Curating an online checklist for Erica L. (Ericaceae): contributing to and supporting global conservation through the World Flora Online.

To support the work of the Global Conservation Consortium for Erica and update the Erica checklist in the World Flora Online (WFO), we have curated the taxonomic backbone in the WFO by expanding it to include updated nomenclatural information from the International Plant Name Index, missing names present in the World Checklist of Vascular Plants (WCVP), the Botanical Database of Southern Africa (BODATSA), and from the "International register of heather names" database, a data source not readily available online. The result is the most robust database of Erica names to date, including 851 species, 111 subspecies, 244 varieties, and 2787 synonyms, which is a reliable reference for initiatives such as the Erica identification aid, conservation prioritisation, and gap analyses. We disambiguate common orthographic variants within the database and present an overview of these. We also comment on the correct orthography of E.heleophila Guthrie & Bolus and E.michellensis Dulfer and the validity of E.tegetiformis E.G.H.Oliv. are discussed, and the use of E.adunca Benth. for a South African species rather than E.triceps Link, which is here regarded as insufficiently known and of uncertain application, is clarified.

Twenty years of big plant genera.

In 2004, David Frodin published a landmark review of the history and concepts of big plant genera. Two decades of taxonomic activity have taken place since, coinciding with a revolution in phylogenetics and taxonomic bioinformatics. Here we use data from the World Flora Online (WFO) to provide an updated list of big (more than 500 species) and megadiverse (more than 1000 species) flowering plant genera and highlight changes since 2004. The number of big genera has increased from 57 to 86; today one of every four plant species is classified as a member of a big genus, with 14% in just 28 megadiverse genera. Most (71%) of the growth in big genera since 2000 is the result of new species description, not generic re-circumscription. More than 15% of all currently accepted flowering plant species described in the last two decades are in big genera, suggesting that groups previously considered intractable are now being actively studied taxonomically. Despite this rapid growth in big genera, they remain a significant yet understudied proportion of plant diversity. They represent a significant proportion of global plant diversity and should remain a priority not only for taxonomy but for understanding global diversity patterns and plant evolution in general.

Use of a pressure sensing sheath: comparison with standard means of blood pressure monitoring in catheterization procedures.

PURPOSE: Monitoring of blood pressure (BP) during procedures is variable, depending on multiple factors. Common methods include sphygmomanometer (BP cuff), separate radial artery catheterization, and side port monitoring of an indwelling sheath. Each means of monitoring has disadvantages, including time consumption, added risk, and signal dampening due to multiple factors. We sought an alternative approach to monitoring during procedures in the catheterization laboratory. METHODS: A new technology involving a 330 µm fiberoptic sensor embedded in the wall of a sheath structure was tested against both radial artery catheter and sphygmomanometer readings obtained simultaneous with readings recorded from the pressure sensing system (PSS). Correlations and Bland-Altman analysis were used to determine whether use of the PSS could substitute for these standard techniques. RESULTS: The results indicated highly significant correlations in systolic, diastolic, and mean arterial pressures (MAP) when compared against radial artery catheterization (p<0.0001), and MAP means differed by <4%. Bland-Altman analysis of the data suggested that the sheath measurements can replace a separate radial artery catheter. While less striking, significant correlations were seen when PSS readings were compared against BP cuff readings. CONCLUSIONS: The PSS has competitive functionality to that seen with a dedicated radial artery catheter for BP monitoring and is available immediately on sheath insertion without the added risk of radial catheterization. The sensor is structurally separated from the primary sheath lumen and readings are unaffected by device introduction through the primary lumen. Time delays and potential complications from radial artery catheterization are avoided.

Outcome Following Surgical Correction of Grade 4 Medial Patellar Luxation in Dogs: 47 Stifles (2001-2012).

