Obesity as an independent risk factor for COVID-19 severity and mortality.

BACKGROUND: Since December 2019, the world has struggled with the COVID-19 pandemic. Even after the introduction of various vaccines, this disease still takes a considerable toll. In order to improve the optimal allocation of resources and communication of prognosis, healthcare providers and patients need an accurate understanding of factors (such as obesity) that are associated with a higher risk of adverse outcomes from the COVID-19 infection. OBJECTIVES: To evaluate obesity as an independent prognostic factor for COVID-19 severity and mortality among adult patients in whom infection with the COVID-19 virus is confirmed. SEARCH METHODS: MEDLINE, Embase, two COVID-19 reference collections, and four Chinese biomedical databases were searched up to April 2021. SELECTION CRITERIA: We included case-control, case-series, prospective and retrospective cohort studies, and secondary analyses of randomised controlled trials if they evaluated associations between obesity and COVID-19 adverse outcomes including mortality, mechanical ventilation, intensive care unit (ICU) admission, hospitalisation, severe COVID, and COVID pneumonia. Given our interest in ascertaining the independent association between obesity and these outcomes, we selected studies that adjusted for at least one factor other than obesity. Studies were evaluated for inclusion by two independent reviewers working in duplicate.  DATA COLLECTION AND ANALYSIS: Using standardised data extraction forms, we extracted relevant information from the included studies. When appropriate, we pooled the estimates of association across studies with the use of random-effects meta-analyses. The Quality in Prognostic Studies (QUIPS) tool provided the platform for assessing the risk of bias across each included study. In our main comparison, we conducted meta-analyses for each obesity class separately. We also meta-analysed unclassified obesity and obesity as a continuous variable (5 kg/m2 increase in BMI (body mass index)). We used the GRADE framework to rate our certainty in the importance of the association observed between obesity and each outcome. As obesity is closely associated with other comorbidities, we decided to prespecify the minimum adjustment set of variables including age, sex, diabetes, hypertension, and cardiovascular disease for subgroup analysis.  MAIN RESULTS: We identified 171 studies, 149 of which were included in meta-analyses.  As compared to 'normal' BMI (18.5 to 24.9 kg/m2) or patients without obesity, those with obesity classes I (BMI 30 to 35 kg/m2), and II (BMI 35 to 40 kg/m2) were not at increased odds for mortality (Class I: odds ratio [OR] 1.04, 95% confidence interval [CI] 0.94 to 1.16, high certainty (15 studies, 335,209 participants); Class II: OR 1.16, 95% CI 0.99 to 1.36, high certainty (11 studies, 317,925 participants)). However, those with class III obesity (BMI 40 kg/m2 and above) may be at increased odds for mortality (Class III: OR 1.67, 95% CI 1.39 to 2.00, low certainty, (19 studies, 354,967 participants)) compared to normal BMI or patients without obesity. For mechanical ventilation, we observed increasing odds with higher classes of obesity in comparison to normal BMI or patients without obesity (class I: OR 1.38, 95% CI 1.20 to 1.59, 10 studies, 187,895 participants, moderate certainty; class II: OR 1.67, 95% CI 1.42 to 1.96, 6 studies, 171,149 participants, high certainty; class III: OR 2.17, 95% CI 1.59 to 2.97, 12 studies, 174,520 participants, high certainty). However, we did not observe a dose-response relationship across increasing obesity classifications for ICU admission and hospitalisation. AUTHORS' CONCLUSIONS: Our findings suggest that obesity is an important independent prognostic factor in the setting of COVID-19. Consideration of obesity may inform the optimal management and allocation of limited resources in the care of COVID-19 patients.

Preterm birth does not increase the risk of developmental dysplasia of the Hip: a systematic review and meta-analysis.

BACKGROUND: The purpose of this systematic review was to appraise the literature on the association between preterm birth and developmental dysplasia of the hip (DDH). METHODS: Medline, Embase, Scopus, and Web of Science databases were queried for all studies pertaining to DDH and preterm birth. Data were imported and analyzed in Revman5 and Comprehensive Meta-Analysis (CMA) for pooled prevalence estimation. RESULTS: Fifteen studies were included in the final analysis. There were 759 newborns diagnosed with DDH in these studies. DDH was diagnosed in 2.0% [95%CI:1.1-3.5%] of the premature newborns. Pooled incidence rate of DDH was not statistically different between those groups (2.5%[0.9%-6.8%] vs. 0.7%[0.2%-2.5%] vs. 1.7%[0.6%-5.3%];Q = 2.363,p = 0.307). CONCLUSIONS: In this systematic review and meta-analysis, we did not find preterm birth to be a significant risk factor for DDH. Data suggests that female sex and breech presentation are associated with DDH in preterm infants, but the data is scarce in the literature.

