Dual-construct fixation is recommended in ipsilateral femoral neck fractures with infra-isthmus shaft fracture: A STROBE compliant study

The aim of this study was to evaluate the risk factors related to osteosynthesis failure in patients with concomitant ipsilateral femoral neck and shaft fractures, including old age; smoking habit; comminuted fragments; infra-isthmus fracture; angular malreduction; unsatisfactory reduction (fracture gap >5 mm); and treatment with single construct.Patients over the age of 20 with concomitant ipsilateral femoral neck and shaft fractures diagnosed at a level one medical center between 2003 and 2019 were included. Treatment modalities included single construct with/without an antirotational screw for the neck and dual constructs. Radiographic outcomes were assessed from anteroposterior and lateral hip radiographs at follow-up. Fisher exact test was used to analyze categorical variables. The presence of avascular necrosis of the femoral head, delayed union, atrophic or hypertrophic nonunion of the femoral shaft fracture, and loss of reduction were identified as factors related to treatment failure.A total of 22 patients were included in this study. The average age was 58.5 years, and the majority was male (68.2%). The minimum radiographic follow-up duration was 12 months, and the median follow-up time was 12 (interquartile range 12–24) months.Femoral neck osteosynthesis failed in 3 patients, whereas femoral shaft osteosynthesis failed in 12 patients. Fisher exact test demonstrated the failure of femoral shaft osteosynthesis was significantly more frequent in the single-construct cohort in 16 infra-isthmus femoral fracture cases (P = .034).In ipsilateral femoral neck and infra-isthmus shaft fractures, it is better to treat the neck and shaft fractures with separate implants (dual constructs).In a dual-construct cohort, separate plate fixation of the femoral shaft achieved a better result in terms of bone union than retrograde nailing of the shaft (bone union rate: 4/8 vs 0/2).     

Treatment of Severely Displaced Radial Neck Fractures in Children With Percutaneous K-wire Leverage and Closed Intramedullary Pinning

To evaluate the efficacy and safety of percutaneous K-wire leverage (PKWL) reduction and closed intramedullary pinning (CIMP) for the treatment of pediatric radial neck fractures.From June 2010 to December 2013, a total of 50 children with Judet III and IV radial neck fractures were treated at our hospital. Manual closed reduction was first attempted to reduce the radial neck fractures. Upon successful closed reduction or the radial neck–shaft angle was reduced to <45°, radial intramedullary pinning or CIMP was performed for fixation. Unsuccessful manual reduction was corrected using percutaneous K-wire leverage and CIMP. The injured arm was fixed at the functional position using plaster for 4 to 6 weeks.Sixteen patients were treated with manual closed reduction and CIMP (group A). Percutaneous K-wire leverage and CIMP were performed for 30 patients (group B). Another 4 patients were treated with open reduction and CIMP (group C). Groups B and C showed no significant difference in the radial neck–shaft angle, fracture displacement, and angle/displace ratio (P > 0.05), but were significantly larger than group A in the radial neck–shaft angle and fracture displacement (P < 0.05). Group A and B had significantly shorter operation time than group C (58.4 ± 14.5 minutes, 55.2 ± 11.2 minutes, versus 81.4 ± 7.5 minutes, P < 0.05). Forty-five patients were followed up for a mean of 2 years. Bone union was achieved in all patients within a mean time of 4.1 months. The patients treated with manual reduction or percutaneous leverage reduction showed excellent results. Three patients, however, treated with open reduction showed 10 to 20° limitation in range of motion of the elbow. No other complications were seen.Percutaneous K-wire leverage and CIMP are safe and effective for the treatment of pediatric Judet III and IV radial neck fractures.     

Factors affecting healing following percutaneous intramedullary fixation of metacarpal fractures

