Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients.

BACKGROUND: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. METHODS: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. RESULTS: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). CONCLUSION: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Theoretical Characterization of Carbonic Acid Clusters in the UV.

Two theoretical structural motifs are proposed to match two experimental solid carbonic acid UV spectra from previous literature ( Astron. Astrophys. 2021, 646, A172): a linear ribbon structure as a single octamer and nonplanar orientations of carbonic acid clusters. The latter have some contribution from approximated amorphous solid carbonic acid in the form of 40 different clusters of 8 carbonic acid molecules ensemble-averaged together, but unoptimized pairs of optimized dimers oriented perpendicular to one another give the strongest intensities of lower energy UV transitions. The linear ribbon structure's predicted spectrum computed with CAM-B3LYP/6-311G(d,p) agrees well with Experimental Solid B─the ß-carbonic acid experimental data in the UV region. Meanwhile, the 40 amorphous clusters are built with a randomization script, and the electronically excited states are calculated with both CAM-B3LYP/6-311G(d,p) and ωB97XD/6-311G(d,p). The resulting theoretical spectrum is constructed by employing a Boltzmann distribution of the intensities and artificially broadening the simulated spectra. The nonplanar dimer pairs are computed with CAM-B3LYP and B3LYP with the 6-311G(d,p) basis set. The results of the amorphous simulation weakly correspond with the Experimental Solid A spectrum, but the fully nonplanar motif matches the experiment much more convincingly. As a result, the previous work appears to have observed the traditional crystalline phase of solid carbonic acid in Experimental Solid B, whereas the nonplanar orientations of the carbonic acids in the clusters appear to correlate with Experimental Solid A. This spectral classification will aid in future laboratory work exploring the role that carbonic acid can play in low temperature, low pressure desorbed environments with potential application to astrochemistry.

Periprosthetic humerus fractures after shoulder arthroplasty: an evaluation of available classification systems.

BACKGROUND: Periprosthetic proximal humerus fractures (PPHFs) are a detrimental complication of shoulder arthroplasty, yet their characterization and management have been poorly studied. We aimed to determine the intra- and interobserver reliability of 4 previously described PPHF classification systems to evaluate which classifications are the most consistent. METHODS: We retrospectively reviewed 32 patients (34 fractures) that were diagnosed with a PPHF between 1990 and 2017. Patient electronic medical records and research electronic data capture (REDCap) were used for data collection. Post-PPHF radiographs in multiple views for all 34 cases were organized into an encrypted, randomized Qualtrics survey. Four blinded fellowship-trained shoulder and elbow surgeons graded each fracture using previously reported classification systems by (1) Wright and Cofield (1995), (2) Campbell et al (1998), (3) Worland et al (1999), and (4) Groh et al (2008), along with selecting a preferred management strategy for each fracture. Grading was performed twice with at least 2 weeks between each randomized attempt. Intraobserver reliability was calculated as an unweighted Cohen kappa coefficient between attempt 1 and attempt 2 for each surgeon. Interobserver reliability and agreeability between surgeons' preferred management strategies were calculated for each classification system using Fleiss kappa coefficient. The kappa coefficients were interpreted using the Landis and Koch criteria. RESULTS: The average intraobserver kappa coefficient for each classification was as follows: Wright and Cofield = 0.703, Campbell = 0.527, Worland = 0.637, Groh = 0.699. The overall Fleiss kappa coefficient for interobserver reliability for each classification was as follows: Wright and Cofield = 0.583, Campbell = 0.488, Worland = 0.496, Groh = 0.483. Interobserver reliability was significantly greater with the Wright and Cofield classification. Using Landis and Koch criteria, all the classification systems assessed demonstrated only moderate interobserver agreement. Additionally, the mean interobserver agreeability kappa coefficient for preferred management strategy was 0.490, indicating only moderate interobserver agreement. CONCLUSION: There is only moderate interobserver reliability among the 4 PPHF classification systems and the preferred management strategy for the fractures assessed. Of the 4 PPHF classification systems, Wright and Cofield demonstrated the greatest mean intraobserver reliability and overall interobserver reliability. Our study highlights a need for the development of a PPHF classification system that can achieve high intra- and interobserver reliability and that can allow for a standardized treatment algorithm in the management of PPHFs.