Risk Factors for Dislocation following Total Hip Arthroplasty in Developmental Dysplasia of the Hip: A Systematic Review and Meta-Analysis.

PURPOSE: This systematic review and meta-analysis aimed to identify risk factors of dislocation after total hip arthroplasty (THA) in patients with developmental dysplasia of the hip (DDH). METHODS: A systematic literature review was performed on 18th August 2022 using Medline, Embase, Scopus, Web of Science electronic databases, and a manual search. The study was conducted according to the PRISMA guidelines and registered with PROSPERO. Statistical analysis includes assessment of heterogeneity and data synthesis using RevMan 5.4. RESULTS: Review of five studies including 2865 patients and 116 dislocated hips found that lower body mass index (BMI) (SMD = 0.22, p = 0.04, I2 = 0%), Crowe classification type IV versus I, II, and III (OR = 2.70, p = 0.004, I2 = 51%), higher cup inclination (SMD = 0.39 p = 0.0007, I2 = 0%), femoral head size < 28 mm (OR = 5.07, p = 0.003, I2 = 71%), lateral surgical approach (OR = 1.96, p = 0.02, I2 = 0%), and postoperative infection (OR = 6.26, p < 0.0001, I2 = 0%) were significant risk factors. However, age, gender, cup anteversion, femoral osteotomy, vertical (V-COR) centre of rotation, intraoperative fracture, preoperative and postoperative leg length discrepancy (LLD) and previous hip surgery were not found to be significant risk factors. CONCLUSION: This study underscores importance of these risk factors in THA planning for DDH patients to reduce dislocation risk. Further research needed to understand mechanisms.

Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients.

Background: Although an intensive care unit (ICU) admission is a risk factor for missed injury, there has been some disagreement on whether missed injuries in trauma ICU patients have a longer length of stay (LOS). With this in mind, these patients' frequency of missed injuries and related factors were investigated. Materials and methods: This was a prospective cohort study on multiple trauma injury patients in a tertiary referral trauma center's trauma intensive care unit (TICU) from March 2020 to March 2021. A tertiary survey was conducted in the TICU by attending physicians to find the types I and II missed injuries (any injury discovered after primary and secondary surveys during the hospital stay). A logistic regression model was designed for predictors of missed injuries in ICU-admitted multiple trauma patients. Results: Out of 290 study participants, 1,430 injuries were found, and of those injuries, 74 cases (25.5%) had missed injuries. In other words, there were 103 missed injuries, resulting in a missed injury detection rate of 7.2%. The most frequently missed injuries (43.4%) were concluded as extremities fractures. The regression model showed that the patients with missed injuries are prone to longer TICU LOS [odds ratio (OR) = 1.15; p = 0.033], and cases who underwent a computed tomography (CT) scan are less likely to have missed injuries (OR = 0.04; p < 0.001). The abbreviated injury scale (AIS) range was 1-3 in missed injuries. Conclusion: Our research underlines the importance of finding missed injuries and the necessity of CT scan to decrease them. In teaching centers, life-threatening injuries decrease with increasing visits and examination times. Although these missed injuries do not increase mortality, they cause longer TICU LOS and costs. How to cite this article: Bahramian M, Shahbazi P, Hemmati N, Mohebzadeh P, Najafi A. Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients. Indian J Crit Care Med 2023;27(3):201-204.

The Rate of Successful Cardiopulmonary Resuscitation in COVID-19 Patients: A Retrospective Cohort Study.