Although percutaneous intramedullary nailing of metacarpal fractures is a straightforward and reliable technique, it is not without complications, and patients experience different outcomes. This study analyzed factors affecting fracture healing time and complication rates in patients who underwent percutaneous intramedullary fixation of metacarpal fractures.This study was a retrospective review of the 25 patients who underwent retrograde percutaneous Kirschner wire (K-wire) nailing for fracture of the metacarpal shaft or neck at a military hospital between May 2016 and October 2018. Correlation study and multiple regression analysis were performed to evaluate variables (age, smoking history in pack-years, body-mass index, fracture site, number of K-wires used) that affect time to bone union. Clinical features of patients with metacarpal neck fractures and those with metacarpal shaft fractures were also compared.The metacarpal shaft fractures (as opposed to metacarpal neck fractures) and higher number of K-wire used were associated with longer time to bone union. Mean union time was significantly longer for metacarpal shaft fracture (8.6 weeks) than for metacarpal neck fracture (6.1 weeks) and for patients who received more K-wires than for those who received less (regression coefficient 1.307). One patient suffered fixation failure and required revision operation, and another experienced superficial infection which was treated with intravenous antibiotics.Percutaneous intramedullary nailing is an effective technique for metacarpal fractures, but fracture site and number of K-wire used affect time to achieve bone union.     

Three-Dimensional Reconstruction Modeling of the Spatial Displacement,Extent and Rotational Orientation of Undisplaced Femoral Neck Fractures

The purpose of this study was to employ a new three-dimensional (3D) reconstruction and modeling method to measure displacement of undisplaced femoral neck fractures (Garden stages I and II). We also aimed to evaluate the effectiveness of the Garden classification for determining the displacement of undisplaced femoral neck fractures.A total of 120 consecutive patients with undisplaced femoral neck fractures were enrolled between 2012 and 2014, including 60 within the Garden I group and 60 within the Garden II group. The displacements of the femoral head center (d1) and the lowest point of the fovea capitis femoris (d2) and rotational displacement of the femoral head (α) in the 3D model were measured with 3D computed tomography reconstruction and modeling. Five observers, trauma surgeons, were asked to found the centers of the femoral heads and the deepest points of the foveae. The intraobserver and inter-observer agreements were calculated using Fleiss’ kappa.The inter-observer and intra-observer kappa values were 0.937 and 0.985, respectively. Current method has good reliability. We discovered that many participants in our study had been misclassified by an anterior–posterior radiograph as having an “incomplete” fracture. In incomplete fracture of Garden stage I group, the average displacements d1 and d2 were 3.69 ± 1.77 mm and 14.51 ± 1.91 mm, respectively. The mean α was 4.91° ± 2.49°. For impacted fracture of Garden stage I, significant spatial displacement in the impacted fractures was observed (d1: 6.22 ± 3.36 mm; d2: 10.30 ± 5.73 mm; and α: 17.83° ± 10.72°). Similarly, significant spatial displacement was observed among the Garden stage II group (d1: 7.16 ± 4.58 mm; d2: 12.95 ± 8.25 mm; and α: 18.77° ± 9.10°). There was no significant difference in α, d1, and d2 between impacted fracture and Garden stage II groups (P > 0.05). However, significant differences were found between incomplete fracture and Garden stage II groups (P < 0.05).Our findings suggest that 3D reconstruction and modeling may be a better tool for assessing femoral neck fractures than the Garden classification. Undisplaced femoral neck fractures showed variable degrees of displacement and were not undisplaced, stable fractures. Garden classification for undisplaced femoral neck fractures has certain limitations.     

The risk assessment model of fracture nonunion after intramedullary nailing for subtrochanteric femur fracture

To investigate the influencing factors of fracture nonunion after intramedullary nailing for subtrochanteric fractures and to construct a risk assessment model.Based on the multicenter retrospective analysis of 251 patients, all patients were divided into modeling group and verification group. In the modeling group, postoperative fracture nonunion rate, general data, fracture-related factors, surgical reduction-related factors, mechanical and biological factors were calculated, and the influencing factors of fracture nonunion were screened by univariate analysis. Logistic regression model was used for multifactor analysis to construct the risk assessment model. Based on the logistic regression model, the risk prediction model was constructed by drawing the Nomogram diagram. Through the verification group, the influencing factors were evaluated again, and the differentiation and calibration of the model were evaluated. The calibration degree was evaluated by Hosmer-Lemeshow test, goodness of fit test, and calibration curve. The discriminant degree was evaluated by the receiver operating characteristic curve.Fracture nonunion occurred in 34 of 149 patients in the modeling group. Among the 14 potential influencing factors, univariate analysis and logistic regression analysis showed that postoperative hip varus, intramedullary nail fixation failure, and reduction of fracture with large incision were the risk factors of fracture nonunion. The medial cortex fracture was seen reduced on X-Ray was a protective factor for fracture nonunion, and a regression equation was established. Based on the logistic regression model, the Nomogram diagram is drawn. Twenty-four cases of fracture nonunion occurred in the verification group. The area under the receiver operating characteristic curve was area under curve =0.883 > 0.7, indicating that there was a moderate differentiation to evaluate the occurrence of fracture nonunion after operation. The goodness of fit test: the Hosmers-Lemeshow test (X² = 2.921, P = .712 > .05) showed that the model had a good calibration.After intramedullary nailing of subtrochanteric fracture, hip varus, failure of intramedullary nail fixation and wide surgical dissection are the risk factors of fracture nonunion, and the postoperative reduction of medial cortex fracture is protective factor.National key research and development projects: 2016YFC0105806     

