Nevin Manimala

West J Emerg Med. 2025 Oct 9;26(6):1702-1709. doi: 10.5811/westjem.29333.

ABSTRACT

INTRODUCTION: Firearm injuries have become increasingly more common in the pediatric population; however, there is a paucity of literature examining the management of these pediatric firearm-related injuries (FRI) specifically as they affect the upper extremity. This study identifies demographic and environmental risk factors in pediatric upper extremity FRIs and evaluates the severity of injury, concomitant injuries, and rates of surgical intervention in pediatric patients treated at a Level I pediatric trauma center over 20 years.

METHODS: We completed a retrospective analysis on 540 patients <18 years of age with FRIs at a single institution from 2001 – 2020. Of these, 72 (13%) had FRIs involving the upper extremity. The patients were stratified into groups based on whether they had received operative intervention or a bedside procedure for their injury and on their year of presentation between two decades (2001 – 2010 vs. 2011 – 2020). We obtained upper extremity injury-specific variables along with hospital demographics. The primary outcomes in this study included hospital length of stay, number of bullet wounds, motor and sensory deficits, and amputation.

RESULTS: In the last 10 years, the rate of upper extremity FRIs observed in the pediatric population has increased by 380% at our institution (15 vs. 57, P < .001). After 2010, cases were more likely to present with an increased number of gunshot wounds per patient (1.14 vs. 1.98, 95% confidence interval [CI] -0.94 – 0.24, P = .03) but were less likely to require admission to the intensive care unit (19% vs. 67%, P < .001). When stratifying by intervention, both the operative intervention and bedside procedure groups had a similar number of gunshot wounds (1.86 vs 1.76, 95% CI -0.52 – 0.43, P = .86). The operative intervention group was more likely to have had a soft tissue injury (68% vs. 35%, P = .005) and motor deficit at follow-up (45% vs.15%, P =.02). Patients in the operative intervention group had longer lengths of stay (9.66 vs. 2.25 days, 95% CI -1.16 – -0.21, P < .01) and more morbid injuries despite similar patient demographics.

CONCLUSION: In the last decade, an increased frequency of pediatric upper extremity firearm-related injuries was noted despite a stagnant state population. Emphasis should continue to be placed on education and improving firearm safety in settings in which children are present.

PMID:41380079 | DOI:10.5811/westjem.29333

West J Emerg Med. 2025 Oct 22;26(6):1679-1687. doi: 10.5811/westjem.43528.

ABSTRACT

INTRODUCTION: Most patients with acute coronary syndrome (ACS) die before hospitalization. Early diagnosis and effective interventions can prevent the disease from worsening. In this single-center, retrospective study we aimed to investigate the appropriateness of the pretreatment of patients referred to the emergency department of our hospital, a percutaneous cardiac intervention (PCI) center, with a prediagnosis of ACS under the previously published European Society of Cardiology guidelines (2017 and 2020) and the new guidelines published in 2023.

METHODS: Based on the date of publication of the European Society of Cardiology’s most recent ACS guidelines (August 25, 2023), we divided patients admitted between August 25, 2022-August 24, 2024, into two groups: patients who were evaluated and received pretreatment under the previous guidelines; and patients who were evaluated and received pretreatment under the new guidelines.

RESULTS: Of 1,675 patients screened for enrollment who were referred to our PCI center with prediagnosis of ACS, after exclusion criteria, we report on 1,450 (86.6%). Pretreatment (before PCI) compliance rate with all aspects of the previous and new guidelines was low, at 9.8%. Study patients were 69.9% (n = 1,013) male with mean age of 63.9 ± 13.0 years. Comparing the compliance rate between the new versus previous guidelines, for individual components, we found better compliance for aspirin administration (72.6 vs. 66.2%) and anticoagulants (40.3 vs. 22.7%), while for P2Y12 inhibitors, we found lower compliance (58.9 vs. 70.0%, all p< .001). For the subset of patients with ST-elevation myocardial infarction, P2Y12 inhibitors were used less appropriately under the new vs. previous guidelines (31.4 vs. 55.0%, p < .001).

CONCLUSION: The compliance rates with the previous and new guidelines for ACS pretreatment by physicians working in hospitals without PCI centers were low. Pretreatment compliance during the new guideline period was lower than compliance during the prior guideline period.

PMID:41380077 | DOI:10.5811/westjem.43528

West J Emerg Med. 2025 Nov 26;26(6):1744-1754. doi: 10.5811/westjem.41507.