Background: This study aims to provide information on the success rate of CPR in COVID-19 patients and some probable risk factors of mortality in these cases. Methods: In this historical cohort design, the CPR success rate probable risk factors of 737 critically ill patients during the COVID-19 pandemic in 17 hospitals in the catchment area of Iran University of Medical Sciences, Tehran, Iran, was evaluated between Feb and Apr 2020. Data were extracted from a database that is a part of a national integrated care electronic health record system and analyzed with logistic and Cox regression models. Results: COVID-19 cases were 341 (46.3%). The mean age in COVID-19 cases and non-COVID-19 patients were 70.0±14.6 and 63.0±19.3 years, respectively (P<0.001). The mortality was significantly higher in COVID-19 patients (99.1% vs. 74%, OR: 39.6, 95%CI: 12.4, 126.2). Cardiovascular diseases were the most frequent underlying disease (46.3% of COVID-19 cases and 35.1% of non-COVID-19 patients). Being a COVID-19 case (OR: 29.0, 95%CI: 8.9, 93.2), Intensive care unit admission (OR: 2.6, 95%CI: 1.5, 4.6) and age for each ten-year increase (OR: 1.2, 95%CI: 1.1, 1.4) were observed to be independent risk factors of mortality following CPR. The hazard ratio of being a COVID-19 patient was HR= 1.8 (95%CI: 1.5, 2.1). Conclusion: Critically ill COVID-19 patients who undergo CPR have a decreased chance of survival in comparison to non-COVID-19 patients.

Predicting acetabular version in native hip joints through plain x-ray radiographs: a comparative analysis of convolutional neural network model and the current gold standard, with insights and implications for hip arthroplasty.

Introduction: This study presents the development and validation of a Deep Learning Convolutional Neural Network (CNN) model for estimating acetabular version (AV) from native hip plain radiographs. Methods: Utilizing a dataset comprising 300 participants with unrelated pelvic complaints, the CNN model was trained and evaluated against CT-Scans, considered the gold standard, using a 5-fold cross-validation. Results: Notably, the CNN model exhibited a robust performance, demonstrating a strong Pearson correlation with CT-Scans (right hip: r = 0.70, p < 0.001; left hip: r = 0.71, p < 0.001) and achieving a mean absolute error of 2.95°. Remarkably, over 83% of predictions yielded errors ≤5°, highlighting the model's high precision in AV estimation. Discussion: The model holds promise in preoperative planning for hip arthroplasty, potentially reducing complications like recurrent dislocation and component wear. Future directions include further refinement of the CNN model, with ongoing investigations aimed at enhancing preoperative planning potential and ensuring comprehensive assessment across diverse patient populations, particularly in diseased cases. Additionally, future research could explore the model's potential value in scenarios necessitating minimized ionizing radiation exposure, such as post-operative evaluations.

Illicit drug abuse and complexity of tibial shaft fracture based on AO/OTA classification: Is there any connection?

Purpose: Illicit drug abuse is a global epidemic afflicting millions worldwide. Several studies have investigated the contribution of this dependence as a risk factor for fracture, but its impacts on fracture severity have been rarely studied. The present study primarily aims to determine the relationship between illicit drug abuse and the severity of tibial shaft fractures. Methods: This retrospective study consecutively included patients aged ≥18 years with tibial shaft fracture who attended Sina Tertiary Hospital, Tehran, Iran, between 2016 and 2021. The fracture patterns were assessed according to the Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association classification. Participants were divided into three individual specialists into groups: simple (A), wedge (B) and multifragmentary (C) fractures. The association of illicit drug abuse and other recorded variables, including age, sex, body mass index (BMI), comorbidities, physical activity, smoking habits and mechanism of injury, was also examined and assessed in multivariate logistic regression. Results: Of 219 patients, 26 were drug abusers, and 193 had no history of use. A total of 20 out of 26 drug abusers experienced a complex fracture, yielding a rate of 76.9%, while this rate for nonusers was 50.3% (97 out of 193), indicating a statistically significant difference between the two subgroups (p = 0.011). The smoking history also influenced the fracture pattern (p = 0.027) based on univariate analysis; however, using adjusted multivariate analysis yielded only illicit drug abuse (odds ratio = 3.495; confidence interval = 1.144-10.680) as a risk factor for more complex fractures. Conclusion: The evidence from this study suggests that complexity and fracture patterns can depend on illicit drug abuse history. Level of Evidence: Level III.

A new case of Melnick-Needles syndrome with skeletal manifestations: A case report.

