Epidemiology of pelvic and acetabular fractures in a tertiary hospital in Singapore.

Introduction: Pelvic and acetabular fractures (PAFs) usually result from high-energy, potentially life-threatening accidents. They are one of the major injuries that lead to death in patients involved in such accidents. We studied the recent epidemiology of these injuries in Singapore. Methods: This is a retrospective data analysis of all trauma patients who underwent surgery for PAFs from 2008 to 2016 in a tertiary trauma centre in Singapore. Data including patient demographics, mechanism of injury and associated injuries was collected. Results: A total of 169 patients were admitted for PAFs over the eight-year period. The majority (79.3%) were male. The mean age was 41 (range 13-79) years. Most patients (51.5%) were Chinese. The most common mechanisms of injury were road traffic accidents (53.8%), falls (33.1%) and crush injuries (13.0%). 46.2% sustained acetabular fractures, while 44.4% sustained pelvic fractures. PAFs were most commonly associated with upper and lower limb injuries, followed by spinal and thoracic injuries. Average of length of stay in hospital was 24 (range 2-375) days. Conclusion: PAF predominantly affects young working males. Compared to previously published local data, there has been a significant reduction in the incidence of PAFs, likely due to improved road and work safety. The demographics of PAFs have changed, with fewer injuries in females (20.7% vs. 33.3%), a reduction in the proportion of injuries in the Chinese (51.5% vs. 70.1%). While road traffic accidents remain the most common cause, crush injuries are now more prevalent (13.0%).

Machine learning algorithms do not outperform preoperative thresholds in predicting clinically meaningful improvements after total knee arthroplasty.

PURPOSE: Patient-reported outcome measures (PROMs) are important measures of success after total knee arthroplasty (TKA) and being able to predict their improvements could enhance preoperative decision-making. Our study aims to compare the predictive performance of machine learning (ML) algorithms and preoperative PROM thresholds in predicting minimal clinically important difference (MCID) attainment at 2 years after TKA. METHODS: Prospectively collected data of 2840 primary TKA performed between 2008 and 2018 was extracted from our joint replacement registry and split into a training set (80%) and test set (20%). Using the training set, ML algorithms were developed using patient demographics, comorbidities and preoperative PROMs, whereas the optimal preoperative threshold was determined using ROC analysis. Both methods were used to predict MCID attainment for the SF-36 PCS, MCS and WOMAC at 2 years postoperatively, with predictive performance evaluated on the independent test set. RESULTS: ML algorithms and preoperative PROM models performed similarly in predicting MCID for the SF-36 PCS (AUC: 0.77 vs 0.74), MCS (AUC: 0.95 vs 0.95) and WOMAC (AUC: 0.89 vs 0.88). For each outcome, the most important predictor of MCID attainment was the patient's preoperative PROM score. ROC analysis also identified optimal preoperative threshold values of 33.6, 54.1 and 72.7 for the SF-36 PCS, MCS and WOMAC, respectively. CONCLUSION: ML algorithms did not perform significantly better than preoperative PROM thresholds in predicting MCID attainment after TKA. Future research should routinely compare the predictive ability of ML algorithms with existing methods and determine the type of clinical problems which may benefit the most from it. LEVEL OF EVIDENCE: II.

Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty?

BACKGROUND: Diabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA. METHODS: We reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM). RESULTS: Compared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (-1.22 points, P-value = .025) and knee ROM (-1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866). CONCLUSION: Patients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.

Correlation Between Gastrocnemius Tightness and Heel Pain Severity in Plantar Fasciitis.