ABSTRACT

INTRODUCTION: Delirium is a critical neuropsychiatric condition that surged among older adults during the coronavirus disease 2019 (COVID-19) pandemic, likely due to social isolation resulting from distancing measures. In this study we examined trends in delirium-related emergency department (ED) visits before and during the pandemic using nationwide data from South Korea, with a focus on different phases of social distancing, to inform healthcare strategies for older adults during public health crises.

METHODS: We obtained data from the National Emergency Department Information System (2017-2022). Changes in ED visits were assessed across pre-pandemic (January 2017-January 2020), early pandemic (February 2020-March 2022), and late pandemic (April 2022-December 2022) phases using interrupted time series analysis.

RESULTS: A total of 80,442 delirium-related ED visits among adults ≥ 65 years of age were recorded. The interrupted time series analysis showed a significant step increase in ED visits during the early pandemic phase (relative risk [RR] 1.290, 95% CI 1.201-1.386; 29.0% increase), followed by a decrease in the late pandemic phase (RR 0.922, 95% CI 0.868-0.981; 7.8% decrease). The most substantial increase was for individuals 65-74 year of age during the early pandemic period (RR 1.406, 95% CI 1.264-1.564) reflecting a 40.6% increase in visits to the ED. Indirect ED visits, such as institutional referrals, also notably increased (RR 1.275, 95% CI 1.184-1.373) reflecting a 27.5% increase.

CONCLUSION: Delirium-related ED visits among older adults showed a notable 7.8% decrease during the late pandemic period, with key risk groups identified, particularly adults 65-74 of age (40.6% increase) and those referred from institutions (27.5% increase) during the early pandemic period. These findings may help inform targeted interventions and public health responses in similar healthcare settings. Despite limitations including reliance on diagnostic codes, lack of subgroup analysis by COVID-19 status, potential duplicate visit counts, and limited regional granularity this study offers important insight into delirium care needs during crisis periods. Further research should further explore causal mechanisms and the specific impact of COVID-19 infection on delirium incidence.

PMID:41380075 | DOI:10.5811/westjem.41507

Cornea. 2025 Dec 5. doi: 10.1097/ICO.0000000000004065. Online ahead of print.

ABSTRACT

PURPOSE: To assess the effect of surgical decision making on the type of corneal crosslinking (CXL) protocol in eyes with keratoconus (KC) based on stromal thickness maps and thinnest corneal pachymetry (TCP).

METHODS: A prospective, nonrandomized cohort study was performed between January 2022 and January 2023. Patients were allocated to Epi-off or transepithelial CXL (TE-CXL) procedures depending on the TCP value using Scheimpflug. TCP ≥450 μm was used to designate patient’s eye to the Epi-off CXL procedure and TCP <450 μm to TE-CXL. On the same day, a combined Placido and Anterior Segment OCT evaluation was performed to assess epithelial thickness (ET) and minimum stromal thickness (MinST). The type of surgery was then finally selected: Epi-off CXL was indicated when MinST ≥400 μm, whereas TE-CXL procedure was indicated when MinST <400 μm. We assessed the percentage of cases in which MinST data changed the surgical decision (Utility).

RESULTS: The study included 245 eyes, MinST was 407.26 ± 50.92 (range 223-497). Stromal thickness maps assessed before surgery altered the surgeon’s decision making in 5.30% (13 out of 245) of cases. The procedure was changed from Epi-off to TE-CXL and from TE-CXL to Epi-Off in 3.67% and 1.63% of the cases, respectively.

CONCLUSIONS: Anterior segment optical coherence tomography stromal thickness maps have minimal impact on the surgical decision making for conventional Epi-off and TE-CXL protocols. Considering that MinST data provide objective information on stromal thickness, unlike TCP, and avoid the need for deepithelialization, their implications in sub-400 protocols may be greater.

PMID:41379517 | DOI:10.1097/ICO.0000000000004065

J Surg Orthop Adv. 2025 Winter;34(4):203-206.

ABSTRACT

The purpose of the study was to determine the relationship between increased body mass index (BMI) and tibial prosthesis characteristics. A retrospective analysis of total knee arthroplasties (TKAs) was completed, and a Cox multivariate regression was performed. In total, 8,548 TKAs were completed, and cumulative survivability was 98.0% at 5 years and 97.1% at 10 years. Age < 70 years (p < 0.01), male sex (p < 0.01), and BMI ≥ 40 kg/m2 (p = 0.04) were significantly related to revision in all implants. Implant type, contact surface area, base plate surface area, and tibial stem length did not have a statistically significant effect on implant survivability (p = 0.62 – 0.91). When stratified based on BMI, there was a significant decrease in survivability for those BMI ≥ 40 kg/m2 (p < 0.01). Patients with high BMI do not necessarily require larger implants, and surface area and stem length do not affect survivability. Patient factors appear to drive survivability outcomes after primary TKA more than the implant factors. (Journal of Surgical Orthopaedic Advances 34(4):203-206, 2025).