Postoperative hypoalbuminemia is an independent predictor of 1-year mortality after surgery for geriatric intertrochanteric femoral fracture: A retrospective cohort study

Preoperative hypoalbuminemia from malnutrition is associated with increased morbidity and mortality after geriatric hip fracture surgery. However, little is known regarding the correlation between postoperative hypoalbuminemia and mortality. This study aimed to evaluate whether postoperative hypoalbuminemia could predict 1-year mortality after intertrochanteric femoral fracture surgery in elderly patients.The medical records of 263 geriatric patients (age ≥65 years) who underwent intertrochanteric femoral fracture surgery between January 2013 and January 2016 in a single hospital were reviewed retrospectively. The patients were allocated to 2 groups based on lowest serum albumin levels within 2 postoperative days (≥3.0 g/dL [group 1, n = 46] and <3.0 g/dL [group 2, n = 217]. Data between the non-survival and survival groups were compared. Multivariable logistic regression analysis was conducted to identify the independent predictor for 1-year mortality.The 1-year mortality rate was 16.3% after intertrochanteric femoral fracture surgery. Multivariable logistic regression analysis revealed that postoperative hypoalbuminemia was significantly associated with 1-year mortality (adjusted odds ratio, 8.03; 95% confidence interval, 1.37-47.09; P = .021). The non-survival group showed a significantly increased incidence of postoperative hypoalbuminemia (95.4% vs 80.0%, P = .015) and intensive care unit admission (11.6% vs 2.7%, P = .020), older age (82.5 ± 5.8 years vs 80.0 ± 7.2 years, P = .032), lower body mass index (20.1 ± 3.2 kg/m² vs 22.4 ± 3.8 kg/m², P < .001), and increased amount of transfusion of perioperative red blood cells (1.79 ± 1.47 units vs 1.43 ± 2.08 units, P = .032), compared to the survival group.This study demonstrated that postoperative hypoalbuminemia is a potent predictor of 1-year mortality in geriatric patients undergoing intertrochanteric femoral fracture surgery. Therefore, exogenous albumin administration can be considered to improve postoperative outcomes and reduce the risk of mortality after surgery for geriatric hip fracture.     

Behavior of Small,Asymptomatic, Nonfunctioning Pancreatic Neuroendocrine Tumors (NF-PNETs)

Small nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) usually exhibit minimal or no growth over many years. However, there is a controversy regarding the optimal management of incidentally discovered, small NF-PNETs. This study aimed to gain insights into tumor behavior and potential strategies for clinical management.We retrospectively reviewed a total of 202 patients with a suspected PNET (size 2 cm or smaller) at Samsung Medical Center from January 1, 1995 to April 30, 2012. Among these patients, 72 patients were excluded and 145 patients were enrolled in our study. Patients were included if the size of the tumor was ≤2 cm without familial syndrome, radiographic evidence of local invasion or metastases.Among the 145 patients, 76 patients (52.4%) had pathologically confirmed PNETs. Eleven (14.5%) and 3 (3.9%) of these 76 patients were diagnosed with NET G2 and G3, respectively. PNETs measuring 1.5 cm or more in size had a higher probability of being classified as NET G2 or G3 compared with PNETs measuring <1.5 cm (P = 0.03). Older age (≥55 years) and a meaningful tumor growth (≥20% or ≥5 mm) were significantly associated with NET G2 or G3 (P < 0.05).Older age (≥55 years), larger tumor size (≥1.5 cm), and a meaningful tumor growth (≥20% or ≥5 mm) were associated with NET G2 or G3. Intensive follow-up could be an acceptable approach in small (especially <1.5 cm), asymptomatic, NF-PNETs.     

