Category: Nevin Manimala

Clin Orthop Relat Res. 2023 Mar 10. doi: 10.1097/CORR.0000000000002611. Online ahead of print.

ABSTRACT

BACKGROUND: THA for high-riding developmental dysplasia of the hip (DDH) is challenging in terms of length equalization. Although previous studies suggested preoperative templating on AP pelvic radiographs is insufficient in patients with unilateral high-riding DDH because of hypoplasia of the hemipelvis on the affected side and unequal femoral and tibial length on scanograms, the results were controversial. The EOS™ (EOS™ Imaging) is a biplane X-ray imaging system using slot-scanning technology. Length and alignment measurements have been shown to be accurate. We used the EOS to compare the lower limb length and alignment in patients with unilateral high-riding DDH.

QUESTIONS/PURPOSES: (1) Is there an overall leg length difference in patients with unilateral Crowe Type IV hip dysplasia? (2) In patients with unilateral Crowe Type IV hip dysplasia with an overall leg length difference, is there a consistent pattern of abnormalities in the femur or tibia that account for observed differences? (3) What is the impact of unilateral high-riding Crowe Type IV dysplasia on femoral neck offset and knee coronal alignment?

METHODS: Between March 2018 and April 2021, we treated 61 patients with THA for Crowe Type IV DDH (high-riding dislocation). EOS imaging was performed preoperatively in all patients. Eighteen percent (11 of 61) of the patients were excluded because of involvement of the opposite hip, 3% (two of 61) were excluded for neuromuscular involvement, and 13% (eight of 61) had previous surgery or fracture, leaving 40 patients for analysis in this prospective, cross-sectional study. Each patient’s demographic, clinical, and radiographic information was collected with a checklist using charts, Picture Archiving and Communication System, and an EOS database. EOS-related measurements that were related to the proximal femur, limb length, and knee-related angles were recorded for both sides by two examiners. The findings of the two sides were statistically compared.

RESULTS: The overall limb length was not different between the dislocated and nondislocated sides (mean 725 ± 40 mm versus 722 ± 45 mm, mean difference 3 mm [95% CI -3 to 9 mm); p = 0.08). Apparent leg length was shorter on the dislocated side (mean 742 ± 44 mm versus 767 ± 52 mm, mean difference -25 mm [95% CI -32 to 3 mm]; p < 0.001). We observed that a longer tibia on the dislocated side was the only consistent pattern (mean 338 ± 19 mm versus 335 ± 20 mm, mean difference 4 [95% CI 2 to 6 mm]; p = 0.002), but there was no difference between the femur length (mean 346 ± 21 mm versus 343 ± 19 mm, mean difference 3 mm [95% CI -1 to 7]; p = 0.10). The femur of the dislocated side was longer by greater than 5 mm in 40% (16 of 40) of patients and shorter in 20% (eight of 40). The mean femoral neck offset of the involved side was shorter than that of the normal side (mean 28 ± 8 mm versus 39 ± 8 mm, mean difference -11 mm [95% CI -14 to -8 mm]; p < 0.001). There was a higher valgus alignment of the knee on the dislocated side with a decreased lateral distal femoral angle (mean 84° ± 3° versus 89° ± 3°, mean difference – 5° [95% CI -6° to -4°]; p < 0.001) and increased medial proximal tibia angle (mean 89° ± 3° versus 87° ± 3°, mean difference 1° [95% CI 0° to 2°]; p = 0.04).

CONCLUSION: A consistent pattern of anatomic alteration on the contralateral side does not exist in Crowe Type IV hips except for the length of the tibia. All parameters of the limb length could be shorter, equal to, or longer on the dislocated side. Given this unpredictability, AP pelvis radiographs are not sufficient for preoperative planning, and individualized preoperative planning using full-length images of the lower limbs should be performed before arthroplasty in Crowe Type IV hips.

LEVEL OF EVIDENCE: Level I, prognostic study.

PMID:36912864 | DOI:10.1097/CORR.0000000000002611

JAMA Neurol. 2023 Mar 13. doi: 10.1001/jamaneurol.2023.0148. Online ahead of print.

ABSTRACT

IMPORTANCE: Pregnant women who have epilepsy need adequate engagement, information, and pregnancy planning and management to improve pregnancy outcomes.

OBJECTIVE: To investigate perinatal outcomes in women with epilepsy compared with women without epilepsy.