BACKGROUND: It is known that there is an association between gastrocnemius tightness and plantar fasciitis, but this has never been quantified. The purpose of the study was to determine the correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis. METHODS: Thirty-three patients were prescribed physiotherapist-directed gastrocnemius stretching exercises, a Strassburg Sock or night splint, and silicone heel insoles as required. Outcome measures included (1) gastrocnemius tightness, (2) 100-mm visual analog scale (VAS) for pain on the first steps in the morning, and (3) 100-mm VAS for the worst pain felt during the previous week. Gastrocnemius tightness was measured by the difference in maximal ankle dorsiflexion between knee bent and straight with a goniometer. RESULTS: The mean gastrocnemius tightness was 22 degrees at baseline compared with 9 degrees at the final follow-up (P < .01). A reduction in VAS for pain on the first steps in the morning and VAS for the worst pain felt during the previous week from baseline to final follow-up was observed (P < .01). Correlation analysis of 105 data points between gastrocnemius tightness and VAS for pain on the first steps in the morning was R = 0.757 (P < .001), and between gastrocnemius tightness and VAS for the worst pain felt during the previous week was R = 0.781 (P < .001). CONCLUSION: The study observed a strong, statistically significant correlation between gastrocnemius tightness and the severity of heel pain in plantar fasciitis. LEVEL OF EVIDENCE: Level IV, case series.

Outcomes of Anterior Cruciate Ligament Reconstruction in Females Using Patellar-Tendon-Bone versus Hamstring Autografts: A Systematic Review and Meta-Analysis.

The current review aims to compare the outcomes of anterior cruciate ligament (ACL) reconstruction in the female population after patellar-tendon-bone and hamstring grafts. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All original randomized controlled trials and prospective cohort studies that compared clinical outcomes after female ACL reconstruction using hamstring versus patellar-tendon-bone grafts were included. All clinical outcomes reported by three or more studies were included. Fifteen publications, with 948 female patients, were included. Most outcomes were reported to have no significant graft differences by all studies that reported the outcome. These included all the outcomes for objective knee scores (International Knee Documentation Committee [IKDC] objective knee score), neuromuscular testing (quadriceps strength, hamstring strength, and single hop test), graft rupture or failure, and subjective knee scores (Lysholm score and IKDC subjective knee score). The pivot shift test, flexion deficit, and presence of crepitus were also reported to have no significant graft differences by all studies. Some studies reported a significant difference in anteroposterior laxity (Lachman's test and instrumented laxity), range of motion deficits (extension deficit), and sports and activity level (Tegner score). However, these statistically significant differences were noted to be clinically insignificant due to the normal population variation or standard error of measurement of these tools of evaluation. Patients reconstructed with patellar-tendon-bone grafts have a higher risk of kneeling pain. There was no significant difference in the incidence of crepitus. Most of the outcomes following female ACL reconstructions showed no clinically and statistically significant difference when either patellar-tendon-bone or hamstring autograft was used. These included outcomes for anteroposterior laxity, objective knee scores, neuromuscular testing, graft rupture or failure, subjective knee scores, sports and activity level, and crepitus. This a level II study.

Impact of maternal obesity and breastfeeding intention on lactation intensity and duration.

Exclusive breastfeeding (EBF) has numerous maternal health benefits. However, EBF rates are lower in mothers with obesity. We sought to better understand whether maternal body composition measurements in early pregnancy are also predictive of lower rates of EBF. Healthy pregnant women with prepregnancy body mass index (BMI) of 17.5-51 kg/m2 underwent determination of percent body fat (% body fat) in early (12-16 weeks) and late (37 weeks) gestation. Intent and duration of EBF were determined by surveys completed at 6 weeks and 6 months postpartum (PP). Unadjusted and adjusted analyses were performed to compare EBF rates and weaning by maternal BMI and % body fat. Increasing BMI and % body fat in early pregnancy were significantly associated with lower rates of EBF among women intending EBF. Women with BMI ≥ 25 were less likely to be EBF at 6 weeks and 6 months PP compared with women of normal BMI (67 and 37% vs. 91 and 79%, P value 0.005 and 0.001, respectively). Among primiparous women intending EBF, 100% of women in the lowest two body fat quartiles in early pregnancy were EBF at 6 weeks PP compared with 66.7 and 63.6% of women in the higher quartiles (P = 0.03). Lactation cessation by 6 months PP was higher with increasing maternal BMI (P = 0.001). Maternal obesity in early gestation is associated with lower EBF rates among women intending EBF and earlier weaning. Excess adiposity in early pregnancy may impede EBF.