The risk factors of gestational diabetes mellitus in patients with polycystic ovary syndrome: What should we care

The influencing factors of gestational diabetes mellitus (GDM) in the polycystic ovary syndrome (PCOS) patients remain unclear, we aimed to investigate the risk factors of GDM in patients with PCOS, to provide reliable evidence for the prevention and treatment of GDM in PCOS patients.PCOS patients treated in our hospital from January 1, 2019 to October 31, 2020 were included. The personal and clinical treatment details of GDM and no GDM patients were analyzed. Logistic regressions were performed to analyze the factors influencing the occurrence of GDM.A total of 196 PCOS patients were included, the incidence of GDM in patients with PCOS was 23.98%. There were significant differences in the age, body mass index, insulin resistance index, fasting insulin, testosterone, androstenedione, and sex hormone-binding protein between GDM and no GDM patients with PCOS (all P < .05), and no significant differences in the family history of GDM, the history of adverse pregnancy, and multiple pregnancies were found (all P > .05). Age ≥30 years (odds ratio (OR) 2.418, 95% confidence interval (CI) 1.181–3.784), body mass index ≥24 kg/m² (OR 1.973, 95%CI 1.266–3.121), insulin resistance index ≥22.69 (OR 2.491, 95%CI 1.193–4.043), fasting insulin ≥22.71 mIU/L (OR 2.508, 95%CI 1.166–5.057), testosterone ≥2.85 nmol/L (OR 1.821, 95%CI 1.104–2.762), androstenedione ≥6.63 nmol/L (OR 1.954, 95%CI 1.262–2.844), sex hormone-binding protein <64.22 nmol/L (OR 1.497, 95%CI 1.028–2.016) were the independent risk factors of GDM in patients with PCOS (all P < .05). The incidence of preeclampsia, premature delivery, premature rupture of membranes, polyhydramnios, and postpartum hemorrhage in the GDM group was significantly higher than that of the no-GDM group (all P < .05). There was no significant difference in the incidence of oligohydramnios between the 2 groups (P = .057).The incidence of GDM in PCOS patients is high, and the measures targeted at the risk factors are needed to reduce the occurrence of GDM in patients with PCOS.     

Risk Factors for Carotid Artery Stenosis in Chinese Patients Undergoing Coronary Artery Bypass Graft Interventions

Current guidelines established in the USA and Europe for coronary artery bypass graft (CABG) suggest that patients ≥65 and ≥70 years of age, or with certain atherosclerotic-risk factors, should be screened preoperatively for extracranial carotid artery stenosis (CAS) to assess their risk of perioperative stoke. We sought factors that should be taken into consideration when treating Chinese CABG patients using CABG guidelines based on an analysis of CAS in a large cohort of Chinese CABG patients.We analyzed data for 1558 Chinese CABG patients who were screened preoperatively for CAS using duplex ultrasonography at a single institution. We defined significant and severe CAS as ≥50% and ≥70% stenosis, respectively, in one or more common or internal carotid arteries. We investigated the prevalence of CAS, the incidence of perioperative stroke, and the risk factors for CAS in the CABG cohort.The prevalence of CAS in the CABG cohort was 21.2%. Multivariate stepwise logistic regression analysis showed that an age ≥50 years and a history of smoking (odds ratios = 8.36 and 1.83, respectively) were independent risk factors for CAS (P < 0.05 for both). The incidence of perioperative stroke among CABG patients with significant or severe CAS was significantly higher (2.4% and 2.9%, respectively) than in CABG patients with <50% stenosis (0.5%; P = 0.004 and 0.029, respectively).Chinese CABG patients with a history of smoking or ≥50 years of age should undergo preoperative screening for CAS to assess their risk of perioperative stroke.     

Retrospective Comparison of Fludarabine in Combination With Intermediate-Dose Cytarabine Versus High-Dose Cytarabine As Consolidation Therapies for Acute Myeloid Leukemia

This retrospective study compared efficacy and safety of fludarabine combined with intermediate-dose cytarabine (FA regimen) versus high-dose cytarabine (HiDAC regimen) as consolidation therapy in acute myeloid leukemia (AML) patients who achieved complete remission.Disease-free survival (DFS) and overall survival (OS) based on age (≥60, <60 years) and cytogenetics were evaluated from data between January 2005 and March 2013.Total 82 patients (FA, n = 45; HiDAC, n = 37; 14–65 years) were evaluated. Five-year DFS was 32.0% and 36.2% for FA and HiDAC groups, respectively (P = 0.729), and 5-year OS was 39.5% and 47.8% (P = 0.568), respectively. Among older patients (≥60 years), 3-year DFS was 26.0% for FA group and 12.5% for HiDAC group (P = 0.032), and 3-year OS was 34.6% and 12.5%, respectively (P = 0.026). In FA group, hematological toxicities were significantly lower. FA regimen was as effective as HiDAC regimen in patients with good/intermediate cytogenetics and significantly improved DFS and OS in older patients.     

