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Femoral Neck Complications in Isolated Femoral Neck Fractures Versus Ipsilateral Femoral Neck and Shaft Fractures.
No full textOBJECTIVES: There are limited data on the difference in outcomes between patients with isolated femoral neck fractures (IsoFN) and those with a femoral neck and ipsilateral femoral shaft fracture (IpsiFNS) in terms of osteonecrosis, nonunion, and revision surgery rates. We hypothesized that displaced IsoFN fractures would have higher rates of femoral neck nonunion, osteonecrosis, and hip revision surgery than displaced IpsiFNS fractures. Comparisons were made to determine the relationship between these outcomes and other variables.
METHODS: A retrospective review of patients age 18 to 55 years from 2005 to 2020 at two level-I trauma academic institutions was performed, identifying 107 patients in total (IpsiFNS 51, IsoFN 56). The review analyzed the rates of displacement, osteonecrosis, nonunion, and revision surgery. Further comparisons were made to determine the effect of reduction quality, fixation method, and reduction type on these outcomes.
RESULTS: Patients with displaced IsoFN had a significantly higher nonunion, revision surgery and osteonecrosis rate (38.5%, 38.5%, 17.3%) than in patients with IpsiFNS (6.7%, 13.3%, 0%; P = 0.004, P = 0.010, P = 0.016 respectively). There was a relationship between nonunion and femoral neck fixation with fully threaded screws (P = 0.036 and P = 0.004). Among patients who underwent an open reduction, nonunion rates were significantly higher for displaced IsoFN than for displaced IpsiFNS (7.4% vs. 43.2%, P = 0.008). Osteonecrosis rates had a relationship with reduction quality (P = 0.044).
CONCLUSIONS: Patients with a displaced isolated femoral neck fractures are at higher risk for nonunion, osteonecrosis, and revision surgery than those with a displaced femoral neck fracture associated with an IpsiFNS. Quality of reduction had a relationship with osteonecrosis rates. An open approach to the neck reduction was associated with nonunion at a higher rate in displaced IsoFN than in displaced IpsiFNS. A fixation construct of multiple cancellous independent screws that included fully threaded screws had higher odds for nonunion
A Quality Improvement Initiative to Reduce Underdosing of Rectal Diazepam as Home Seizure Rescue Medication After Hospitalization.
No full textBACKGROUND AND OBJECTIVES: Seizure rescue medications are commonly prescribed to patients with epilepsy to treat and prevent clusters of seizures or status epilepticus. Underdosing of rescue medications decreases their efficacy, which may lead to status epilepticus and potentially avoidable emergency department (ED) visits or hospitalizations. In this quality improvement initiative, we aimed to reduce the rate of underdosed rectal diazepam prescriptions for children discharged from the inpatient neurology service at our institution from a baseline of 6% to 3% by July 2023.
METHODS: The primary intervention was an order panel in the electronic health record that automated selection of correct dosing for age-based and weight-based seizure rescue medications including rectal diazepam, intranasal diazepam, and intranasal midazolam. A statistical process control p-chart was used to analyze our primary outcome measure, the monthly rate of underdosed rectal diazepam prescriptions for patients discharged from the inpatient neurology service. The process measure was use of the new order panel. Balancing measures included the dispense rate, cost for seizure rescue medications, and provider satisfaction.
RESULTS: During the baseline period, July 2020-August 2022, rectal diazepam was underdosed for 6% of patients discharged from the neurology service. After intervention, we achieved and sustained 0% underdosing of rectal diazepam. We observed no concerning changes in the dispense rate for the medications, the average copay cost remained low, and surveys of ordering providers showed overall high rates of satisfaction. By spreading the intervention, we reduced underdosing from 21% to 0.6% in the ED and from 12% to 4% across the health care system.
DISCUSSION: An order panel that automated selection of correct dosing effectively and sustainably reduced underdosing of seizure rescue medications and is transferrable across care settings. We expect that proper dosing of seizure rescue medications should reduce the occurrence of status epilepticus and associated complications
Recurrence and survival in high-intermediate risk endometrial cancers with isolated tumor cell lymph node metastasis.
No full textOBJECTIVE: To compare clinical outcomes of patients with early-stage, high-intermediate risk (HIR) endometrial cancer (EC) and isolated tumor cells (ITC) lymph node metastases treated with chemotherapy/radiotherapy (CRT) vs. external beam radiotherapy (EBRT)/vaginal brachytherapy (VBT).
METHODS: We retrospectively identified all patients with early-stage HIR endometrioid EC and ITC treated with CRT or EBRT from our institutional database (January-2015 to December-2023). All patients underwent sentinel lymph node (SLN) assessments per NCCN guidelines. Progression-free survival (PFS) and cancer specific survival (CSS) were analyzed using Kaplan-Meier method. We utilized a GOG-99 scoring system in the HIR-ITC cohort to assess risk factors for recurrence.
RESULTS: 48 patients were identified, 32(67 %) treated with CRT, 15(31 %) with EBRT and 1(2 %) with VBT alone. Median follow-up was 63.2 and 28 months in CRT vs EBRT/VBT, respectively (
CONCLUSION: In this retrospective study, there was no significant difference in survival for patients with HIR endometrial cancer and ITC SLNs treated with either EBRT/VBT or CRT. Patients with three or more HIR risk factors remain at risk for recurrence despite CRT. Further prospective studies should assess recurrence risk factors in HIR EC with ITC, likely incorporating standard histopathology and molecular profiles to tailor adjuvant CRT
Developing aneurysm clipping capacity in Ghana through global neurosurgical collaboration: a case series from two global brainsurgery initiative mission trips.
No full textINTRODUCTION: The management of cerebral aneurysms in low- and middle-income countries (LMICs) faces significant barriers, including limited access to specialized neurosurgical care and equipment and dissipating human resources. Ghana\u27s inaugural experience with cerebral aneurysm clipping, facilitated by the Global Brainsurgery Initiative (GBI), represent an attempt to address these challenges through international collaboration.
METHODS: This case series details the outcomes of six patients who underwent cerebral aneurysm clipping procedures at two neurosurgical centers. These cases were done in 2023 and 2024 by a team comprising local and international neurosurgeons. After a series of virtual case discussions, patients were selected. Case load was mainly limited by logistics and operative schedules. The preoperative planning; challenges encountered and strategies for capacity building are discussed.
RESULTS: The patients were aged 15 to 63 years, predominantly female and presented with ruptured aneurysms at the internal carotid artery terminus, posterior communicating artery, and middle cerebral artery. All patients had their aneurysms clipped. There was an intraoperative rupture in one case and perioperative rupture with subsequent infarct in another. Most patients achieved good functional recovery, with mRS scores indicating minimal to moderate disability.
CONCLUSION: We outline the beginnings of a new global neurosurgery partnership. The GBI mission demonstrates that with appropriate planning and collaboration, neurosurgical care in low-resource settings can achieve appreciable outcomes. Continued investment in early diagnosis, advanced treatment modalities, and healthcare infrastructure is essential for scaling access to surgical aneurysm care in Ghana
Tibiotalar Nailing for Geriatric Pilon Fractures: Case Report and Review of the Literature.
No full textINTRODUCTION: Tibial pilon fractures present a complex challenge, particularly in geriatric patients with comorbidities and compromised soft tissue. Traditional treatment options such as open reduction and internal fixation (ORIF) and tibiotalocalcaneal (TTC) nailing have shown variable outcomes, often complicated by infection, nonunion, and malunion. Tibiotalar nailing is an alternative approach that preserves subtalar joint motion while providing stable fixation, though, there is limited literature on its efficacy in geriatric pilon fractures. This report describes a case of a 64-year-old female with multiple comorbidities presenting with tibial pilon fracture successfully managed with antegrade tibiotalar intramedullary nailing, highlighting the potential advantages of this technique.
CASE REPORT: A 64-year-old female with a history of chronic obstructive pulmonary disease, hypertension, and a significant smoking history presented with a right tibial pilon and distal fibula fracture following a fall down the stairs. Due to her medical comorbidities and poor soft tissue envelope, she was at high risk for complications with ORIF. After discussing multiple treatment options, she elected to proceed with a tibiotalar intramedullary nail to optimize function while minimizing surgical morbidity. The procedure was performed using a suprapatellar approach, and an 8mm nail was inserted to preserve bone stock and future surgical options. Postoperatively, she progressed well, achieving full fracture healing by 9 months with minimal pain and functional independence. She declined further surgical intervention for hardware removal or ankle fusion, reporting satisfaction with her outcome.