Grade 4/4 medial patellar luxation (MPL) is a complex disease of the canine stifle that often requires surgical realignment of the patella to resolve clinical lameness. Outcome following surgery remains poorly described. Medical records were retrospectively reviewed for surgical correction of grade 4 MPL. Signalment and exam findings, surgical procedures performed, complications, and clinical outcome were reported. Data was statistically analyzed for association with major complication occurrence and unacceptable function following surgery. Forty-seven stifles from 41 dogs were included. The surgical procedures most frequently utilized for patellar realignment were the combination of femoral trochleoplasty, tibial tuberosity transposition, and joint capsule modification. Median in-hospital veterinary examination was performed at 69 days (range 30-179 days) following surgery. Full function was reported for 42.6% of cases (n=20). Acceptable function was reported for 40.4% of cases (n=19). Unacceptable function was reported for 17% of cases (n=8). The overall complication rate was 25.5% (n=12), with revision surgery for major complications required in 12.8% of cases (n=6). Corrective osteotomies were associated with major complications (P < 0.001). In general, pelvic limb function improves following surgical correction of grade 4 MPL; however, a return to full function should be considered guarded.

Prediction of esophageal varices and variceal hemorrhage in patients with acute upper gastrointestinal bleeding.

In patients with upper gastrointestinal bleeding (UGIB), identifying those with esophageal variceal hemorrhage prior to endoscopy would be clinically useful. This retrospective study of a large cohort of patients with UGIB used logistic regression analyses to evaluate the platelet count, aspartate aminotransferase (AST) to platelet ratio index (APRI), AST to alanine aminotransferase (ALT) ratio (AAR) and Lok index (all non-invasive blood markers) as predictors of variceal bleeding in (1) all patients with UGIB and (2) patients with cirrhosis and UGIB. 2233 patients admitted for UGIB were identified; 1034 patients had cirrhosis (46%) and of these, 555 patients (54%) had acute UGIB due to esophageal varices. In all patients with UGIB, the platelet count (cut-off 122,000/mm(3)), APRI (cut-off 5.1), AAR (cut-off 2.8) and Lok index (cut-off 0.9) had area under the curve (AUC)s of 0.80 0.82, 0.64, and 0.80, respectively, for predicting the presence of varices prior to endoscopy. To predict varices as the culprit of bleeding, the platelet count (cut-off 69,000), APRI (cut-off 2.6), AAR (cut-off 2.5) and Lok Index (0.90) had AUCs of 0.76, 0.77, 0.57 and 0.73, respectively. Finally, in patients with cirrhosis and UGIB, logistic regression was unable to identify optimal cut-off values useful for predicting varices as the culprit bleeding lesion for any of the non-invasive markers studied. For all patients with UGIB, non-invasive markers appear to differentiate patients with varices from those without varices and to identify those with a variceal culprit lesion. However, these markers could not distinguish between a variceal culprit and other lesions in patients with cirrhosis.

The Beneficial Effect of Beta-Blockers in Patients With Cirrhosis, Portal Hypertension and Ascites.

BACKGROUND: Patients with cirrhosis and portal hypertensive complications have reduced survival. As such, it has been suggested that nonselective beta-blocker therapy in patients with advanced ascites is harmful. The aim of this study was, therefore, to determine the risk of mortality in patients with cirrhosis and ascites taking nonselective beta-blocker therapy for the prevention of variceal hemorrhage. MATERIALS AND METHODS: This study was a retrospective analysis of 2,419 patients with cirrhosis and portal hypertension admitted to Parkland Memorial Hospital (a university-affiliated county teaching hospital) from 2003-2010. Patients were subdivided into those with varices only, ascites only and those with both varices and ascites. The primary outcome measure for this study was all-cause in-hospital mortality. RESULTS: Overall, 68 of 1,039 (6.5%) patients taking beta-blockers died during their hospitalization, while 223 of 1,380 (16.2%) patients not taking beta-blockers died (P < 0.001). Beta-blocker use was also assessed in specific cohorts; mortality was 21.1% in patients with severe ascites with varices who were not taking beta-blockers compared with 8.9% in patients who were taking beta-blockers (P = 0.05). Overall, fewer patients taking beta-blockers died compared with those not taking beta-blockers in patients with varices only (6.4% versus 12.1%) and those with ascites with or without varices (6.6% versus 18.1%) (P < 0.001). CONCLUSIONS: Mortality was lower in patients with cirrhosis and portal hypertension taking nonselective beta-blockers than in those not taking beta-blockers. The use of nonselective beta-blockers provided a significant survival benefit in patients with all grades of ascites, including those with severe ascites.