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences

Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938–3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.     

Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune,Western India

Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials.     

Intensive care unit model and in-hospital mortality among patients with severe sepsis and septic shock: A secondary analysis of a multicenter prospective observational study

We aimed to determine the association between the intensive care unit (ICU) model and in-hospital mortality of patients with severe sepsis and septic shock.This was a secondary analysis of a multicenter prospective observational study conducted in 59 ICUs in Japan from January 2016 to March 2017. We included adult patients (aged ≥16 years) with severe sepsis and septic shock based on the sepsis-2 criteria who were admitted to an ICU with a 1:2 nurse-to-patient ratio per shift. Patients were categorized into open or closed ICU groups, according to the ICU model. The primary outcome was in-hospital mortality.A total of 1018 patients from 45 ICUs were included in this study. Patients in the closed ICU group had a higher severity score and higher organ failure incidence than those in the open ICU group. The compliance rate for the sepsis care 3-h bundle was higher in the closed ICU group than in the open ICU group. In-hospital mortality was not significantly different between the closed and open ICU groups in a multilevel logistic regression analysis (odds ratio = 0.83, 95% confidence interval; 0.52–1.32, P = .43) and propensity score matching analysis (closed ICU, 21.2%; open ICU, 25.7%, P = .22).In-hospital mortality between the closed and open ICU groups was not significantly different after adjusting for ICU structure and compliance with the sepsis care bundle.     

Cardiovascular Risk Factors Increase the Risks of Diabetic Peripheral Neuropathy in Patients With Type 2 Diabetes Mellitus: The Taiwan Diabetes Study

This study aimed to examine whether poor glycemic control, measured by glycated hemoglobin A1C (HbA1c) and other cardiovascular risk factors, can predict diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (DM).Patients aged ≥30 years with type 2 DM, enrolled in the National Diabetes Care Management Program, and free of DPN (n = 37,375) in the period 2002 to 2004 were included and followed up until 2011. The related factors were analyzed using Cox proportional hazards regression models.For an average follow-up of 7.00 years, 8379 cases of DPN were identified, with a crude incidence rate of 32.04/1000 person-years. After multivariate adjustment, patients with HbA1c levels 7 to 8%, 8 to 9%, 9 to 10%, and ≥10% exhibited higher risk of DPN (adjusted HR: 1.11 [1.04–1.20], 1.30 [1.21–1.40], 1.32 [1.22–1.43], and 1.62 [1.51–1.74], respectively) compared with patients with HbA1c level 6 to 7%. There was a significant linear trend in DPN incidence with increasing HbA1c (P < 0.001) and significant HRs of DPN for patients with HbA1c level ≥7%, blood pressure ≥130/85 mm Hg, triglycerides (TG) ≥150 mg/dL, high density of lipoprotein-cholesterol (HDL-C) <40 mg/dL in males and <50 mg/dL in females, low density of lipoprotein-cholesterol (LDL-C) ≥100 mg/dL, and estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m².Patients with type 2 DM and HbA1c ≥7.0% exhibit increased risk of DPN, demonstrating a linear relationship. The incidence of DPN is also associated with poor glucose control and cardiovascular risk factors like hypertension, hyper-triglyceridemia, low HDL-C, high LDL-C, and decreased eGFR.     