Computational UV spectra for amorphous solids of small molecules.

Ices in the interstellar medium largely exist as amorphous solids composed of small molecules including ammonia, water, and carbon dioxide. Describing gas-phase molecules can be readily accomplished with current high-level quantum chemical calculations with the description of crystalline solids becoming more readily accomplished. Differently, amorphous solids require more novel approaches. The present work describes a method for generating amorphous structures and constructing electronic spectra through a combination of quantum chemical calculations and statistical mechanics. The structures are generated through a random positioning program and DFT methods, such as ωB97-XD and CAM-B3LYP. A Boltzmann distribution weights the excitations to compile a final spectrum from a sampling of molecular clusters. Three ice analogs are presented herein consisting of ammonia, carbon dioxide, and water. Ammonia and carbon dioxide provide semi-quantitative agreement with experiment for CAM-B3LYP/6-311++G(2d,2p) from 30 clusters of 8 molecules. Meanwhile, the amorphous water description improves when the sample size is increased in cluster size and count to as many as 105 clusters of 32 water molecules. The described methodology can produce highly comparative descriptions of electronic spectra for ice analogs and can be used to predict electronic spectra for other ice analogs.

Linear and Helical Carbonic Acid Clusters.

Crystallization of carbonic acid likely begins with a linear or ribbon-esque oligomerization, but a helical spiral is shown here to be a new, competing motif for this process. The present combined density functional theory and coupled-cluster theory work examines both the ribbon and the new helical spiral motifs in terms of relative energies, sequential binding energies, and electronic spectra which could potentially aid in distinguishing between the two forms. The helix diverges in energy from the ribbon by roughly 0.2 eV (∼4 kcal/mol) per dimer addition, but the largest intensity absorption features at 9.16 eV (135 nm) and 7.11 eV (175 nm), respective of the ribbon and spiral, will allow these to be separately observed and classified via electronic spectroscopy to determine more conclusively which motif holds in the earliest formation stages of solid carbonic acid.

Three-times-daily subcutaneous unfractionated heparin and neuraxial anesthesia: a retrospective review of 928 cases.

BACKGROUND AND OBJECTIVES: Subcutaneous (SC) unfractionated heparin (UFH) administered 3 times daily (TID) is widely used for venous thromboembolism prophylaxis in the perioperative period. There are no data in the literature regarding the incidence of adverse outcomes with neuraxial analgesia in the setting of this regimen. In this retrospective review, we report the incidence of untoward events related to anticoagulation with SC UFH TID in patients with indwelling epidural catheters. METHODS: We queried the electronic hospital databases to identify patients receiving thoracic epidural analgesia in conjunction with 5000 U UFH SC TID from July 2008 to October 2010. In this group, we identified the diagnoses of neuraxial hematoma, deep vein thrombosis, or pulmonary embolism and examined measured blood coagulation parameters. In addition, we determined the percentage of patients receiving concomitant therapy with ketorolac. RESULTS: We identified 928 patients who received thoracic epidural analgesia in conjunction with 5000 U UFH SC TID during this period. There were no cases of neuraxial bleeding. Seven patients had a diagnosed deep vein thrombosis or pulmonary embolism. Thirty-four percent (315/928) of patients received ketorolac. The measured activated thromboplastin time was more than 40 seconds (35 seconds being the upper limit of normal) in 115 patients (12%). CONCLUSIONS: Given the rare incidence of neuraxial hematoma, statements regarding the appropriateness of epidural analgesia in the setting of TID SC UFH cannot be made from this limited sample size. At present, information regarding epidural hematoma in the setting of a TID SC UFH dosing regimen does not exist in the literature. Our study represents an initial step in the accumulation of data needed to prove or disprove the safety of this practice.