Injury severity and comorbidities alone do not predict futility of care after geriatric trauma.

BACKGROUND: When counseling surrogates of massively injured elderly trauma patients, the prognostic information they desire is rarely evidence based. OBJECTIVE: We sought to objectively predict futility of care in the massively injured elderly trauma patient using easily available parameters: age, Injury Severity Score (ISS), and preinjury comorbidities. METHODS: Two cohorts (70-79 years and ≥80 years) were constructed from The National Trauma Data Bank (NTDB) for years 2007-2011. Comorbidities were tabulated for each patient. Mortality rates at every ISS score were tabulated for subjects with 0, 1, or ≥2 comorbidities. Futility was defined a priori as an in-hospital mortality rate of ≥95% in a cell with ≥5 subjects. RESULTS: A total of 570,442 subjects were identified (age 70-79 years, n=217,384; age ≥80 years, n=352,608). Overall mortality was 5.3% for ages 70-79 and 6.6% for ≥80 years. No individual ISS score was found to have a mortality rate of ≥95% for any number of comorbidities in either age cohort. The highest mortality rate seen in any cell was for an ISS of 66 in the ≥80 year-old cohort with no listed comorbidities (93.3%). When upper extremes of ISS were aggregated into deciles, mortality for both cohorts across all number of comorbidities was 45.5%-60.9% for ISS 40-49, 56.6%-81.4% for ISS 50-59, and 73.9%-93.3% for ISS ≥60. CONCLUSIONS: ISS and preinjury comorbidities alone cannot be used to predict futility in massively injured elderly trauma patients. Future attempts to predict futility in these age groups may benefit from incorporating measures of physiologic distress.

Gender differences in outcomes of patients with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is a common life-shortening genetic disease in which women have been described to have worse outcomes than males, particularly in response to respiratory infections with Pseudomonas aeruginosa. However, as advancements in therapies have improved life expectancy, this gender disparity has been challenged. The objective of this study is to examine whether a gender-based survival difference still exists in this population and determine the impact of common CF respiratory infections on outcomes in males versus females with CF. METHODS: We conducted a retrospective cohort analysis of 32,766 patients from the United States Cystic Fibrosis Foundation Patient Registry over a 13-year period. Kaplan-Meier and Cox proportional hazards models were used to compare overall mortality and pathogen based survival rates in males and females. RESULTS: Females demonstrated a decreased median life expectancy (36.0 years; 95% confidence interval [CI] 35.0-37.3) compared with men (38.7 years; 95% CI 37.8-39.6; p<0.001). Female gender proved to be a significant risk factor for death (hazard ratio 2.22, 95% CI 1.79-2.77), despite accounting for variables known to influence CF mortality. Women were also found to become colonized earlier with several bacteria and to have worse outcomes with common CF pathogens. CONCLUSIONS: CF women continue to have a shortened life expectancy relative to men despite accounting for key CF-related comorbidities. Women also become colonized with certain common CF pathogens earlier than men and show a decreased life expectancy in the setting of respiratory infections. Explanations for this gender disparity are only beginning to be unraveled and further investigation into mechanisms is needed to help develop therapies that may narrow this gender gap.

Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome.