Risk factors and nursing countermeasures of postoperative pulmonary infection in patients with breast cancer: A retrospective analysis

It is necessary to elucidate the potential risk factors of pulmonary infection to provide references for the management of breast cancer.Our study was a retrospective design, patients who underwent modified radical mastectomy for breast cancer in our department of breast surgery from January 2019 to November 2020 were included. The personal and clinical data of included patients with and without pulmonary infection were compared.A total of 234 patients with radical mastectomy were included, the incidence of pulmonary infection was 15.38% with 95%confidence interval (CI) 11.42% to 18.98%. There were significant differences in the age, body mass index, diabetes, duration of surgery, combined radiotherapy and chemotherapy, and duration of drainage between patients with and without pulmonary infections (all P < .05). Logistic regression analysis indicated that age ≥55 years (odds ratio [OR] 2.128, 95%CI 1.105–3.426), body mass index ≥ 24 kg/m²(OR 2.344, 95%CI 1.031–3.299), diabetes (OR 2.835, 95%CI 1.132–4.552), duration of surgery ≥120 minutes (OR 1.394, 95%CI 1.012–1.044), combined radiotherapy and chemotherapy (OR 3.122, 95%CI 1.124–5.273), duration of drainage ≥5 days (OR 1.851, 95%CI 1.112–2.045) might be the independent risk factors of pulmonary infection in patients after radical mastectomy(all P < .05). Pseudomonas aeruginosa and Klebsiella pneumoniae are the most commonly seen bacteria.The incidence of postoperative pulmonary infections in breast cancer patients is high, and there are many associated risk factors. The perioperative management of patients should be strengthened targeted on those risk factors in clinical practice.     

Different patterns of tibial plateau fractures associated with hyperextension injuries of the knee with or without varus/valgus component

This study aims to introduce a morphological classification of hyperextension tibial plateau fractures based on CT scans and to reveal the correlation between the anterior compression and posterior tension fractures.From January 2015 to January 2019, 37 patients with hyperextension tibial plateau fractures were studied retrospectively. Based on this classification, the fractures were divided into 2 groups: group A had anterolateral or anteromedial compression fractures while group B had both. Three observers classified the fractures and recorded the morphology and incidences of posterior plateau fractures and proximal fibular fractures.All 37 fractures were allocated to group A (n = 15; 40%) and B (n = 22; 60%). Of the posterior tibial plateau fractures, 10 (27%) fractures were defined as partial and 27 (73%) as total. Of the 37 fractures, 18 (49%) proximal fibular avulsion fractures were observed. There was a significant difference between groups A and B regarding the incidence of total posterior tibial plateau fractures (P < .05). However, there was no significant difference between the incidence of proximal fibular avulsion fractures in the 2 groups or the combined and non-combined type fractures in group B (P > .05).Hyperextension tibial plateau fractures with a decreased posterior slope angle always involve both the anteromedial and anterolateral plateaus. This CT-based classification may improve the understanding of fracture features and is helpful for planning treatment.     

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation

BackgroundTo evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).MethodsBetween January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.ResultsAfter propensity score matching, the patients’ characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.ConclusionsFemoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.     

CHA2DS2-VASc score predicts the slow flow/no-reflow phenomenon in ST-segment elevation myocardial infarction patients with multivessel disease undergoing primary percutaneous coronary intervention

ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) have a higher incidence of slow-flow/no-reflow (SF-NR) phenomenon during primary percutaneous coronary intervention (PPCI) than those with single vessel disease. Currently, no effective tools exist to predict the risk of SF-NR in this population. The present study aimed to evaluate whether CHA₂DS₂-VASc score can be used as a simple tool to predict this risk.This study consecutively included STEMI patients hospitalized in Beijing Anzhen Hospital from January 2005 to January 2015. Among these patients, 1032 patients with MVD were finally enrolled. Patients were divided into SF-NR (+) group and SF-NR (–) group according to whether SF-NR occurred during PPCI. SF-NR was defined as the thrombolysis in myocardial infarction (TIMI) grade ≤2.There were 134 patients (13%) in the SF-NR (+) group. Compared with the SF-NR (–) group, patients in the SF-NR (+) group are elder, with lower left ventricular ejection fraction and higher CHA₂DS₂-VASc score. Multiple logistic regression analysis indicated that CHA₂DS₂-VASc score ≥3 (odds ratio [OR], 2.148; 95% confidence interval [CI], 1.389–3.320; P = .001), current smoking (OR, 1.814; 95% CI, 1.19–2.764; P = .006), atrial fibrillation (OR, 2.892; 95% CI, 1.138–7.350; P = .03), complete revascularization (OR, 2.307; 95% CI, 1.202–4.429; P = .01), and total length of stents ≥40 mm (OR, 1.482; 95% CI, 1.011–2.172; P = .04) were independent risk factors of SF-NR. The incidence of SF-NR in patients with CHA₂DS₂-VASc score ≥3 was 1.7 times higher than that in patients with CHA₂DS₂-VASc score <3. Additionally, patients with CHA₂DS₂-VASc score ≥3 plus ≥2 risk factors have 3 times higher incidence of SF-NR than those with CHA₂DS₂-VASc score ≥3 plus 0 to 1 risk factor.CHA₂DS₂-VASc score ≥3 can be used as a simple and sensitive indicator to predict SF-NR phenomenon and guide the PPCI strategy in STEMI patients with MVD.     