INTRODUCTION AND IMPORTANCE: Melnick-Needles syndrome (MNS) is a rare skeletal dysplasia that affects skeletal and connective tissue. Less than 70 cases of MNS reported in the literature. MNS had various clinical manifestations such as skeletal deformity, cortical bony sclerosis, facial abnormality, and urogenital symptoms. CASE PRESENTATION: We presented a 5-year-old girl who referred to our orthopedic clinic with knee valgus deformity, spinal kyphoscoliosis, bilateral coxa valga, and humerus cortical irregularity. Based on some facial and skeletal feature, MNS was confirmed with genetic evaluation (heterozygote Filamin A genome). CLINICAL DISCUSSION: The diagnosis of MNS requires a thorough medical and family history, physical examination, and radiographic evaluation. Differential diagnoses for patients with skeletal and facial deformities like MNS include Camurati-Engelmann disease, cystinuria, Galloway-Mowat syndrome, Joubert syndrome, and mucopolysaccharidosis. Treatment for MNS patients with bony deformities without lethal conditions can be conservative, but corrective surgery may be necessary in some cases. CONCLUSIONS: MNS was a rare syndrome with common clinical manifestations such as limb and spine deformity. It is important to conduct a careful examination of any patient who presents with limb and skeletal deformity to the orthopedic clinic, as the disease may have some lethal clinical implications.

External iliac artery thrombosis as a result of acetabular fixation through the ilioinguinal approach: a case report.

Introduction and importance: Acetabular fractures mostly occur in young people who are involved in high-energy trauma and they are treated by orthopedic trauma surgeons. Patients with acetabular fractures are at high risk for different kinds of complications. We report a case of postoperative thrombosis of the external iliac artery following fixation surgery performed by an ilioinguinal approach while receiving thromboprophylaxis during admission to the hospital. Case presentation: A 57-year-old healthy woman presented with a left both-column acetabular fracture and underwent acetabular fixation through the ilioinguinal approach. The patient was receiving antithrombotic prophylaxis medications in the course of treatment. Clinical discussion: During her convalescence, while at the hospital, she was diagnosed with left external iliac artery thrombosis, needing surgical thrombectomy. These severe and rare complications will lead to uncertainty about a commonly used ilioinguinal approach. Postoperative arterial thrombosis may be rare in patients undergoing acetabular fixation surgery but searching for signs and symptoms of this condition is always necessary. Conclusion: It is possible to prevent severe complications by performing a routine measurement of the distal arterial pressure after similar surgeries.

Two case reports of adult traumatic inferior hip dislocations following road traffic accidents without complications.

Inferior dislocation of the hip is the rarest type of hip dislocation, mainly occurring from high-energy incidents, mostly from road traffic accidents or sports. It is generally an injury among adults. Case presentation: A 17-year-old male sustained injuries as a pedestrian, and a 30-year-old male sustained a traffic accident as a motorcycle rider. Both patients complained of severe pain in the hip, decreasing range of motion, and the inability to weight bearing. In both, the affected hip joint was fixed in 90° flexion, abduction, and external rotation, and the leg was slightly shorter than the other limb. An X-ray showed the inferior dislocation of the right hip and left hip, respectively, without any sign of fracture. We reduced both dislocations closely after sedation without any complications during follow-ups. Conclusion: This injury should be treated as an emergency, and reduction performed as soon as possible, within 6 h. It can be managed usually with closed reduction under general anesthesia. Close follow-up is necessary to prevent its complications, including avascular necrosis, associated fractures, neurovascular compromise, and articular cartilage injuries.

Platelet-rich plasma versus corticosteroid: a randomized controlled trial on tennis elbow patients resistant to nonsurgical treatments.

Background: Although some studies on tennis elbow indicate corticosteroid (CS) effectiveness in the short term, according to the role of race, this study evaluates the efficacy of platelet-rich plasma (PRP) compared with CS for a more cost-effective treatment. Methods: This randomized controlled trial included 30 positive-resisted wrist extension patients with a minimum five visual analog scale (VAS) pain score. Participants were randomly assigned to treatment or control groups via computer-generated randomization and were matched for baseline and clinical characteristics. Cases received either 40 mg of prednisolone acetate or 2 ml of PRP, followed for 1 month. VAS and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were the primary outcomes. Results: The median VAS and the mean DASH scores had a statistically significant difference in the PRP and CS groups before and after injection (P<0.001).The mean DASH difference between preinjection and follow-up time in the PRP and CS groups was 59.72±14.17 and 43.16±10.87, respectively, with a mean difference of 16.55 (95% CI 7.10-26.00) and a significant difference (P=0.001).The mean VAS pain score difference in preinjection and follow-up time had a statistically significant difference between the PRP and CS groups (P=0.026), and the mean VAS pain score difference in the CS group was 6.46±1.50 and 7.73±0.96 in the PRP group. Conclusion: In conclusion, larger studies with parallel groups and more diverse CS doses and types with baseline matching are needed to confirm the short-term benefits of PRP. Investigating the effects of different CS doses using ultrasound techniques is recommended.