DATA SOURCES: Ovid MEDLINE, Embase, CINAHL, and PsycINFO were searched with no language or date restrictions (database inception through December 6, 2022). Searches also included OpenGrey and Google Scholar and manual searching in journals and reference lists of included studies.

STUDY SELECTION: All observational studies comparing women with and without epilepsy were included.

DATA EXTRACTION AND SYNTHESIS: The PRISMA checklist was used for abstracting data and the Newcastle-Ottawa Scale for risk-of-bias assessment. Data extraction and risk-of-bias assessment were done independently by 2 authors with mediation conducted independently by a third author. Pooled unadjusted odds ratios (OR) or mean differences were reported with 95% CI from random-effects (I2 heterogeneity statistic >50%) or fixed-effects (I2 < 50%) meta-analyses.

MAIN OUTCOMES AND MEASURES: Maternal, fetal, and neonatal complications.

RESULTS: Of 8313 articles identified, 76 were included in the meta-analyses. Women with epilepsy had increased odds of miscarriage (12 articles, 25 478 pregnancies; OR, 1.62; 95% CI, 1.15-2.29), stillbirth (20 articles, 28 134 229 pregnancies; OR, 1.37; 95% CI, 1.29-1.47), preterm birth (37 articles, 29 268 866 pregnancies; OR, 1.41; 95% CI, 1.32-1.51) and maternal death (4 articles, 23 288 083 pregnancies; OR, 5.00; 95% CI, 1.38-18.04). Neonates born to women with epilepsy had increased odds of congenital conditions (29 articles, 24 238 334 pregnancies; OR, 1.88; 95% CI, 1.66-2.12), neonatal intensive care unit admission (8 articles, 1 204 428 pregnancies; OR, 1.99; 95% CI, 1.58-2.51), and neonatal or infant death (13 articles, 1 426 692 pregnancies; OR, 1.87; 95% CI, 1.56-2.24). The increased odds of poor outcomes was increased with greater use of antiseizure medication.

CONCLUSIONS AND RELEVANCE: This systematic review and meta-analysis found that women with epilepsy have worse perinatal outcomes compared with women without epilepsy. Women with epilepsy should receive pregnancy counseling from an epilepsy specialist who can also optimize their antiseizure medication regimen before and during pregnancy.

PMID:36912826 | DOI:10.1001/jamaneurol.2023.0148

Liver Int. 2023 Mar 13. doi: 10.1111/liv.15561. Online ahead of print.

ABSTRACT

BACKGROUND & AIMS: Spleen stiffness measurement (SSM) by transient elastography (VCTE) has been tested in a limited number of studies versus hepatic venous pressure gradient (HVPG), especially with the 100 Hz spleen specific module. The current study aims to evaluate the diagnostic performance of this novel module for detecting clinically significant portal hypertension (CSPH) in a cohort of compensated patients with metabolic-associated fatty liver disease (MAFLD) as the main etiology and to improve the performance of the Baveno VII criteria for CSPH diagnosis by including SSM.

METHODS: This is a retrospective single center study including patients with available measurements of HVPG, liver stiffness (LSM) and SSM by VCTE with the 100 Hz module. AUROC analysis was conducted to identify dual cut-offs (rule-out and in) associated with the absence/presence of CSPH. The diagnostic algorithms were adequate if negative (NPV) and positive predictive values (PPV) were >90%.

RESULTS: A total of 85 patients were included, 60 MAFLD and 25 non-MAFLD. SSM showed a good correlation with HVPG (MAFLD: r=0.74; p<0.0001; non-MAFLD: r=0.62; p< 0.0011). In MAFLD patients, SSM had a high accuracy in discarding/diagnosing CSPH (cutoffs values of <40.9 and >49.9 kPa, AUC 0.95). The addition of these cutoffs in a sequential or combined approach to the Baveno VII criteria significantly reduced the grey zone (60% vs 15-20%), while maintaining adequate NPV and PPV.

CONCLUSIONS: our findings support the utility of SSM for diagnosing CSPH in MAFLD patients and demonstrates that the addition of SSM to the Baveno VII criteria increases accuracy.

PMID:36912787 | DOI:10.1111/liv.15561

Elife. 2023 Mar 13;12:e85082. doi: 10.7554/eLife.85082. Online ahead of print.

