meniscal root repair effectively protects the ACLR against excessive strain. METHODS: Fresh-frozen cadaveric knees were tested with an 88-N anterior drawer force and an internal and external torque of 5-Nm applied at 0°, 15°, 30°, 60°, and 90° of flexion. A simulated pivot shift was also applied at 0, 15, and 30° of flexion. Rotation and translation of the tibia, and strain across the ACL graft were recorded. Testing was repeated for the following four conditions: ACL-intact, ACLR with intact LM, ACLR with LM posterior root complex tear, and ACLR with root repair. RESULTS: The kinematic data from 12 fresh frozen cadaveric knees underwent analysis. Only 11 specimens had usable strain data. Sectioning the meniscofemoral ligaments and the LM posterior root increased rotational and translational laxity at 30° of knee flexion. ACLR graft strain significantly increased when an anterior load and internal torque were applied. Repair of the LM posterior root reduced strain when the knee was internally rotated but was unable to normalize strain when an anterior force was applied. CONCLUSIONS: This cadaveric biomechanical study suggests injury to the LM posterior root complex increases rotational and anterior laxity of the knee and places increased strain across reconstructed ACL grafts. Subsequent root repair did not result in a statistically significant reduction in strain. CLINICAL RELEVANCE: This study provides quantitative data on the implications of a LM posterior root injury in the setting of an ACL reconstruction to help guide clinical decision-making.

Mechanical Properties of the Interfacial Bond between Asphalt-Binder and Aggregates under Different Aging Conditions.

Aging has a detrimental impact on the interfacial interaction and bonding between asphalt-binder and aggregates, which influence ultimately on the performance of asphalt mixtures and pavements. Evaluation of the mechanical properties of the interface between the asphalt-binder and aggregates has thus become a hot research topic, particularly as a function of aging. In this study, the interfacial tensile strength, compressive strength, elastic modulus, and interfacial recovery energy were measured and quantified using molecular dynamic simulation. Whilst the free volume of the asphalt mixtures exhibited sensitivity to aging, the interfacial tensile strength decreased with an increase in the degree of aging. In general, the mechanical properties of the asphalt-binder-aggregate interface were found to be significantly dependent on the aggregate type. Furthermore, the study results indicated that interfacial recovery energy is a key characteristic property for characterizing the interfacial adhesive force within asphalt mixtures. Overall, the study of mechanical properties of the asphalt-binder and aggregate interface, as presented in this paper, contributes to quantifying the adhesive properties and improving the performance of asphalt mixtures.

The improvement on total nitrogen removal in nitrate reduction by using a prepared CuO-Co3O4/Ti cathode.

In this work, a CuO-Co3O4/Ti composite was prepared via the coating-calcination method and employed as a cathode for the NO3--N reduction to increase the removal efficiency of total nitrogen (TN). SEM, EDS, and XRD characterization results indicated that CuO and Co3O4 were successfully introduced to the surface of Ti. The CuO-Co3O4/Ti electrode eventually removed NO3--N with the main products of N2, NH4+-N and NO2--N. In comparison to the Co3O4/Ti electrode, the better hydrogen evolution properties of the CuO-Co3O4/Ti electrode resulted in pH increase and NH3 gas release, so the TN removal for CuO-Co3O4/Ti electrode was improved approximately 20%. The presence of Cl- with the concentration up to 1000 mg L-1 greatly promoted the removal of TN from 40.1% to 94.0%, as a result of NH4+-N oxidation with free chlorine produced from the anode. Furthermore, the CuO-Co3O4/Ti electrode was applied to conduct three types of actual wastewater (biological effluent of municipal wastewater and industrial wastewater, and a regeneration concentrate from an anion exchange process) for nitrate removal. The highest TN removal efficiency (78.5%) and current efficiency (54.5%), and the lowest energy consumption (2 × 10-4 kWh mg-1 TN) were obtained for the regeneration concentrate, suggesting the feasibility of the CuO-Co3O4/Ti electrode to the water with high conductivity and high Cl- concentration for removing TN by the reduction of nitrate.

Sports Participation Is an Appropriate Expectation for Recreational Athletes Undergoing Shoulder Arthroplasty.