Type-2 diabetes mellitus: does prenatal care affect outcomes?

OBJECTIVE: To determine if prenatal care affects adverse perinatal outcomes in pregnant women with Type-2 diabetes mellitus (T2DM). STUDY DESIGN: This was a retrospective cohort study of pregnant women with pregestational diabetes mellitus pregnancies in the state of California between 1997 and 2006, using vital statistics data linked to birth certificates. Women were stratified by time of presentation to care and we compared those who presented in the first trimester, third trimester, and those who had no prenatal care prior to delivery. Perinatal outcomes looked at included: preeclampsia, macrosomia, preterm delivery, cesarean delivery, and intrauterine fetal demise (IUFD). The two groups were compared with chi-squared testing to determine statistical significance. RESULTS: In women with pregestational diabetes those who presented at time of delivery had an 11.3% risk of IUFD compared to 0.9% in those who presented in the first trimester. There was also an increased rate of preterm birth in the late presentation cohort (29.4% at time of delivery versus 21.0% in the first trimester). After adjusting for possible confounding variables using logistic regression models, rates of IUFD and preterm delivery were still found to be statistically significant with adjusted odds ratios of 11.37 (95% CI: 6.10-21.16) and 1.55 (95% CI: 1.03-2.32), respectively. There were no differences in rates of macrosomia or preeclampsia between the three cohorts. CONCLUSIONS: Treatment of T2DM throughout pregnancy leads to improved maternal and neonatal outcomes.

Shifting Patterns in Cesarean Delivery Scheduling and Timing in Oregon before and after a Statewide Hard Stop Policy.

OBJECTIVES: To assess the use and timing of scheduled cesareans and other categories of cesarean delivery and the prevalence of neonatal morbidity among cesareans in Oregon before and after the implementation of Oregon's statewide policy limiting elective early deliveries. DATA SOURCES: Oregon vital statistics records, 2008-2013. STUDY DESIGN: Retrospective cohort study, with multivariable logistic regression, regression controlling for time trends, and interrupted time series analyses, to compare the odds of different categories of cesarean delivery and the odds of neonatal morbidity pre- and postpolicy. DATA COLLECTION/EXTRACTION METHODS: We analyzed vital statistics data on all term births in Oregon (2008-2013), excluding births in 2011. PRINCIPAL FINDINGS: The odds of early-term scheduled cesareans decreased postpolicy (adjusted odds ratio [aOR], 0.70; 95 percent confidence interval [CI], 0.66-0.74). In the postpolicy period, there were mixed findings regarding assisted neonatal ventilation and neonatal intensive care unit admission, with regression models indicating higher postpolicy odds in some categories, but lower postpolicy odds after controlling for time trends. CONCLUSIONS: Oregon's hard stop policy limiting elective early-term cesarean delivery was associated with lower odds of cesarean delivery in the category of women who were targeted by the policy; more research is needed on impact of such policies on neonatal outcomes.

The utility of magnetic resonance imaging in addition to computed tomography scans in the evaluation of cervical spine injuries: a study of obtunded blunt trauma patients.

PURPOSE: Evidence guiding the use of CT and MRI scans in blunt trauma patients who are obtunded remains controversial. This study aims to determine and predict if computed tomography (CT) scans alone can be performed without risking oversight of substantial injuries found on follow-up magnetic resonance imaging (MRI). METHODS: This is a retrospective cohort study of 63 blunt trauma patients with a Glasgow Coma Scale of < 8. Data were collated from electronic medical records and included patient demographics, premorbid mobility, mechanism of injury, suspected level of injury and neurological examination findings. Patients were urgently evaluated using CT scans, followed by non-contrast MRI scans within 48 h of admission. The accuracy of CT scan was evaluated using MRI as a reference. Adjusted multivariable analysis was also performed to identify predictors for findings detected on MRI but not on CT. RESULTS: The mean age of patients was 42.3 years and 90.5% were males. CT scans had a high specificity of 100% and sensitivity of 87.2%. Predictors of MRI abnormalities include females, patients with relatively milder mechanisms of injury, patients with suspected thoracic spine injury, and CT scan findings of facet dislocation and intracranial haemorrhage. There was no predictor for spinal cord oedema. CONCLUSIONS: MRI should be performed in the presence of the aforementioned predictive factors and in the presence of neurological deficits. Otherwise, patients can be treated medically without the fear of missing a substantial cervical injury.