Better discrimination of the concomitant peri-ankle fractures in the spiral tibial shaft fractures by thin-slice axial and three-dimensional CT

The objective of this study was to examine the morphologic features of spiral tibial shaft as well as concomitant fibular and peri-ankle fractures on multidetector high-resolution CT and to speculate about the mechanisms underlying these combined fractures.This is a retrospective cohort study. A total of 197 tibial shaft fractures underwent multidetector high-resolution CT before intramedullary nailing. The presence and location of peri-ankle fractures were recorded using thin-slice axial CT. Tibial shaft fractures were classified as spiral or non-spiral. The morphologies of spiral tibial fractures and concomitant lateral malleolar fractures were delineated using three-dimensional CT.Seventy-five spiral and 122 non-spiral fractures were identified. Peri-ankle fractures excluding lateral malleolar fractures were found in 77.3% of spiral fractures and 18.9% of non-spiral fractures. The most frequent location of peri-ankle fractures in the spiral group was the posterior malleolus, followed by the anterolateral distal tibia, while the medial malleolus was the most frequent site in the non-spiral group. Of 75 spiral fractures, 72 showed a fracture morphology attributed to external rotation force. There were 13 lateral malleolar fractures that were defined as within 6 cm from the distal end of the fibula. No lateral malleolar fractures showed the typical morphology of isolated supination/external rotation-type ankle injuries. The displaced syndesmotic injuries commonly coexisting in pronation/external rotation-type ankle injuries were not observed.Most spiral tibial shaft fractures were caused by external rotation force. However, the morphology of concomitant peri-ankle fractures was inconsistent with typical mechanisms of isolated external rotation ankle injuries.     

Association of Admission Glycaemia With High Grade Atrioventricular Block in ST-Segment Elevation Myocardial Infarction Undergoing Reperfusion Therapy: An Observational Study

Several studies have demonstrated the association between elevated admission glycaemia (AG) and the occurrence of some arrhythmias such as atrial fibrillation, ventricular tachycardia, and ventricular fibrillation after myocardial infarction. However, the impact of elevated AG on the high grade atrioventricular block (AVB) occurrence after ST-segment elevation myocardial infarction (STEMI) remains unclear.Included were 3359 consecutive patients with STEMI who received reperfusion therapy. The primary endpoint was the development of high grade AVB during hospital course. Patients were divided into non-diabetes mellitus (DM), newly diagnosed DM, and previously known DM according to the hemoglobin A1c level. The optimal AG value was determined by receiver operating characteristic curves analysis with AG predicting the high grade AVB occurrence.The best cut-off value of AG for predicting the high grade AVB occurrence was 10.05 mmol/L by ROC curve analysis. The prevalence of AG ≥ 10.05 mmol/L in non-DM, newly diagnosed DM, and previously known DM was 15.7%, 34.1%, and 68.5%, respectively. The incidence of high grade AVB was significantly higher in patients with AG ≥ 10.05 mmol/L than <10.05 mmol/L in non-DM (5.7% vs. 2.1%, P < 0.001) and in newly diagnosed DM (10.2% vs.1.4%, P < 0.001), but was comparable in previously known DM (3.6% vs. 0.0%, P = 0.062). After multivariate adjustment, AG ≥ 10.05 mmol/L was independently associated with increased risk of high grade AVB occurrence in non-DM (HR = 1.826, 95% CI 1.073–3.107, P = 0.027) and in newly diagnosed DM (HR = 5.252, 95% CI 1.890–14.597, P = 0.001). Moreover, both AG ≥ 10.05 mmol/L and high grade AVB were independent risk factors of 30-day all cause-mortality (HR = 1.362, 95% CI 1.006–1.844, P = 0.046 and HR = 2.122, 95% CI 1.154–3.903, P = 0.015, respectively).Our study suggested that elevated AG level (≥10.05 mmol/L) might be an indicator of increased risk of high grade AVB occurrence in patients with STEMI.