A shotgun-induced nonunion humeral fracture treated by Masquelet technique and arthrodesis: a case report.

Introduction and importance: The Masquelet technique remains one of the procedures with low rates of failure and infection. The use of this technique in humeral defects is still rare. Case presentation: A 38-year-old male patient with an open humeral comminuted fracture induced by shotgun injury was referred to our hospital. The Masquelet technique was chosen as the best option with a lower risk of infection and the lower expenses at this stage due to the second time of open reduction and internal fixation and bone graft failure, low patient compliance, and the increasing size of the defect due to bone absorption. An arthrodesis procedure was performed 5 days after the second Masquelet stage as restoring the elbow joint's range of motion was impossible. Clinical discussion: The Masquelet technique, is a two-step surgical procedure to manage pseudoarthroses and bone defects. Various surgical options are available for performing this procedure. There are several reasons behind the rising popularity of this technique during recent years. Some of these reasons include the reproducibility of this technique, as well as requiring less time, not being technically challenging, and having fewer neurovascular complications. Conclusion: This case was one of the limited examples of successful implementation of the Masquelete procedure on severe traumatic injuries of the upper limb with bone defects providing more evidence on the safety and efficacy of this technique in similar conditions.

Late Complications of COVID-19; An Umbrella Review on Current Systematic Reviews.

Introduction: Several clinical manifestations have been discovered for COVID-19 since the emergence of SARS-CoV-2, which can be classified into early, medium, and long-term complications. However, late complications can be present after recovery from acute COVID-19 illness. The present study aims to comprehensively review the available evidence of late complications related to COVID-19. Method: A search was conducted, using keywords, through electronic databases, which included Scopus, Web of Science, PubMed, and Embase up to August 29, 2022. Study selection was performed according to a strict inclusion and exclusion criteria. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist was followed, and studies were appraised using the National Institute of Health (NIH) quality assessment and risk of bias tool. Results: In total, 50 studies were included, and nine distinct COVID-19 late complication categories were identified. A review of these studies revealed that neurologic and psychiatric (n=41), respiratory (n=27), musculoskeletal and rheumatologic (n=22), cardiovascular (n=9), and hepatic and gastrointestinal (n=6) complications were the most prevalent complications of long COVID-19. Conclusion: Almost all human body systems are affected by late complications of COVID-19 with different severity and prevalence. Fatigue and some other neuropsychiatric symptoms are the most common late complications among long COVID-19 patients. Respiratory symptoms including dyspnea (during exercise), cough, and chest tightness were the next most prevalent long-term complications of COVID-19. Since these complications are persistent and late, being aware of the signs and symptoms is essential for the healthcare providers and patients.

Cortical bridging a union predictor: A prospective study after intramedullary nailing of the femoral shaft fractures.

Early prediction of the union helps for timely intervention, reduction of hospitalization, treatment costs, and disability in cases of nonunion. With this in mind, we tried to find how long any cortical bridging predicts the union in femoral shaft fractures. A prospective study of 113 femoral shaft fractures treated with reamed, locked intramedullary nailing was performed. Radiographs were taken during months 2 to 4, 6, 9, and one-year follow-up. The cortical bridging (presence and number) was assessed by anterior-posterior and lateral views. The ROC curve provides the prediction of the union. The overall nonunion rate was 10.6% (12 of 113 fractures). Age and diabetes mellitus were statistically significant with nonunion (p value < 0.001). The final analysis demonstrated that any cortical bridging at four months postoperatively was the most accurate and earlier indicator (105 of 113, 92.9% accuracy), while it was 84.9% at six months in bicortical and 80.5% accuracy at nine months in tricortical bridging. Low-cost and simple radiographic imaging presents cortical bridging in any form 4 months after surgery that precisely predicts a union in femoral shaft fractures.