BACKGROUND: We have recognized a unique clinical syndrome in patients with upper gastrointestinal bleeding who are found to have severe esophagitis. AIM: We aimed to more clearly describe the clinical entity of upper gastrointestinal bleeding in patients with severe esophagitis. METHODS: We conducted a retrospective matched case-control study designed to investigate clinical features in patients with carefully defined upper gastrointestinal bleeding and severe esophagitis. Patient data were captured prospectively via a Gastrointestinal Bleeding Healthcare Registry, which collects data on all patients admitted with gastrointestinal bleeding. Patients with endoscopically documented esophagitis (cases) were matched with randomly selected controls that had upper gastrointestinal bleeding caused by other lesions. RESULTS: Epidemiologic features in patients with esophagitis were similar to those with other causes of upper gastrointestinal bleeding. However, hematemesis was more common in patients with esophagitis 86% (102/119) than in controls 55% (196/357) (p < 0.0001), while melena was less common in patients with esophagitis 38% (45/119) than in controls 68% (244/357) (p < 0.0001). Additionally, the more severe the esophagitis, the more frequent was melena. Patients with esophagitis had less abnormal vital signs, lesser decreases in hematocrit, and lesser increases in BUN. Both pre- and postRockall scores were lower in patients with esophagitis compared with controls (p = 0.01, and p < 0.0001, respectively). Length of hospital stay (p = 0.002), rebleeding rate at 42 days (p = 0.0007), and mortality were less in patients with esophagitis than controls. Finally, analysis of patients with esophagitis and cirrhosis suggested that this group of patients had more severe bleeding than those without cirrhosis. CONCLUSIONS: We have described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. This syndrome is manifest by typical clinical features and is associated with favorable outcomes.

Cognitive gains from gist reasoning training in adolescents with chronic-stage traumatic brain injury.

Adolescents with traumatic brain injury (TBI) typically demonstrate good recovery of previously acquired skills. However, higher-order and later emergent cognitive functions are often impaired and linked to poor outcomes in academic and social/behavioral domains. Few control trials exist that test cognitive treatment effectiveness at chronic recovery stages. The current pilot study compared the effects of two forms of cognitive training, gist reasoning (top-down) versus rote memory learning (bottom-up), on ability to abstract meanings, recall facts, and utilize core executive functions (i.e., working memory, inhibition) in 20 adolescents (ages 12-20) who were 6 months or longer post-TBI. Participants completed eight 45-min sessions over 1 month. After training, the gist reasoning group (n = 10) exhibited significant improvement in ability to abstract meanings and increased fact recall. This group also showed significant generalizations to untrained executive functions of working memory and inhibition. The memory training group (n = 10) failed to show significant gains in ability to abstract meaning or on other untrained specialized executive functions, although improved fact recall approached significance. These preliminary results suggest that relatively short-term training (6 h) utilizing a top-down reasoning approach is more effective than a bottom-up rote learning approach in achieving gains in higher-order cognitive abilities in adolescents at chronic stages of TBI. These findings need to be replicated in a larger study; nonetheless, the preliminary data suggest that traditional cognitive intervention schedules need to extend to later-stage training opportunities. Chronic-stage, higher-order cognitive trainings may serve to elevate levels of cognitive performance in adolescents with TBI.

A risk scoring system to predict in-hospital mortality in patients with cirrhosis presenting with upper gastrointestinal bleeding.

GOALS: We aimed to develop a simple and practical risk scoring system to predict in-hospital mortality in cirrhotics presenting with upper gastrointestinal (GI) bleeding. STUDY: Extensive clinical data were captured in patients with documented cirrhosis who underwent endoscopic evaluation for upper GI bleeding between January 1, 2003 and June 30, 2011 at Parkland Memorial Hospital. Predictors of mortality were identified by multivariate regression analysis. RESULTS: A total of 884 patients with cirrhosis admitted for upper GI bleeding were identified; 809 patients survived and 75 died (8.4%). The etiology of bleeding was similar in both groups, with bleeding attributed to esophageal varices in 59% of survivors and 60% of non-survivors (ulcer disease and other etiologies of bleeding accounted for the other causes of bleeding). Mortality was 8.6% and 8.3% in patients with variceal bleeding and nonvariceal bleeding, respectively. While survivors and those who died were similarly matched with regard to gender, age, ethnicity and etiology of cirrhosis, patients who died had lower systolic blood pressures, higher pulse rates and lower mean arterial pressures at admission than patients who survived. Non-survivors were more likely to be Childs C (61% vs. 19%, P<0.001). Multivariate regression analysis identified the following 4 predictors of in-hospital mortality: use of vasoactive pressors, number of packed red blood cells transfused, model for end-stage liver disease (MELD) score, and serum albumin. A receiver operating characteristic curve including these 4 variables yielded an area under the receiver operating characteristic (AUROC) curve of 0.94 (95% confidence interval, 0.91-0.98). Classification and Regression Tree analysis yielded similar results, identifying vasoactive pressors and then MELD>21 as the most important decision nodes for predicting death. By comparison, using the Rockall scoring system in the same patients, the AUROC curve was 0.70 (95% confidence interval, 0.64-0.76 and the comparison of the University of Texas Southwestern model to the Rockall model revealed P<0.0001). A validation set comprised of 150 unique admissions between July 1, 2011 and July 31, 2012, had an AUROC of 0.92, and the outcomes of 97% of the subjects in this set were accurately predicted by the risk score model. CONCLUSIONS: Use of vasoactive agents, packed red blood cell transfusion, albumin, and MELD score were highly predictive of in-hospital mortality in cirrhotics presenting with upper GI bleeding. These variables were used to formulate a clinical risk scoring system for in-hospital mortality, which is available at: http://medweb.musc.edu/LogisticModelPredictor.