BACKGROUND: Several studies have investigated sports participation in patients who undergo total shoulder arthroplasty (TSA). However, there are limited data in the setting of hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA), particularly regarding the frequency of participation in common sports. HYPOTHESIS: The majority of patients who undergo TSA or HA will be able to maintain active lifestyles with high levels of sports participation after their procedure, while patients who undergo rTSA will have lower levels of sports participation. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We identified patients who underwent TSA, rTSA, stemmed HA, or humeral head resurfacing (the latter 2 were defined collectively as the HA group) by surgeons within our department since January 2004. We excluded patients who (1) underwent revision arthroplasty, (2) had a history of chronic pain syndrome, (3) experienced septic arthritis of the involved shoulder, and/or (4) were deceased at the time of follow-up. The minimum follow-up from the time of surgery was 2 years. Qualified patients were sent a questionnaire that asked about sports participation and the frequency of participation at the time of follow-up. Frequency was rated as 0, 1 to 3, or 4 to 7 times a week. Sports were defined as lower extremity sport, volleyball, tennis, skiing, bowling, swimming, weight lifting, golf, and other sport. RESULTS: Overall, 95% of the TSA group, 40% of the rTSA group, and 76% of the HA group who had participated in at least 1 sport before surgery indicated that they were doing so at the time of follow-up. Among active patients in the TSA and HA groups, the most common sports at the time of follow-up were weight lifting (52%), swimming (36%), and golf (25%). For the 2 active patients in the rTSA group, 1 participated in swimming and hunting and fishing, while the other participated in weight lifting. For the active patients in the TSA and HA groups who were participating in at least 1 of the 3 most common sports, most patients indicated that they were doing so 1 to 3 times a week at the time of completing the questionnaire. CONCLUSION: Patients undergoing shoulder arthroplasty can maintain an active lifestyle with moderate to high frequencies of participation after surgery, particularly regarding weight lifting, swimming, and golf.

Mid-Term Outcomes After Open Reduction Internal Fixation of Proximal Interphalangeal Joint Dorsal Fracture-Dislocations Through a Volar, Shotgun Approach and a Review of the Literature.

BACKGROUND: Proximal interphalangeal (PIP) fracture dislocations remain a complex injury pattern to treat. There are several treatment methods available aimed to restore stability, preserve range of motion, and reconstitute the articular surface. This study looked at the mid-term clinical and radiographic results of open reduction internal fixation through a shotgun approach of comminuted PIP fracture dislocations. METHODS: A retrospective review was conducted of all PIP fracture dislocations treated through a volar, shotgun approach at a single institution over a 15-year period. Patients identified were contacted and asked to return to the office for clinical and radiographic evaluation. Patient reported outcomes were assessed with the Michigan hand questionnaire (MHQ) and visual analog scale (VAS) for pain. RESULTS: 5 patients returned to the office for further evaluation with average follow-up of 69 months (range, 33-133 months). 3 patients were found to have post traumatic arthritis on radiographs. 1 case had recurrent instability and one case had a deep infection, both necessitating further surgical intervention. Average PIP arc of motion was found to be 79°. Average VAS score of 0 and MHQ result of 95 (out of a possible score of 100) indicating no residual pain and excellent functionality of the affected hand. CONCLUSION: Open reduction internal fixation of comminuted PIP fracture dislocations utilizing the volar, shotgun approach provides excellent mid-term functional results despite the high incidence of post traumatic arthritis.

Feasibility and safety comparison of laparoscopy-assisted versus open gastrectomy for advanced gastric carcinoma with D2 lymphadenectomy.

OBJECTIVE: Laparoscopy-assisted gastrectomy for advanced gastric cancer still remains controversial. The aim of this study is to compare oncologic feasibility and technical safety of laparoscopic versus open gastrectomy for advanced gastric cancer with D2 lymphadenectomy by comparing patients' short-term postoperative outcomes. METHODS: One hundred and one patients with laparoscopy-assisted gastrectomy and 101 patients with open gastrectomy were one-to-one matched and then compared in terms of operative outcomes and hospital courses. RESULTS: The laparoscopic group showed significantly longer operating time (297.4 vs. 198.1 min, P < 0.001), earlier first flatus time (2.8 vs. 3.6 days, P < 0.001), earlier diet start time (3.8 vs. 4.6 days, P < 0.001), shorter hospital stay (10.5 vs. 11.9 days, P < 0.001) and less morbidity (21.8 vs. 37.6%, P = 0.019). However, retrieval lymph nodes, intraoperative blood loss, transfused patients, postoperative fever and mortality were similar in the two groups. As for complications, incision infection (1.0 vs. 8.9%, P = 0.021) was significantly more common in the open group than in the laparoscopic group. In the subgroup comparisons of outcomes of laparoscopy-assisted gastrectomy, the tumor, node, metastasis III group showed significantly increased retrieval lymph nodes (37.2 vs. 31.0, P < 0.001), increased intraoperative blood loss (147.2 vs. 120.5 ml, P = 0.010), increased length of hospital stay (11.1 vs. 9.9 days, P < 0.001) and increased morbidity (32.6 vs. 13.8%, P = 0.024) when compared with the tumor, node, metastasis II group. CONCLUSIONS: Laparoscopy-assisted gastrectomy is feasible and safe for the treatment of advanced gastric cancer with D2 lymphadenectomy compared with open gastrectomy. Higher-level tumor stage (tumor, node, metastasis III) may increase the operative risk and should be performed with caution by surgeons with considerable experience of laparoscopic gastrectomy.