Traumatic dislocation of the S1 polyaxial pedicle screw head: a case report.

Polyaxial screw head dislocation in the absence of a manufacture defect is extremely rare and represents a biomechanical overload of the screw, leading to early failure. A 58-year-old gentleman underwent instrumented fusion using polyaxial pedicle screws-titanium rod construct with interbody cage for spondylolytic spondylolisthesis at the L5/S1 level. He attempted to bend forward ten days after the surgery which resulted in a dislocation of the right S1 polyaxial screw head from the screw shank with recurrence of symptoms. He underwent revision surgery uneventfully. This case highlights the need to pay particular attention to the strength of fixation and the amount of release to avoid such a complication.

Single Working Portal Technique for Knotless Arthroscopic Bankart Repair.

Arthroscopic Bankart repair is widely accepted as the method of choice in restoring the labrum to the glenoid rim. It has been shown to have comparable outcomes with open stabilization. This usually involves the use of 2 portals anteriorly: one anterosuperior accessory portal and another anteroinferior working portal. The aim of this Technical Note is to present a simple and reproducible technique for Bankart repair using a single working portal anteriorly without an accessory portal.

Overcoming chemoresistance in prostate cancer with Chinese medicine Tripterygium wilfordii via multiple mechanisms.

A leading cause of cancer chemotherapy failure is chemoresistance, which often involves multiple mechanisms. Chinese medicines (CM) usually contain multiple components which could potentially target many mechanisms simultaneously and may offer an advantage over single compounds that target one mechanism at a time. The purpose of this study was to investigate the chemosensitizing effect (CE) of a specific CM, Tripterygium wilfordii (TW), on prostate cancer cells resistant to docetaxel (Dtx) and identify the potential mechanisms. The CE of TW (in combination with Dtx) was evaluated in two Dtx resistant prostate cancer cell lines (PC3-TxR and DU145-TxR) and the efficacy of the combination for resistant PC3-TxR tumor was investigated using a xenograft mouse model. For mechanistic study, the inhibitory effect of TW on P-glycoprotein activity was assessed. In addition, novel gene targets of TW were identified using DNA microarray and quantitative PCR. Results showed that TW induced a CE of 8 and >38 folds in PC3-TxR and DU145-TxR cells, respectively with Dtx IC50 reversed back to that of the sensitive parent cells. An optimum dose of TW+Dtx significantly retarded tumor growth in mice compared to TW or Dtx alone. TW inhibited P-glycoprotein activity and induced a significant gene expression changes in genes related to angiogenesis, cell cycle regulation and differentiation. Our in vitro and in vivo studies demonstrate that TW in combination with Dtx was able to overcome the chemoresistance and suppress resistant prostate tumor growth via multi-mechanisms.

The Importance of Patient Sex in the Outcomes of Anterior Cruciate Ligament Reconstructions: A Systematic Review and Meta-analysis.