Predictors of failed primary abdominal closure in the trauma patient with an open abdomen.

BACKGROUND: We sought to characterize risk factors for failed closure after damage-control laparotomy and to examine the impact of two broad categories of open abdomen-management technique on rates of fascial approximation. METHODS: We retrospectively reviewed (January 2006-December 2008) all trauma patients with an open abdomen after damage-control laparotomy. Patients with definitive abdominal closure before discharge were classified as successful closure (SC) and those discharged with a planned ventral hernia were classified as failed closure (FC). Univariate stepwise logistical analyses were conducted to identify covariates related to resuscitation volumes and injury severity that were associated with FC. Surgical techniques were dichotomized as fascial based or vacuum based and compared with chi square. RESULTS: Sixty-two subjects met final eligibility (SC 44, FC 18). SC and FC were similar, with the exception of, respectively, initial base excess (-8.0 ± 4.2 vs -11.4 ± 4.9; P = 0.009), injury severity score (ISS; 29.0 ± 15.2 vs 20.6 ± 12.1; P = 0.04), and frequency of penetrating injury (47.7% vs 77.8%; P = 0.03). Stepwise regression showed significant associations between failed closure and increasing Penetrating Abdominal Trauma Index (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.11), worsening base excess on arrival (OR 0.79, 95% CI 0.66-0.93), and lower ISS (OR 0.94, 95% CI 0.89-1.00). Fascial-based versus vacuum-based management techniques had no effect on closure rates. CONCLUSIONS: Volume of blood transfused, crystalloid given, and open abdomen management technique were not related to closure rates; however, worsened base excess on arrival, penetrating trauma, higher Penetrating Abdominal Trauma Index, and a lower ISS were associated with FC. The latter was true despite an association also being found between FC and lower ISS scores, reflecting the propensity of ISS to underestimate injury burden after penetrating injury.

Altered mental status in cirrhosis: etiologies and outcomes.

BACKGROUND: Cirrhotic patients admitted with altered mental status (AMS) represent a clinical challenge, as many potentially life-threatening diseases must be considered. Although many patients with AMS have hepatic encephalopathy (HE), other causes of AMS occur, and we hypothesized that these may have different outcomes. AIM: We aimed to understand the causes of AMS in cirrhotic patients admitted to the hospital and investigate their associated outcomes. METHODS: We performed a retrospective cohort study in 1218 inpatients with cirrhosis. Altered mental status was defined a priori (HE, sepsis/infectious, metabolic, exogenous drugs/toxins, structural lesions, or psychiatric abnormalities). RESULTS: Patients with AMS had higher levels of serum bilirubin, international normalized ratio, blood urea nitrogen, creatinine, and lower levels of albumin and platelets than those with normal mental status (NMS) (P = < 0.001). The most common cause of AMS was HE, accounting for nearly half of all patients. Other causes of AMS included the following: sepsis/infection (23%), metabolic disorders (8%), drugs/toxins (7%), structural lesions (5%), psychiatric disorders (1%), or multiple causes (8%). Mortality in patients with AMS was 35% compared to 16% in those with NMS (P < 0.0001). Patients with sepsis/infection, structural lesions, or multiple disorders causing AMS had the highest mortality (61%, 68%, and 79%, respectively). CONCLUSIONS: Nearly one third of admissions in cirrhotic patients were due to AMS, most commonly caused by HE. The overall mortality of patients admitted with AMS was greater than with NMS, particularly for those with infection or structural lesions, emphasizing the importance of a search for these causes of AMS in all patients with cirrhosis.