Dextran-coated gold nanoprobes for the concentration and detection of protein biomarkers.

The lateral-flow immunoassay (LFA) is a well-established point-of-care detection assay that is rapid, inexpensive, easy to use, and portable. However, its sensitivity is lower than that of traditional lab-based assays. Previously, we improved the sensitivity of LFA by concentrating the target biomolecules using aqueous two-phase systems (ATPSs) prior to their detection. In this study, we report the first-ever utilization of dextran-coated gold nanoprobes (DGNPs) as the colorimetric indicator for LFA. In addition, the DGNPs are the key component in our pre-concentration process, where they remain stable and functional in the high salt environment of our ATPS solution, capture the target protein with conjugated antibodies, and allow the rapid concentration of the target protein in our ATPS for use in the subsequent LFA detection step. By combining this pre-concentration step with LFA, the detection limit of LFA for a model protein was improved by 10-fold. We further improved our ATPS from previous studies by enabling phase separation at room temperature in 30 min. By using DGNPs for the concentration and detection of protein biomarkers in the sequential combination of the ATPS and LFA steps, we move closer to developing an effective protein detection assay which uses no power or lab-based equipment.

Improving the systemic drug delivery efficacy of nanoparticles using a transferrin variant for targeting.

Targeted therapy for the treatment of cancers using nanoparticles (NPs) decorated with transferrin (Tf) has been relatively successful, as several such nanocarriers are currently undergoing clinical trials. However, since native Tf has a low probability of delivering its payload due to its short residence time in the cell, or low cellular association, there is room to significantly improve the potency of current systems. We pioneered the redesign of this targeting ligand by altering the ligand-metal interaction, as suggested by our mathematical model, and here we present the first study to investigate the enhanced therapeutic efficacy of NPs conjugated to our engineered oxalate Tf. Our mathematical model was first used to predict that NPs conjugated to oxalate Tf will exhibit a higher degree of cellular association compared to native Tf-conjugated NPs. Our in vitro trafficking experiments validated the model prediction, and subsequent in vitro and in vivo efficacy studies demonstrated that this increase in cellular association further translates into an enhanced ability to deliver chemotherapeutics. Our findings signify the importance of the cellular trafficking properties of targeting ligands, as they may significantly influence therapeutic potency when such ligands are conjugated to NPs. Given the early success of a number of native Tf-conjugated NPs in clinical trials, there is potential for using Tf-variant based therapeutics in systemic drug delivery applications for cancer treatment.

Mathematical modeling of vesicle drug delivery systems 2: targeted vesicle interactions with cells, tumors, and the body.

Vesicles have been studied for several years in their ability to deliver drugs. Mathematical models have much potential in reducing time and resources required to engineer optimal vesicles, and this review article summarizes these models that aid in understanding the ability of targeted vesicles to bind and internalize into cancer cells, diffuse into tumors, and distribute in the body. With regard to binding and internalization, radiolabeling and surface plasmon resonance experiments can be performed to determine optimal vesicle size and the number and type of ligands conjugated. Binding and internalization properties are also inputs into a mathematical model of vesicle diffusion into tumor spheroids, which highlights the importance of the vesicle diffusion coefficient and the binding affinity of the targeting ligand. Biodistribution of vesicles in the body, along with their half-life, can be predicted with compartmental models for pharmacokinetics that include the effect of targeting ligands, and these predictions can be used in conjunction with in vivo models to aid in the design of drug carriers. Mathematical models can prove to be very useful in drug carrier design, and our hope is that this review will encourage more investigators to combine modeling with quantitative experimentation in the field of vesicle-based drug delivery.