BACKGROUND: One of the well-studied epidemiological phenomena of anterior cruciate ligament (ACL) injuries is the 2- to 9-fold increase in the relative risk of ACL rupture in female athletes compared with male athletes. However, the influence of patient sex on the outcome after ACL reconstruction remains unclear, with some authors reporting inferior outcomes in females and others noting no significant difference. PURPOSE: To provide a comprehensive systematic review and meta-analysis to examine the possible association between patient sex and the subjective and objective outcomes after ACL reconstruction. METHODS: This study was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies that reported clinical outcomes after ACL reconstruction in males and females independently were included in the review. A quantitative random-effects meta-analysis was performed to compare outcomes between sexes. For outcomes with considerable heterogeneity, meta-regression was used to identify potential moderators. Articles were evaluated qualitatively when quantitative data were not reported. RESULTS: A total of 135 publications were included in the review. Females had inferior outcomes in instrumented laxity (standardized mean difference [SMD], 0.24; 95% CI, 0.11-0.37), revision rate (relative risk [RR], 1.15; 95% CI, 1.02-1.28), Lysholm score (SMD, -0.33; 95% CI, -0.55 to -0.11), Tegner activity scale (SMD, -0.37; 95% CI, -0.49 to -0.24), and incidence of not returning to sports (RR, 1.12; 95% CI, 1.04-1.21), all of which were statistically significant. Other outcomes were comparable between sexes, including anterior drawer test, Lachman test, pivot-shift test, timed single-legged hop test, single-legged hop test, quadriceps testing, hamstring testing, extension loss, flexion loss, development of cyclops lesion, and International Knee Documentation Committee (IKDC) knee examination score. Females and males were equally likely to develop anterior knee pain and osteoarthritis after ACL reconstruction. The graft rupture and graft failure rates did not differ significantly between sexes. CONCLUSION: There were comparable or inferior results for females compared with males in all outcomes analyzed. No statistically significant sex difference was identified in most of the objective parameters. However, subjective and functional outcomes, including Lysholm score, Tegner activity scale, and ability to return to sports, have been shown to be poorer in females.

Emerging lessons from regional and state innovation in value-based payment reform: balancing collaboration and disruptive innovation.

CONTEXT: In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States. METHODS: As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice. FINDINGS: The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers' limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment. CONCLUSIONS: From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected "honest broker" that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a "burning bridge" between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of "reformed" fee-for-service with bundled payments and global payments.

A report on eight early-stage state and regional projects testing value-based payment.

To help contain health care spending and improve the quality of care, practitioners and policy makers are trying to move away from fee-for-service toward value-based payment, which links providers' reimbursement to the value, rather than the volume, of services delivered. With funding from the Robert Wood Johnson Foundation, eight grantees across the country are designing and implementing value-based payment reform projects. For example, in Salem, Oregon, the Physicians Choice Foundation is testing "Program Oriented Payments," which include incentives for providers who follow a condition-specific program of care designed to meet goals set jointly by patient and provider. In this article we describe the funding rationale and the specific objectives, strategies, progress, and early stages of implementation of the eight projects. We also share some early lessons and identify prerequisites for success, such as ensuring that providers have broad and timely access to data so they can meet patients' needs in cost-effective ways.

Identifying cell and molecular stress after radiation in a three-dimensional (3-D) model of oral mucositis.

Mucositis is a debilitating adverse effect of chemotherapy and radiation treatment. It is important to develop a simple and reliable in vitro model, which can routinely be used to screen new drugs for prevention and treatment of mucositis. Furthermore, identifying cell and molecular stresses especially in the initiation phase of mucositis in this model will help towards this end. We evaluated a three-dimensional (3-D) human oral cell culture that consisted of oral keratinocytes and fibroblasts as a model of oral mucositis. The 3-D cell culture model was irradiated with 12 or 2 Gy. Six hours after the irradiation we evaluated microscopic sections of the cell culture for evidence of morphologic changes including apoptosis. We used microarrays to compare the expression of several genes from the irradiated tissue with identical genes from tissue that was not irradiated. We found that irradiation with 12 Gy induced significant histopathologic effects including cellular apoptosis. Irradiation significantly affected the expression of several genes of the NF-kB pathway and several inflammatory cytokines, such as IL-1B, 1L-8, NF-kB1, and FOS compared to tissue that was not irradiated. We identified significant upregulation of several genes that belong to damage-associated molecular patterns (DAMPs) such as HMB1, S100A13, SA10014, and SA10016 in the 3-D tissues that received 12 Gy but not in tissues that received 2 Gy. In conclusion, this model quantifies radiation damage and this is an important first step towards the development 3-D tissue as a screening tool.

Measuring the medical home infrastructure in large medical groups.

The patient-centered medical home is taking center stage in discussions of primary care innovation as a new delivery model that provides comprehensive, coordinated care across the lifespan. Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006-07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership.