Factors associated with nonunion of the posttraumatic subtalar arthrodesis after displaced intra-articular calcaneal fractures

BackgroundThis study investigated the incidence of and risk factors for nonunion in patients with posttraumatic subtalar arthrodesis (SA).MethodsWe retrospectively reviewed 165 posttraumatic SA cases. Nonunion was diagnosed at 6 months after surgery based on the findings of clinical evaluations, plain radiographs, and CT scans. Patient-specific factors and surgeon-specific factors were evaluated as potential risk factors.ResultsThe overall nonunion rate was 13.3 % (22 of 165 cases). In the final multivariate logistic regression analysis, smoking (odds ratio [OR] = 3.64; 95 % confidence interval [CI] = 1.23–10.75), parallel screw configuration (OR = 5.70; 95 % CI = 1.62–20.06), and freeze dried iliac crest (OR = 9.16; 95 % CI = 2.28–36.79) were demonstrated as risk factors for nonunion of posttraumatic SA.ConclusionPatients with a history of smoking, parallel screw configuration fixation, and those who received freeze dried iliac crest as an interpositional graft, had a significantly higher rate of nonunion.     

Risk factors of lateral epicondylitis: A meta-analysis

IntroductionLateral Epicondylitis is commonly associated with numerous anatomical and mechanical risk factors. Thus far, there have been no reviews synthesising the risk factors of lateral epicondylitis. We hence aimed to perform a meta-analysis of factors associated with lateral epicondylitis.MethodologyWe searched MEDLINE, Scopus and Web of Science for 1032 articles. Eventually, based on our exclusion criteria, we had 33 articles remaining for our systematic review. 15 of these articles were used for our meta-analysis. Data was analysed using Mantel-Haenszel statistics and random effect models where appropriate.ResultsFemales had a 1.29 times higher odds of sustaining lateral epicondylitis (OR Males: Females = 0.77, 95% CI = 0.67–0.89, Z = 3.52, I² = 33%, p < 0.001). The odds of an individual with a current or past tobacco smoking history sustaining lateral epicondylitis was 1.49 times that of an individual with no tobacco smoking history (95% CI = 1.18–1.87, Z = 3.40, I² = 0%, p < 0.001). There was no statistical difference in sustaining lateral epicondylitis when comparing individuals with a current tobacco smoking history to individuals with a past or no tobacco smoking history (OR = 1.18, 95% CI = 0.91–1.51, Z = 1.26, I² = 0%, p = 0.21). Neither was there a statistical difference in sustaining lateral epicondylitis when comparing individuals with a BM ≥ 25 to those with a BMI<25 (OR = 1.12, 95% CI = 0.69–1.83, Z = 0.46, I² = 62%, p = 0.65).ConclusionFemale gender and a positive and past smoking history were associated with lateral epicondylitis. Further studies should focus on identifying other associations with lateral epicondylitis and the pathophysiological explanation of such associations.     

Considering extended right lobe grafts as major extended donor criteria in liver transplantation is justified

The outcomes of split-liver transplantation are controversial. This study compared outcomes and morbidity after extended right lobe liver transplantation (ERLT) and whole liver transplantation (WLT) in adults. MEDLINE and Web of Science databases were searched systematically and unrestrictedly for studies on ERLT and its impact on graft and patient survival, and postoperative complications. Graft loss and patient mortality odds ratios (OR) and 95% confidence intervals (CI) were assessed by meta-analyses using Mantel–Haenszel tests with a random-effects model. Vascular and biliary complications, primary nonfunction, 3-month, 1-, and 3-year graft and patient survival, and retransplantation after ERLT and WLT were analyzed. The literature search yielded 10 594 articles. After exclusion, 22 studies (n = 75 799 adult transplant patients) were included in the analysis. ERLT was associated with lower 3-month (OR = 1.43, 95% CI = 1.09–1.89, P = 0.01), 1-year (OR = 1.46, 95% CI = 1.08–1.97, P = 0.01), and 3-year (OR = 1.37, 95% CI = 1.01–1.84, P = 0.04) graft survival. WL grafts were less associated with retransplantation (OR = 0.57; 95% CI = 0.41–0.80; P < 0.01), vascular complications (OR = 0.53, 95% CI = 0.38–0.74, P < 0.01) and biliary complications (OR = 0.67; 95% CI = 0.47–0.95; P = 0.03). Considering ERLT as major Extended Donor Criteria is justified because ERL grafts are associated with vasculobiliary complications and the need for retransplantation, and have a negative influence on graft survival.     

The Association of Race/Ethnicity and Total Knee Arthroplasty Outcomes in a Universally Insured Population

BackgroundPrior studies have documented racial/ethnic disparities in the United States for total knee arthroplasty (TKA) outcomes. One factor cited as a potential mediator is unequal access to care. We sought to assess whether racial/ethnic disparities persist in a universally insured TKA population.MethodsA US integrated health system’s total joint replacement registry was used to identify elective primary TKA (2000-2016). Racial/ethnic differences in revision and 90-day postoperative events (readmission, emergency department [ED] visit, infection, venous thromboembolism, and mortality) were analyzed using Cox proportional hazard and logistic regression with adjustment for confounders.ResultsOf 129,402 TKA, 68.8% were white, 16.2% were Hispanic, 8.4% were black, and 6.6% were Asian. Compared to white patients, Hispanic patients had lower risks of septic revision (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.57-0.83) and infection (odds ratio [OR] = 0.42, 95% CI = 0.30-0.59), but a higher likelihood of ED visit (OR = 1.28, 95% CI = 1.22-1.34). Black patients had higher risks of aseptic revision (HR = 1.61, 95% CI = 1.42-1.83), readmission (OR = 1.13, 95% CI = 1.02-1.24), and ED visit (OR = 1.31, 95% CI = 1.23-1.39). Asian patients had lower risks of aseptic revision (HR = 0.67, 95% CI = 0.54-0.83), septic revision (HR = 0.78, 95% CI = 0.60-0.99), readmission (OR = 0.89, 95% CI = 0.79-1.00), and venous thromboembolism (OR = 0.59, 95% CI = 0.45-0.78).ConclusionWe observed differences in TKA outcome, even within a universally insured population. While lower risks in some outcomes were observed for Asian and Hispanic patients, the higher risks of aseptic revision and readmission for black patients and ED visit for black and Hispanic patients warrant further research to determine reasons for these findings to mitigate disparities.Level of EvidenceLevel III.     

Are Patients Being Appropriately Selected for Same-Day Discharge Total Knee Arthroplasty?

BackgroundDecreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days.ResultsWhen comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD.ConclusionThe unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA.Level of EvidenceIII.     

Ankle-brachial index in patients with intermittent claudication is a poor indicator of patient-centered and clinician-based evaluations of functional status

BackgroundThe association between the severity of ankle-brachial index (ABI), a traditional measure of the severity of peripheral artery disease (PAD), and patients' perceptions of their health status is poorly characterized. In Patient-Centered Outcomes Related to Treatment Practices in Peripheral Artery Disease: Investigating Trajectories (PORTRAIT), a study of patients with intermittent claudication (IC), we studied the correlation of ABI values and Rutherford symptom classification with PAD-specific health status as measured by the Peripheral Artery Questionnaire (PAQ).MethodsAmong 1251 patients with new onset or exacerbation of IC enrolled at 16 sites in the United States, Netherlands, and Australia, ABI values were categorized as mild (>0.80), moderate (0.40-0.79), and severe (<0.40). Spearman rank correlation coefficients were calculated between raw ABI values and PAQ scores and between the Rutherford classification and PAQ scores.ResultsMean ABI was 0.67 (standard deviation, 0.19); 24.3% had mild, 67.6% moderate, and 8.1% severe PAD. According to the Rutherford classification, 22.7% were stage 1 (mild claudication), 49.5% stage 2 (moderate claudication), and 27.8% stage 3 (severe claudication). Correlations (95% confidence interval) were found between ABI and the PAQ summary score (r = 0.09 [0.04-0.15]) and the PAQ physical limitations score (r = 0.14 [0.09-0.20]); no correlations were found between ABI and the PAQ quality of life score (r = 0.03 [−0.02 to 0.09]) and the PAQ symptoms score (r = 0.04 [−0.01 to 0.10]). With the correlations between ABI and PAQ scores, ABI explained only 0.1% to 2.1% of the variation in PAQ scores. Rutherford classification had stronger but still modest associations with PAQ scores (PAQ summary, r = −0.27 [−0.21 to −0.32]; PAQ quality of life, r = −0.21 [−0.16 to −0.27]; PAQ symptoms, r = −0.18 [−0.13 to −0.23]; PAQ physical limitations, r = −0.27 [−0.22 to −0.32]); Rutherford class explained 3.2% to 7.3% of the variation in PAQ scores.ConclusionsIn a large, international cohort of patients with IC, patient-centered health status assessments are weakly associated with physicians' or hemodynamic assessments. To best measure the impact of PAD on patients' symptoms, functional capacity, and quality of life, direct assessment from patients is needed, rather than relying on physiologic or clinician-assigned assessments.     

The role of tumor phenotype in the surgical treatment of early-stage breast cancer

BackgroundWe investigated whether tumor phenotype influences surgical decision-making, and how that may impact overall survival (OS) for early-stage breast cancer.MethodsWomen aged 18–69 with cT0-2/cN0/cM0 breast cancer in the National Cancer Database (2010–2017) were included. A generalized logistic model was used to identify factors associated with surgery type. A Kaplan-Meier curve was used to visualize unadjusted OS, and the log-rank test was used to test for differences in OS between surgery types.ResultsOf 597,149 patients, 58% underwent lumpectomy with radiation (BCT), 25% unilateral mastectomy (UM), and 17% bilateral mastectomy (BM). After adjustment, HER2+ and triple-negative (TN) tumors were less likely to undergo UM than BCT, versus hormone receptor-positive tumors (OR = 0.881, 95% CI = 0.860–0.903; OR = 0.485, 95% CI = 0.470–0.501). UM and BM had worse 5-year OS versus BCT (UM: 0.926, vs BM: 0.952, vs BCT: 0.960).ConclusionsBCT is increasingly used to treat HER2+ and TN tumors. More extensive surgery is not associated with better survival outcomes, regardless of tumor phenotype.     

Predicting Inpatient Status After Primary Total Knee Arthroplasty in Medicare-Aged Patients

BackgroundThe Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from its inpatient only (IPO) list as of January 1, 2018. The purpose of this study was to establish a risk-stratifying nomogram to aid in determining the need for inpatient admission among Medicare-aged patients undergoing primary TKA.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients aged ≥65 years who underwent primary TKA between 2006 and 2015. The primary outcome measure was inpatient admission, as defined by hospital length of stay longer than 2 days. Multiple demographic, comorbid, and perioperative variables were incorporated in a multivariate logistic regression model to yield a risk stratification nomogram.ResultsSixty-one thousand two hundred eighty-four inpatient and 26,066 outpatient admissions were analyzed. Age >80 years (odds ratio [OR] = 2.27, P < .0001, 95% confidence interval [CI] = 2.13-2.42), simultaneous bilateral TKA (OR = 2.02, P < .0001, 95% CI = 1.77-2.30), dependent functional status (OR = 1.95, P < .0001, 95% CI = 1.62-2.35), metastatic cancer (OR = 1.91, P = .055, 95% CI = 0.99-3.73), and female gender (OR = 1.76, P < .0001, 95% CI = 1.70-1.82) were the greatest determinants of inpatient stay. The resulting predictive model demonstrated acceptable discrimination and excellent calibration.ConclusionOur model enabled a reliable and straightforward identification of the most suitable candidates for inpatient admission in Medicare aged–patients undergoing primary TKA. Larger multicenter studies are necessary to externally validate the proposed predictive nomogram.     

Meta‐analysis of the association of oestrogen receptor‐beta gene RsaI (G/A) and AluI (A/G) polymorphisms with male infertility

A more precise assessment of association of oestrogen receptor‐beta genes RsaI(G/A) and AluI(A/G) polymorphisms with male infertility from current contradictory results is the aim of this meta‐analysis including five RsaI and six AluI studies respectively. No association was observed between infertility and RsaI or AluI. In the stratified analysis by ethnicity, increased risk was found among Caucasians with GA versus GG (OR = 2.263, 95% CI = 1.073–4.776, I² = 57.1%) and dominant model (OR = 2.117, 95% CI = 1.018–4.403, I² = 49.0%) of RsaI. It was not observed for AluI. In the stratified analysis by infertility subtypes, a reduced risk in GA of AluI was observed among azoospermia or severe oligospermia (GA versus AA: OR = 0.686, 95% CI = 0.498–0.945, I² = 21.2%; recessive model: OR = 1.403, 95% CI = 1.056–1.864, I² = 31.7%), and reduced risk was in recessive model (OR = 0.650, 95% CI = 0.446–0.948, I² = 0.0%) of subtypes, except for azoospermia or severe oligospermia. However, this finding was not observed in RsaI. The meta‐analysis showed GA and GG of AluI are possibly resistant factors for spermatogenesis dysfunction and deteriorated sperm quality.     

The value of three-dimensional visualization techniques in hepatectomy for complicated hepatolithiasis: A propensity score matching study

ObjectiveThe present study aimed to investigate the safety, feasibility, and efficacy of three-dimensional visualization technique (3DVT)-guided hepatectomy in the treatment of complicated hepatolithiasis.MethodsThe clinical and follow-up data of 279 patients with complicated hepatolithiasis were retrospectively analyzed. The patients were divided into a 3DVT group (group A, 66 cases) and a non-3DVT group (group B, 213 cases). After baseline data were balanced using propensity score matching (PSM), the clinical characteristics and follow-up data of the two groups were observed.ResultsAfter 1:1 PSM, 58 patients in each group were successfully matched with each other. When the groups were compared, the surgical duration (p = 0.033) and intraoperative blood loss (p = 0.002) of group A were lower than those of group B. The immediate stone clearance rate (91.4% vs. 75.9%, p = 0.024) and quality of life outcome (p = 0.034) of group A were significantly higher than those of group B. Logistic regression analysis showed that history of two or more biliary tract operations (odds ratio [OR] = 6.544, 95% confidence interval [CI] = 1.193–35.890, p = 0.031), bilateral stone distribution (OR = 4.198, 95% CI = 1.186–14.854, p = 0.026), and Geng grade III or IV (OR = 12.262, 95% CI = 2.224–67.617, p = 0.004) were independent risk factors for poor outcomes in patients with complicated hepatolithiasis.ConclusionCompared to conventional imaging examinations, 3DVT can be used to guide and achieve accurate preoperative diagnosis of complicated hepatolithiasis and has good safety, feasibility, and efficacy.     

Post-transplant eosinophilic gastrointestinal disorders and lymphoproliferative disorder in pediatric liver transplant recipients on tacrolimus

AimTo examine and characterize post-transplant eosinophilic gastrointestinal disorders (PTEGID) and post-transplant lymphoproliferative disorder (PTLD) in pediatric liver transplant recipients.MethodsThis is a single center retrospective study of all liver transplant recipients aged 0–18 years from 1999 to 2019 who received tacrolimus as their primary immunosuppressant. Demographic data and clinical/laboratory data including PTEGID, PTLD, liver transplant types, Epstein-Barr virus status, and blood eosinophil count were reviewed. Analysis was done with logistic regression and Mann-Whitney U test.ResultsNinety-eight pediatric liver transplant recipients were included with median age at transplantation of 3.3 years (IQR: 1.1–9.3). The major indication for transplantation was biliary atresia, 51 (52%) cases. Eight (8%) children had PTLD and 14 (14%) had PTEGID. Receiving liver transplantation at an age of ≤1 year was associated with developing PTEGID (OR = 11.9, 95% CI = 3.5–45.6, p < 0.001). Additionally, eosinophilic count of ≥500/μL was associated with having PTLD (OR = 10.7, 95% CI = 1.8–206.0, p = 0.030) as well as having at least one liver rejection (OR = 2.8, 95% CI = 1.2–7.0, p = 0.024). The frequency of food-induced anaphylaxis significantly increased post-transplantation (p = 0.023).ConclusionsPTEGID and PTLD are common in this cohort and are associated with certain risk factors that help screen children to improve recipient survival. Further studies are needed to evaluate the clinical benefits of these findings.     

Does Regional Anesthesia Reduce Complications Following Total Hip and Knee Replacement Compared With General Anesthesia? An Analysis From the National Joint Registry for England,Wales, Northern Ireland and the Isle of Man

BackgroundRegional anesthesia is increasingly used in enhanced recovery programs following total hip replacement (THR) and total knee replacement (TKR). However, debate remains about its potential benefit over general anesthesia given that complications following surgery are rare. We assessed the risk of complications in THR and TKR patients receiving regional anesthesia compared with general anesthesia using the world’s largest joint replacement registry.MethodsWe studied the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man linked to English hospital inpatient episodes for 779,491 patients undergoing THR and TKR. Patients received either regional anesthesia (n = 544,620, 70%) or general anesthesia (n = 234,871, 30%). Outcomes assessed at 90 days included length of stay, readmissions, and complications. Regression models were adjusted for patient and surgical factors to determine the effect of anesthesia on outcomes.ResultsLength of stay was reduced with regional anesthesia compared with general anesthesia (THR = −0.49 days, 95% confidence interval [CI] = −0.51 to −0.47 days, P < .001; TKR = −0.47 days, CI = −0.49 to −0.45 days, P < .001). Regional anesthesia also had a reduced risk of readmission (THR odds ratio [OR] = 0.93, CI = 0.90-0.96; TKA OR = 0.91, CI = 0.89-0.93), any complication (THR OR = 0.88, CI = 0.85-0.91; TKA OR = 0.90, CI = 0.87-0.93), urinary tract infection (THR OR = 0.85, CI = 0.77-0.94; TKR OR = 0.87, CI = 0.79-0.96), and surgical site infection (THR OR = 0.87, CI = 0.80-0.95; TKR OR = 0.84, CI = 0.78-0.89). Anesthesia type did not affect the risk of revision surgery or mortality.ConclusionRegional anesthesia was associated with reduced length of stay, readmissions, and complications following THR and TKR when compared with general anesthesia. We recommend regional anesthesia should be considered the reference standard for patients undergoing THR and TKR.     

Genetic polymorphism in hOGG1 is associated with triple-negative breast cancer risk in Chinese Han women

8-hydroxy-2′-deoxyguanine (8-OHdG), a typical product of oxidative stress-induced DNA damage, can cause a G–T transversion during DNA replication if it is not removed. Human 8-oxoguanine glycosylase 1 (hOGG1), a key DNA repair gene, recognizes and excises 8-OHdG from damaged DNA accurately; however, a c.977C>G (Ser326Cys) polymorphism in hOGG1 can inhibit the gene's ability to remove 8-OHdG. The aim of present study was to investigate the association between the c.977C>G polymorphism in hOGG1 and the risk of breast cancer in Chinese Han women. We used high-resolution melting and sequencing to analyze the genotypes of 630 patients with sporadic breast cancer patients and 777 healthy controls. We also performed risk-stratified subgroup analyses to determine the association between the c.977C>G polymorphism and other characteristics of breast cancer subgroups. Breast cancer patients and healthy controls did not have significantly different of c.977C/G genotypes (odds ratio [OR] = 1.10, 95% confidence interval [CI] = 0.82–1.49, p = 0.57) and c.977G/G genotypes (OR = 1.34, 95% CI = 0.97–1.84, p = 0.09). However, the c.977G/G genotype was especially prevalent in breast cancer patients who were younger than 55 years (OR = 1.58, 95% CI = 1.05–2.39, p = 0.04), were premenopausal status (OR = 1.87, 95% CI = 1.14–3.06, p = 0.02), had triple-negative disease (OR = 2.14, 95% CI = 1.06–4.29, p = 0.04), or p53-positive disease (OR = 1.56, 95% CI = 1.14–2.12, p = 0.005). These findings suggest that the c.977C>G polymorphism in hOGG1 is associated with an increased risk of breast cancer in Chinese Han women who are younger than 55 years, premenopausal, triple-negative, or p53-positive subgroups.     

Risk factors associated with Hepatitis E virus infection in kidney transplant recipients in a single tertiary Center in the United States

BackgroundHepatitis E virus (HEV), the causative agent of hepatitis E, is a common but self-limiting disease. However, in immunosuppressed kidney transplant 47 recipients (KTRs), HEV infection can become chronic. We investigated risk factors associated with HEV infection among 271 KTRs at the Johns Hopkins Hospital transplanted between 1988 and 2012.MethodsHEV infection was defined as having positive anti-HEV IgM, anti-HEV IgG, or HEV RNA. The risk factors included: age at transplant, sex, hemodialysis/peritoneal dialysis, plasmapheresis, transfusions, community urbanization, and other socioeconomic factors. Logistic regression was used to determine independent risk factors associated with HEV infection.ResultsOut of 271 KTRs, 43 (16%) had HEV infection though not active disease. HEV infection in KTRs was associated with older age (≥45 years; OR = 4.04; 95% CI = 1.81–57 10.03; p = 0.001) and living in communities with low proportions of minorities (OR = 0.22; 95% 58 CI = 0.04–0.90; p = 0.046).ConclusionKTRs who had HEV infection may be at an increased risk of developing chronic HEV.     

Exploration of the association between chronic periodontal disease and erectile dysfunction from a population‐based view point

Several cross‐sectional studies have indicated an association between chronic periodontal disease (CPD) and cardiovascular disease and metabolic syndrome. Erectile dysfunction (ED) also shares pathological mechanisms with these diseases. Using a nationwide population‐based data set, we examined the association between ED and CPD and assessed the effect of dental extraction (DE) on ED prevalence in different aged CPD populations in Taiwan. We identified 5105 patients with ED and randomly selected 10 210 patients as controls. Of these patients, 2617 (17.09%) were diagnosed with CPD according to the index data: 1196 (23.43%) in the ED group and 1421 (13.92%) in the control group. After adjusting for comorbid factors, patients with ED were more likely to have been diagnosed with prior CPD than controls (OR = 1.79, 95% CI = 1.64–1.96, P < 0.001). Moreover, the association was much stronger in the populations aged less than 30 years (OR = 2.13, 95% CI = 1.23–3.70, P < 0.001) and more than 59 years (OR = 2.27, 95% CI = 1.99–2.59, P < 0.001). Dental extraction seems to attenuate damage to the penile endothelial beds caused by CPD‐related inflammation and overcame the process of ED in the middle‐aged and older populations.     

Association studies of cytochrome P450, family 2, subfamily E,polypeptide 1 (CYP2E1) gene polymorphisms with acute rejection in kidney transplantation recipients

Recent studies have shown that single‐nucleotide polymorphisms (SNPs) are associated with allograft rejection in kidney transplantation recipients. We evaluated the possible association between SNPs of the cytochrome P450, family 2, subfamily E, polypeptide 1 (CYP2E1) gene, and acute rejection (AR) among renal transplant patients in a Korean population. We conducted a case–control association study in 63 AR and 284 non‐AR kidney transplant recipients. The SNPs of CYP2E1 were genotyped by direct sequencing. Recipient sex (p = 0.023) and the use of tacrolimus (p = 0.017) were significantly different between the two groups. The use of mycophenolate mofetil (MMF) and antibody induction therapy was significantly lower in the AR group. Multiple logistic regression models (codominant, dominant, recessive, and log‐additive models) adjusted by sex and type of immunosuppressive regimens were applied to determine the odds ratios (ORs), 95% confidence intervals (CIs), and p‐values. The rs2515641 of CYP2E1 showed significant differences between the AR patient group and non‐AR group (p = 0.003, OR = 2.55, 95% CI = 1.37–4.75 in the codominant 1 model; p = 0.002, OR = 2.61, 95% CI = 1.43–4.77 in the dominant model; p = 0.0035, OR = 2.13, 95% CI = 1.29–3.50 in the log‐additive model). The allele of the rs2515641 SNP also showed a significant association (p = 0.004, OR = 1.99, 95% CI = 1.24–3.21). This study suggests that the CYP2E1 polymorphism may be related to the development of AR in Korean kidney transplantation recipients.     

Prognostic value of hypocholesterolemia in patients with gastric cancer

BackgroundAccording to previous studies, low serum total cholesterol (TC) is associated with higher cancer incidence and mortality. However, the prognostic implications of preoperative TC in patients with gastric cancer (GC) remain to be determined.MethodsA total of 1251 patients with GC, who underwent radical gastrectomy between 2005 and 2008, were recruited. Propensity score weighting (PSW) based on a generalized boosted method (GBM) was used to control for selection bias.ResultsAfter balancing the preoperative and operative covariates, low TC was associated with high incidence of complications (severe complication rate: 15.2% (Low TC) vs. 4.7% (Normal TC) vs 5.5% (High TC); p = 0.004). In multivariable analysis, lowering TC was associated with poor OS and RFS in weighted population. [OS: hazard ratio (HR) = 0.92; 95% CI = 0.867–0.980; P = 0.009 and RFS: HR = 0.93; 95% CI = 0.873–0.988; P = 0.02].ConclusionsPreoperative TC is a useful predictor of postoperative survival and postoperative complications in patients with stage I–III GC and may help to identify high-risk patients for rational therapy, including nutritional support, and timely follow-up.     

Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score–Matched Cohort Analysis

BackgroundGeneral anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA.MethodsA large veteran’s database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 56,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics.ResultsUpon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients.ConclusionUsing a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.     

Using machine learning methods to predict prolonged operative time in elective total shoulder arthroplasty

BackgroundMachine learning (ML) is a form of artificial intelligence in which computer algorithms improve automatically with experience. Recently, ML has been utilized to predict operative characteristics and patient outcomes for orthopedic procedures, thereby allowing for better patient selection and preoperative planning. This study sought to develop ML models to aid in predicting operative time and 30-day postoperative complications for elective total shoulder arthroplasty and to compare them to regression models.MethodsThis cross-sectional national database study identified patients who underwent elective total shoulder arthroplasty from 2012 to 2018 in the American College of Surgeons National Surgical Quality Improvement Program registry. Boosted decision tree and artificial neural network (ANN) ML models were developed to predict prolonged operative time and 30-day postoperative complication rates. Model performance was measured using the area under the receiver operating characteristic curve and overall accuracy. Multivariate binary logistic regression analyses were also used to identify variables that predicted prolonged operative time and 30-day postoperative complication rates. ML model performance was then compared to the regression models in predicting outcomes.ResultsIn total, 21,544 elective total shoulder arthroplasty procedures met inclusion criteria. Variables associated with greater odds of prolonged operative time included male sex (odds ratio [OR] = 0.66; 95% confidence interval [CI] = 0.61-0.71; P < .001), obesity (OR = 1.19; 95% CI = 1.09-1.29; P < .001), age under 70 years (OR = 0.77; 95% CI = 0.71-0.85; P < .001), smoking history (OR = 1.16; 95% CI = 1.03-1.32; P = .022), and history of cancer (OR = 2.91; 95% CI = 1.52-5.54; P = .001). The boosted decision tree model yielded an area under the curve (AUC) of 0.642, with an overall accuracy of 85.6% for predicting prolonged operative time. The ANN model had an AUC of 0.906 and overall accuracy of 84.7%, while the regression model had an AUC of 0.590 with overall accuracy of 85.6%. Thirty-day complication rate (7.7% vs. 3.9%, respectively; P < .001) and reoperation rate (1.8% vs. 1.2%, respectively; P = .006) also differed significantly between the prolonged operative duration and normal operative duration cohorts.ConclusionThis is the first study to successfully develop ML models for predicting operative time in total shoulder arthroplasty and compare them to existing methods of data analysis. The ANN model was superior to the other models in predicting prolonged operative time. With regard to 30-day postoperative complications, both ML models displayed fair predictive capacity, compared to the regression model, which had poor predictive performance.Level of evidenceLevel III; Database Retrospective Comparative Cohort Study