CONCLUSION: This case highlights the successful use of tibiotalar nailing as a viable alternative to ORIF and TTC nailing for managing geriatric pilon fractures with significant comorbidities. By preserving subtalar joint function, this approach offers potential advantages in mobility and quality of life while mitigating the risks associated with more invasive procedures. Given the limited existing literature on this technique, this report contributes to the growing body of evidence supporting its use. Further studies are warranted to compare tibiotalar nailing with conventional approaches in larger cohorts to refine its indications and optimize patient outcomes
Prehospital Trauma Compendium: Management of geriatric trauma patients - A position statement and resource document of NAEMSP.
No full textTrauma in geriatric patients (traditionally defined as adults aged 65 and older) is associated with high morbidity and mortality. Although older adults have lower average Injury Severity Scores (ISS) than younger patients, their mortality rates are higher. There are multiple hypotheses to explain these disparities; however, there is an incomplete consensus on how to best care for these patients in the prehospital setting. To address this issue, the National Association of Emergency Medical Services Physicians (NAEMSP) conducted a structured, rapid review of the literature to develop evidence-based guidance on the care of geriatric trauma patients in the prehospital setting.NAEMSP recommends:EMS clinicians should use age-adjusted, physiologic criteria to guide decisions to transport geriatric trauma patients to the most appropriate level of trauma center available in the community.Geriatric trauma patients should be promptly evaluated for pain and should receive analgesic interventions in a timely manner. Analgesic medications should be dosed following weight-based guidance and should be administered with consideration of potential drug interactions and age-related changes in drug metabolism and side effects.EMS clinicians should consult advance care planning documents, e.g., Physician Orders for Life-Sustaining Treatment (POLST), when available, to guide care in emergency scenarios, including management of traumatic injuries.While older patients are at higher risk for spinal injuries, including lumbar and cervical spine fractures, traditional spinal motion restriction practices may not be suitable for older patients due to age-related anatomic changes in spinal alignment and increased risk for cutaneous pressure-related injuries. EMS clinicians should exercise judgment to determine when and how to best achieve spinal motion restriction if spinal injury is suspected in geriatric trauma patients
Cisplatin-ineligible patients with muscle-invasive bladder cancer demonstrate poor long-term survival following immediate radical cystectomy.
No full textOBJECTIVES: To compare survival and oncological outcomes of cisplatin-ineligible patients (Cis-I) and cisplatin-eligible (Cis-E) patients with muscle-invasive bladder cancer (MIBC) undergoing immediate radical cystectomy (IRC), as IRC is currently considered the standard-of-care for Cis-I patients with MIBC.
PATIENTS AND METHODS: Data from patients with clinical (c)T2-4cN0-1M0 MIBC undergoing IRC, between 2006 and 2021, were retrospectively analysed from four tertiary care centres in the United States. Overall, recurrence-free and event-free survival were described using the Kaplan-Meier method and tested using the log-rank test. For context, we compared survival outcomes against those in Cis-E patients with MIBC undergoing IRC from the Southwest Oncology Group (SWOG)-8710 trial.
RESULTS: Overall, 379 Cis-I and 125 Cis-E patients with cT2-4cN0-1M0 MIBC who underwent IRC were included. Cis-I patients included 44.8% cT3/4 vs 60% cT3/4 in the Cis-E group. Overall, 83.3% of Cis-I and 79.2% of Cis-E patients died during follow-up. The median event-free survival and overall survival were 14.5 and 60.1 months vs 12.1 and 28.8 months in favour of the Cis-E group (P \u3c 0.001). Limitations include retrospective comparison of contemporary multi-institutional data with that of a randomised control trial.
CONCLUSIONS: The Cis-I patients with MIBC undergoing IRC fared poorly, with a median overall survival of 14.5 (95% confidence interval 11.1-17.9) months, mostly due to non-cancer-related deaths. These results provide a benchmark for clinical trials exploring novel agents or alternative chemotherapy regimens in Cis-I patients with MIBC