ABSTRACT

In this work, we expand the normative model repository introduced in (Rutherford, Fraza, et al., 2022) to include normative models charting lifespan trajectories of structural surface area and brain functional connectivity, measured using two unique resting-state network atlases (Yeo-17 and Smith-10), and an updated online platform for transferring these models to new data sources. We showcase the value of these models with a head-to-head comparison between the features output by normative modeling and raw data features in several benchmarking tasks: mass univariate group difference testing (schizophrenia versus control), classification (schizophrenia versus control), and regression (predicting general cognitive ability). Across all benchmarks, we show the advantage of using normative modeling features, with the strongest statistically significant results demonstrated in the group difference testing and classification tasks. We intend for these accessible resources to facilitate wider adoption of normative modeling across the neuroimaging community.

PMID:36912775 | DOI:10.7554/eLife.85082

Int J Surg. 2023 Mar 14. doi: 10.1097/JS9.0000000000000301. Online ahead of print.

ABSTRACT

BACKGROUND: Because of relatively little data for management and evaluation surrounding spontaneous isolated visceral artery dissection (IVAD), existing studies failed to provide comprehensive analysis for the management, evaluation, prevalence as well as natural course of the disease. Therefore, we collected and analyzed current evidence on spontaneous IVAD aiming to provide quantitative pooled data for the natural course and treatment standardization of the disease.

METHODS: A systematic search of PubMed, Embase, Cochrane Library and Web of Science up to June 1, 2022 was conducted for relevant studies that investigating the natural course, treatment, classification, and outcomes of IVAD. The primary outcomes were to determine the difference of prevalence, risk factors and characteristics in different spontaneous IVAD. Two reviewers assessed trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2 and Stata 12.0.

RESULTS: A total of 80 reports with 1040 patients were identified. The pooled results indicated that in IVAD, isolated superior mesenteric artery dissection (ISMAD) was more prevalent, with a pooled prevalence of 60% (95% CI: 50%－71%), followed by isolated celiac artery dissection (ICAD) (prevalence 37%; 95% CI: 27%－46%). IVAD was male predominated with a pooled proportion of 80% (95% CI: 72%－89%). Similar result was found in ICAD (prevalence 73%; 95% CI: 52%－93%). More IVAD patients were diagnosed with symptoms than ICAD (64% vs. 59%). Regarding to the risk factors, our pooled analysis found smoking and hypertension were the top two conditions in both spontaneous IVAD and ICAD patients, with proportion of 43%, 41% and 44%, 32% respectively. It was observed that ICAD appeared shorter dissection length (MD -3.4 cm; 95% CI: -4.9, -2.0; P<0.0001), higher prevalence of Sakamoto’s classification Π (OR 5.31; 95% CI: 1.77 ‒ 15.95; P=0.003) and late progression (OR 2.84; 95% CI: 1.02 ‒ 7.87; P=0.05) than ISAMD.

CONCLUSIONS: Spontaneous IVAD was male predominant and ISMAD was most prevalent followed by ICAD. Smoking and hypertension were the top two conditions in both spontaneous IVAD and ICAD patients. The majority of patients diagnosed with IVAD received observation and conservative treatment and experienced low proportion of re-intervention or progression, especially for ICAD patients. In addition, ICAD and ISMAD had several differences in clinical features and dissection characteristics. Future studies with enough sample size and long follow-up are required to clear the management, long-term outcome and risk factors of IVAD prognosis.

PMID:36912770 | DOI:10.1097/JS9.0000000000000301

Int J Surg. 2023 Mar 14. doi: 10.1097/JS9.0000000000000291. Online ahead of print.

ABSTRACT

BACKGROUND: Controversy remains over the choice of anaesthetic technique for patients undergoing surgery for hip fracture.

AIM: To compare the risk of complication of neuraxial anaesthesia with general anaesthesia in patients undergoing hip fracture surgery.

METHODS: This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and was registered at PROSPERO(CRD42022337384). The study included eligible randomised controlled trials published before February 2022. Data synthesis was performed to compare the differences between general and neuraxial anaesthesia. Meta-regression analysis was performed to investigate the influence of the publication year. Subgroup analysis was performed based on patient age and anaesthetic technique used. GRADE assessment was performed to assess the quality of each outcome.

RESULTS: Twenty randomised controlled trials and 4802 patients were included. Data synthesis revealed significant higher risk of acute kidney injury in the general anaesthesia group(P=0.01). There were no significant differences between the two techniques in postoperative short-term mortality (P=0.34), delirium (P=0.40), postoperative nausea and vomiting (P=0.40), cardiac infarction (P=0.31), acute heart failure (P=0.34) and pulmonary embolism (P=0.24) and pneumonia(P=0.15). Subgroup analysis based on patient age and use of sedative medication did not reveal any significant differences. Meta-regression analysis of the publication year versus each adverse event revealed no statistically significant differences.