Needle electromyography predicts outcome after lumbar epidural steroid injection.

INTRODUCTION: Needle electromyography (NEE) would be more valuable if it could predict outcomes after lumbar epidural steroid injections (LESIs) in lumbosacral radiculopathy (LSR). METHODS: We investigated the predictive value of NEE for outcome after LESI compared with other known predictive variables in 89 subjects with clinical LSR. Seventy patients completed the study, which included diagnostic lower extremity NEE and LESI. Outcome measures included changes in pain, physical function, and psychosocial function [assessed using the Pain Disability Questionnaire (PDQ)]. RESULTS: NEE was an independent predictor of long-term pain improvement after LESI and was not predictive of PDQ functional improvement. A regression model, with NEE as one of several independent variables, showed strong outcome-predictive ability. CONCLUSIONS: NEE is an independent predictor of long-term pain relief after LESI for LSR. Abnormal NEE is predictive of better outcome than normal NEE. A regression equation including NEE and other independent predictors was predictive of pain and functional outcomes.

Higher-order reasoning training years after traumatic brain injury in adults.

OBJECTIVE: To conduct a feasibility study to compare the effects of top-down Strategic Memory and Reasoning Training (SMART) versus information-based Brain Health Workshop (BHW, control) on gist-reasoning (ie, abstracting novel meaning from complex information), memory, executive functions, and daily function in adults with traumatic brain injury. PARTICIPANTS: Twenty-eight participants (of the 35 recruited), 16 men & 12 women, aged 20 to 65 years (M = 43, SD = 11.34) at chronic stages posttraumatic brain injury (2 years or longer) completed the training. Fourteen participants that received SMART and 14 participants that completed BHW were assessed both pre- and posttraining. Thirteen of the SMART trained and 11 from BHW participated in a 6-month testing. DESIGN: The study was a single blinded randomized control trial. Participants in both groups received a minimum of 15 hours of training over 8 weeks. RESULTS: The SMART group significantly improved gist-reasoning as compared to the BHW group. Benefits of the SMART extended to untrained measures of working memory and participation in functional activities. Exploratory analyses suggested potential transfer effects of SMART on memory and executive functions. The benefits of the SMART program as compared to BHW were evident at immediately posttraining and 6 months posttraining. CONCLUSION: This study provides preliminary evidence that short-term intensive training in top-down modulation of information benefits gist-reasoning and generalizes to measures of executive function and real life function at chronic stages of post-TBI.

A SAS(®) macro implementation of a multiple comparison post hoc test for a Kruskal-Wallis analysis.

The Kruskal-Wallis (KW) nonparametric analysis of variance is often used instead of a standard one-way ANOVA when data are from a suspected non-normal population. The KW omnibus procedure tests for some differences between groups, but provides no specific post hoc pair wise comparisons. This paper provides a SAS(®) macro implementation of a multiple comparison test based on significant Kruskal-Wallis results from the SAS NPAR1WAY procedure. The implementation is designed for up to 20 groups at a user-specified alpha significance level. A Monte-Carlo simulation compared this nonparametric procedure to commonly used parametric multiple comparison tests.

Prediction of pulmonary morbidity and mortality in patients with femur fracture.