PMID:41379512

J Surg Orthop Adv. 2025 Winter;34(4):193-195.

ABSTRACT

The purpose of this study was to quantify femoral rotation in the axial plane for posterior-stabilized total knee replacements performed with a modified gap-balancing technique. In total, 2442 knees were selected from a computer-assisted orthopaedic surgery navigation system database. The knees were stratified into three groups based on preoperative coronal plane alignment. The computer navigation recorded distal femoral and tibial resection angles, and the rotational position of the femoral component. Means were calculated for each of the three groups. There was substantial variation of femoral axial rotation in all three groups. In aggregate, the mean rotational position for all knees was 2.4° external (-10.2° – 20.9°). The mean rotation for the varus group was 2.5° (-9.8° – 15.7°), 2.5° (-9.8° – 20.9°) for the neutral group, and 1.1° (-10.2° – 9.9°) for the valgus group (p < 0.0001). The data indicates that choosing a predetermined rotational position for the femoral component may lead to flexion gap asymmetry more frequently than by adjusting the rotational position intraoperatively to achieve a rectangular flexion space. This is the first study to quantify differences between varus and valgus knees related to flexion gap stability. Correlation of these findings to clinical outcomes is needed. There is no single rotational position for the femoral component that will produce a balanced flexion gap for every knee. There is a statistically significant difference between mean rotational position for femoral components for varus and valgus knees. (Journal of Surgical Orthopaedic Advances 34(4):193-195, 2025).

PMID:41379510

J Surg Orthop Adv. 2025 Winter;34(4):174-177.

ABSTRACT

There is a dearth of studies analyzing outcomes in patients with chronic obstructive pulmonary disorder (COPD) receiving total ankle arthroplasty (TAA). The present study aimed to compare preoperative characteristics and 30-day postoperative outcomes for patients with COPD undergoing TAA. The National Surgical Quality Improvement Program (NSQIP) database was queried for primary TAA (CPT: 27702) from 2012 – 2020. Baseline comorbidities were compared using univariable statistics and subsequently multivariable regression was performed to measure the effect of COPD on operative time, LOS, and 30-day readmissions after TAA. In a sample of 1,619 total patients, on multivariate regression, COPD was found to be an independent risk factor predictor for shorter operative time ( b = -0.33; p = 0.037), and hospital LOS (b = 0.37; p = 0.039). In conclusion, it was determined that COPD is an independent risk factor for shorter operative time and increased duration of hospital length of stay in patients undergoing TAA. Clinical level of evidence: Level III. (Journal of Surgical Orthopaedic Advances 34(4):174-177, 2025).

PMID:41379505

J Surg Orthop Adv. 2025 Winter;34(4):168-173.

ABSTRACT

Patients undergoing thumb ligament reconstruction tendon interposition (LRTI) for carpometacarpal (CMC) arthritis are often treated with metacarpophalangeal (MCP) arthrodesis for concomitant MCP hyperextension. The effects of MCP arthrodesis on LRTI were evaluated in this study. Thirty-one LRTI surgeries were compared to 22 LRTIs with MCP arthrodesis surgeries. All patients answered Michigan Hand Outcomes (MHQ), QuickDASH, and Visual Analog Score (VAS) questionnaires. Grip, tip pinch, lateral pinch and opposition were measured. The LRTI alone and LRTI with MCP arthrodesis cohorts were then compared to each other and all of the non-operative thumbs of the same patients. The LRTI and MCP arthrodesis group showed no statistical difference in MHQ, QuickDASH, VAS, or measured strength compared to LRTI alone. This study shows no difference in patient reported outcomes between patients with LRTI alone and LRTI with MCP arthrodesis performed by the same surgeon on average 4 years after surgery. (Journal of Surgical Orthopaedic Advances 34(4):168-173, 2025).

PMID:41379504

Acta Orthop. 2025 Dec 11;96:897-903. doi: 10.2340/17453674.2025.44923.

ABSTRACT

BACKGROUND AND PURPOSE: Both cemented and uncemented stem fixation is used in 2-stage hip revision arthroplasty addressing periprosthetic joint infection (PJI). We aimed to compare the risk of infection relapse and the risk of reoperation for any reason between uncemented and cemented stem fixation.