CONCLUSION: A significantly higher risk of postoperative acute kidney injury was found in patients receiving general anaesthesia. This study revealed no significant differences in terms of postoperative mortality and other complications between general and neuraxial anaesthesia. The results were consistent across the age groups.

PMID:36912758 | DOI:10.1097/JS9.0000000000000291

Acta Paediatr. 2023 Mar 13. doi: 10.1111/apa.16753. Online ahead of print.

ABSTRACT

AIM: Organisation of care, and perinatal and neonatal management of very preterm infants in the Nordic regions were hypothesised to vary significantly. The aim of this observational study was to test this hypothesis.

METHODS: Information on preterm, liveborn infants in the 21 greater health care regions of Denmark, Finland, Iceland, Norway and Sweden was gathered from national registers in 2021. Preterm birth rates, case-mix, perinatal interventions, neonatal morbidity, and survival to hospital discharge in very (<32 weeks) and extremely preterm infants (<28 weeks of gestational age) were compared.

RESULTS: Out of 287,642 infants born alive, 16,567 (5.8%) were preterm, 2389 (0.83%) very preterm (1282 boys), and 800 (0.28%) were extremely preterm. In very preterm infants, exposure to antenatal corticosteroids varied from 85% to 98%, live births occurring at regional centres from 48% to 100%, surfactant treatment from 28% to 69%, and use of mechanical ventilation varied from 13% to 77% (p<0.05 for all comparisons). Significant regional variations within and between countries were also seen in capacity in neonatal care, case-mix, and number of admissions, whereas there were no statistically significant differences in survival or major neonatal morbidities.

CONCLUSION: Management of very preterm infants exhibited significant regional variations in the Nordic countries.

PMID:36912750 | DOI:10.1111/apa.16753

Eur J Neurol. 2023 Mar 13. doi: 10.1111/ene.15777. Online ahead of print.

ABSTRACT

BACKGROUND: The genetics of late seizure or epilepsy secondary to traumatic brain injury (TBI) or stroke is poorly understood. We undertook a systematic review to test the association of single nucleotide polymorphisms (SNPs) with the risk of posttraumatic epilepsy (PTE) and post-stroke epilepsy (PSE).

METHODS: We followed methods from our prespecified protocol on PROSPERO to identify indexed articles for this systematic review. We collated the association statistics from the articles to assess the association of SNPs with the risk of epilepsy amongst TBI or stroke patients. We assessed the study quality using the Q-Genie tool. We report Odds Ratio (OR) and Hazard Ratio with a 95% confidence interval (CI).

RESULTS: The literature search yielded 420 articles. We included 16 studies in our systematic review, of which seven were of poor quality. We examined published data on 127 SNPs from 32 genes identified in PTE and PSE patients. Eleven SNPs were associated with a significantly increased risk of PTE. Three SNPs, TRMP6 rs2274924, ALDH2 rs671, and CD40 -1C/T, were significantly associated with an increased risk of PSE, while two SNPs, AT1R rs12721273 and rs55707609, were significantly associated with reduced risk. The meta-analysis for the association of the APOE 𝜀4 with PTE was non-significant (OR 1.8, CI 0.6-5.6).

CONCLUSIONS: The current evidence on the association of genetic polymorphisms in epilepsy secondary to TBI or stroke is of low quality and lacks validation. A collaborative effort to pool genetic data linked to epileptogenesis in stroke and TBI patients is warranted.

PMID:36912749 | DOI:10.1111/ene.15777

Disaster Med Public Health Prep. 2023 Mar 13;17:e350. doi: 10.1017/dmp.2023.15.

ABSTRACT

Crises such as Hurricane Maria and the coronavirus disease 2019 (COVID-19) pandemic have revealed that untimely reporting of the death toll results in inadequate interventions, impacts communication, and fuels distrust on response agencies. Delays in establishing mortality are due to the contested definition of deaths attributable to a disaster and lack of rapid collection of vital statistics data from inadequate health system infrastructure. Readily available death counts, combined with geographic, demographic, and socioeconomic data, can serve as a baseline to build a continuous mortality surveillance system. In an emergency setting, real-time Total, All-cause, Excess Mortality (TEM) can be a critical tool, granting authorities timely information ensuring a targeted response and reduce disaster impact. TEM measurement can identify spikes in mortality, including geographic disparities and disproportionate deaths in vulnerable populations. This study recommends that measuring total, all-cause, excess mortality as a first line of response should become the global standard for measuring disaster impact.