BACKGROUND: We aimed to determine the effect of femur fractures on mortality, pulmonary complications, and adult respiratory distress syndrome (ARDS). In addition, we aimed to compare the effect of femur fractures with other major musculoskeletal injuries and to determine the effect of timing to surgery on these complications. METHODS: All patients were identified from the trauma registries of two Level I trauma centers. Outcomes were defined at mortality in hospital, pulmonary complications, and ARDS in hospital. Regression analysis was used to determine the effect of femur fractures, while controlling for age, Abbreviated Injury Scales, Glasgow Coma Scale, and systolic blood pressure at presentation. We compared femur fractures with other major musculoskeletal injuries in similar models. Within the patients with femur fracture, time to surgery (< 8 hours, 8 hours to 24 hours, and > 24 hours) was evaluated using similar regression analysis. RESULTS: Of the total 90,510 patients, 3,938 (4.35%) died in the hospital, 2,055 (2.27%) had a pulmonary complication, and 285 (0.31%) developed ARDS. Femur fracture is statistically predictive of mortality (odds ratio [OR], 1.606; 95% confidence interval [CI], 1.288-2.002) and pulmonary complications (OR, 1.659; 95% CI, 1.329-2.070), when controlling for other injury factors. This was comparable with the effect of pelvic fracture and other major musculoskeletal injuries. Femur fracture had a strong relationship with ARDS (OR, 2.129; 95% CI, 1.382-3.278). Patients treated in the 8 hours to 24 hours window had the lowest mortality risk (OR, 0.140; 95% CI, 0.052-0.375), and there was a trend to increased risk of ARDS in a delay to surgery of > 24 hours. CONCLUSIONS: Femur fractures are a major musculoskeletal injury and increase the risk of mortality and pulmonary complications as much as any other musculoskeletal injuries. There is a unique relationship between ARDS and femur fractures, and this must be considered carefully in treatment planning for these patients.

Interrater reliability of needle electromyographic findings in lumbar radiculopathy.

OBJECTIVE: This study was performed to investigate the interrater reliability of needle electromyographic findings and electrodiagnostic impressions among expert electrodiagnosticians. DESIGN: Twenty-nine electromyographic recordings were chosen for this study from a larger prospective, observational cohort of 89 consecutive subjects, who were referred for electrodiagnostic evaluation of the lower limbs in a hospital-based spine clinic. The parent study was designed to evaluate the utility of electrodiagnostic findings in predicting outcomes after epidural steroid injections in lumbar radiculopathy. An unmasked, American Board of Electrodiagnostic Medicine board-certified examiner with knowledge of the patient's history and physical examination performed all initial electrodiagnostic evaluations, including needle electromyographic examination of a standardized set of six limb muscles and lumbar paraspinals representing L3 through S1 myotomes. The insertional and spontaneous activities of all muscles were recorded as de-identified digital video files with only muscle names visible. Motor units were not analyzed. Two independent, American Board of Electrodiagnostic Medicine board-certified examiners, who were masked to the patient's name, history, physical examination, and the electrodiagnostic report, reviewed 29 study subjects' digital video files. They rated each muscle's insertional and spontaneous activity on a standardized scoring sheet. After the examination was scored, they also generated a diagnostic impression of no evidence, possible evidence, or clear evidence of lumbar radiculopathy. Interrater reliability between the unmasked examiner and the two independent, masked examiners was assessed by Cohen's kappa statistic for electromyographic scoring of the muscles examined and for diagnostic impression. RESULTS: The interrater reliability was substantial (kappa >0.60) showing >60% agreement for the scoring of most of the muscles examined. The overall diagnostic impression showed outstanding interrater reliability (kappa >0.90) showing >90% agreement between the unmasked and masked examiners. There were no significant differences in the scoring between the two masked examiners. CONCLUSIONS: Needle electromyographic assessment of lower-limb and lumbar paraspinal muscles in the electrodiagnostic evaluation of lumbar radiculopathy is objective and highly reliable when performed by well trained and qualified electromyographers. Masked validation can be performed in electromyographic-based research.

Creation and use of a database in clinical and translational research.

Often data collection for clinical studies is an afterthought. The results of such an approach are incomplete or confusing data that can, as a worst case, result in scrapping and restarting the entire study. We discuss the planning process for data collection and storage to include encounter form development; data flow and capture; data checking, verification, and validation; advantage of relational databases over spreadsheets; data security; and aspects of a complete data system.