METHODS: Patients who underwent 2-stage hip revision arthroplasty for PJI between 2005 and 2020 were included. Data on baseline demographics, implant type, and microbiological and antibiotic treatment data was obtained from a local registry and medical records. Kaplan-Meier analysis compared relapse-free survival and reoperation-free survival between uncemented (n = 60) and cemented (n = 34) stems. Cox regression models were fitted to assess adjusted hazard ratios (aHR) for the risk of relapse or reoperation with 95% confidence intervals (CIs).

RESULTS: 94 patients underwent 2-stage revision hip arthroplasty for PJI. Unadjusted 2-year relapse-free survival rates were 95% (CI 89-100) for patients with uncemented stem fixation and 97% (CI 90-100) for those with cemented fixation. Reoperation-free survival at 10 years was 82% (CI 70-95) for patients with uncemented fixation and 61% (CI 43-85) for those with cemented fixation. Using cemented fixation as the reference, the aHR for infection relapse was 2.0 (CI 0.2-20.1, P = 0.6) for uncemented fixation, whereas the aHR for reoperation was 0.3 (CI 0.1-0.9, P = 0.03).

CONCLUSION: We showed no statistical difference in the risk of infection relapse, but uncemented stem fixation in 2-stage revision arthroplasty for PJI was associated with a reduced risk of reoperation for any reason. Uncemented stems may thus be a suitable choice in 2-stage revisions for PJI when this concept is believed to provide better fixation.

PMID:41379462 | DOI:10.2340/17453674.2025.44923

JAMA Oncol. 2025 Dec 11. doi: 10.1001/jamaoncol.2025.5220. Online ahead of print.

ABSTRACT

IMPORTANCE: Breast cancer treatment is associated with cancer-related cognitive impairment (CRCI). However, the association of endocrine therapy (ET) vs chemotherapy plus endocrine therapy (CET) with CRCI is poorly understood.

OBJECTIVE: To compare patient-reported CRCI between women with breast cancer treated with ET vs CET and to consider whether menopausal status may be associated.

DESIGN, SETTINGS, AND PARTICIPANTS: This was a prespecified secondary analysis of RxPONDER (SWOG S1007), a multinational phase 3 randomized clinical trial of more than 5000 women with hormone receptor-positive ERBB2-negative (formerly HER2-negative) breast cancer with 1 to 3 involved lymph nodes and Oncotype DX (21-gene recurrence score) of 25 or less. Participants were enrolled from February 2011 to September 2017, with results first reported in December 2020. Participants were randomly assigned to CET or ET, with ongoing follow-up. This secondary analysis assessed cognitive function using the Patient-Reported Outcomes Measurement Information System Perceived Cognitive Function Concerns (PCF) questionnaire at baseline, 6, 12, and 36 months. Data were analyzed from July 2022 to August 2025.

INTERVENTION: Random assignment to CET or ET.

MAIN OUTCOMES AND MEASURES: Mean PCF standardized (T) scores by menopausal status over time using generalized estimating equations analysis for continuous outcomes.

RESULTS: Of the 568 patients who completed the baseline questionnaire and were included in the analysis, 139 (24%) were premenopausal (median [range] age, 47.8 [28.0-56.3] years) and 429 (76%) were postmenopausal (median [range] age, 62.3 [37.3-87.6] years). Among the 274 (48%) who received CET and the 294 (52%) who received ET alone, CET was determined to have a greater negative association with patient-reported CRCI in both the pre- and postmenopausal participants during the 36-month follow-up. In the ET alone group, PCF scores for premenopausal participants decreased from baseline to 6 and 12 months (53.53, 51.51, and 51.72, respectively) but recovered to baseline (54.36) at 36 months. For postmenopausal participants, mean PCF scores were essentially stable (51.72, 51.13, 51.11, and 51.70, respectively); however, in the CET group, PCF scores for both pre- and postmenopausal participants decreased from baseline to 6 and 12 months (premenopausal, 52.84, 49.27, 48.04; postmenopausal, 50.65, 48.39, 47.13, respectively) and did not return to baseline at 36 months (premenopausal, 49.25; postmenopausal, 48.44). The difference in longitudinal mean PCF scores over time between CET and ET groups was -3.02 (95% CI, -5.33 to -0.72; P = .01) for premenopausal and -2.37 (95% CI, -3.92 to -0.82; P = .003) for postmenopausal participants.

CONCLUSIONS AND RELEVANCE: This secondary analysis of the RxPONDER found that CET had a greater negative association with patient-reported CRCI compared to ET alone in both pre- and postmenopausal participants over a 36-month follow-up period. Interventions to prevent or treat CRCI are needed to improve the long-term quality of life of these patients treated with chemotherapy.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01272037.

PMID:41379459 | DOI:10.1001/jamaoncol.2025.5220