PMID:36912748 | DOI:10.1017/dmp.2023.15

Cochrane Database Syst Rev. 2023 Mar 13;3:CD005431. doi: 10.1002/14651858.CD005431.pub5.

ABSTRACT

BACKGROUND: Traumatic hyphema is the entry of blood into the anterior chamber, the space between the cornea and iris, following significant injury to the eye. Hyphema may be associated with significant complications that uncommonly cause permanent vision loss. Complications include elevated intraocular pressure, corneal blood staining, anterior and posterior synechiae, and optic nerve atrophy. People with sickle cell trait or disease may be particularly susceptible to increases in intraocular pressure and optic atrophy. Rebleeding is associated with an increase in the rate and severity of complications.

OBJECTIVES: To assess the effectiveness of various medical interventions in the management of traumatic hyphema.

SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 3); MEDLINE Ovid; Embase.com; PubMed (1948 to March 2022); the ISRCTN registry; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The last date of the search was 22 March 2022.

SELECTION CRITERIA: Two review authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. We included randomized and quasi-randomized trials that compared various medical (non-surgical) interventions versus other medical interventions or control groups for the treatment of traumatic hyphema following closed-globe trauma. We applied no restrictions on age, gender, severity of the closed-globe trauma, or level of visual acuity at time of enrollment.

DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane and assessed the certainty of evidence using GRADE.

MAIN RESULTS: We included 23 randomized and seven quasi-randomized studies with a total of 2969 participants. Interventions included antifibrinolytic agents (systemic and topical aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest. We found no evidence of an effect on visual acuity for any intervention, whether measured within two weeks (short term) or for longer periods. In a meta-analysis of two trials, we found no evidence of an effect of aminocaproic acid on long-term visual acuity (RR 1.03, 95% confidence interval (CI) 0.82 to 1.29) or final visual acuity measured up to three years after the hyphema (RR 1.05, 95% CI 0.93 to 1.18). Oral tranexamic acid appeared to provide little to no benefit on visual acuity in four trials (RR 1.12, 95% CI 1.00 to 1.25). The remaining trials evaluated the effects of various interventions on short-term visual acuity; none of these interventions was measured in more than one trial. No intervention showed a statistically significant effect (RRs ranged from 0.75 to 1.10). Similarly, visual acuity measured for longer periods in four trials evaluating different interventions was also not statistically significant (RRs ranged from 0.82 to 1.02). The evidence supporting these findings was of low or very low certainty. Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (RR 0.28, 95% CI 0.13 to 0.60), as assessed in six trials with 330 participants. A sensitivity analysis omitting two studies not using an intention-to-treat analysis reduced the strength of the evidence (RR 0.43, 95% CI 0.17 to 1.08). We obtained similar results for topical aminocaproic acid (RR 0.48, 95% CI 0.20 to 1.10) in two trials with 131 participants. We assessed the certainty of the evidence as low. Systemic tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (RR 0.33, 95% CI 0.21 to 0.53) in seven trials with 754 participants, as did aminomethylbenzoic acid (RR 0.10, 95% CI 0.02 to 0.41), as reported in one study. Evidence to support an associated reduction in risk of complications from secondary hemorrhage (i.e. corneal blood staining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no evidence of an effect on the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The number of days for the primary hyphema to resolve appeared to be longer with the use of systemic aminocaproic acid compared with no use, but this outcome was not altered by any other intervention. The available evidence on usage of systemic or topical corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials. We found no evidence of an effect between a single versus binocular patch on the risk of secondary hemorrhage or time to rebleed. We also found no evidence of an effect on the risk of secondary hemorrhage between ambulation and complete bed rest.

AUTHORS’ CONCLUSIONS: We found no evidence of an effect on visual acuity of any of the interventions evaluated in this review. Although the evidence was limited, people with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhage. However, hyphema took longer to clear in people treated with systemic aminocaproic acid. There is no good evidence to support the use of antifibrinolytic agents in the management of traumatic hyphema, other than possibly to reduce the rate of secondary hemorrhage. The potentially long-term deleterious effects of secondary hemorrhage are unknown. Similarly, there is no evidence to support the use of corticosteroids, cycloplegics, or non-drug interventions (such as patching, bed rest, or head elevation) in the management of traumatic hyphema. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.

PMID:36912744 | DOI:10.1002/14651858.CD005431.pub5