Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to ...complications.
To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases.
Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs).
Time elapsed from hospital arrival to surgery (in hours).
Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia).
Among 42 230 patients with hip fracture (mean SD age, 80.1 years 10.7, 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 6.5% vs 790 5.8%; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 12.2%) vs 1383 10.1%; % absolute RD, 2.16; 95% CI, 1.43-2.89).
Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.
The Septuagint is the most influential of the Greek versions of the Torah, the first five books of the Hebrew Bible. The exact circumstances of its creation are uncertain, but different versions of a ...legend about the miraculous nature of the translation have existed since antiquity. Beginning in the Letter of Aristeas, the legend describes how Ptolemy Philadelphus commissioned seventy-two Jewish scribes to translate the sacred Hebrew scriptures for his famous library in Alexandria. Subsequent variations on the story recount how the scribes, working independently, produced word-for-word, identical Greek versions. In the course of the following centuries, to our own time, the story has been adapted and changed by Jews, Christians, Muslims and pagans for many different reasons: to tell a story, to explain historical events and to lend authority to the Greek text for the institutions that used it. This book offers the first account of all of these versions over the last two millennia, providing a history of the uses and abuses of the legend in various cultures around the Mediterranean.
Purpose To systematically review the available evidence for arthroscopic repair of chronic massive rotator cuff tears and identify patient demographics, pre- and post-operative functional ...limitations, reparability and repair techniques, and retear rates. Methods Medline, Embase, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched to identify all clinical papers describing arthroscopic repair of chronic massive rotator cuff tears. Papers were excluded if a definition of “massive” was not provided, if the definition of “massive” was considered inappropriate by agreement between the 2 reviewers, or if patients with smaller tears were also included in the study population. Study quality and clinical outcome data were pooled and summarized. Results There were 18 papers that met the eligibility criteria; they involved 954 patients with a mean age of 63 (range, 37 to 87), 48% of whom were female. There were 5 prospective and 13 retrospective study designs. The overall study quality was poor according to the Modified Coleman Methodology Score. Of the 954 repairs, 81% were complete repairs and 19% were partial repairs. The follow-up range was between 33 and 52 months, and the mean duration between symptom onset and surgery was 24 months. Single-row repairs were performed in 56% or patients, and double-row repairs were performed in 44%. A pooled analysis demonstrated an improvement in visual analog scale from 5.9 to 1.7, active range of motion from 125° to 169°, and the Constant-Murley score from 49 to 74. The pooled retear rate was 79%. Conclusions Arthroscopic repair of chronic massive rotator cuff tears is associated with complete repair in the majority of cases and consistently improves pain, range of motion, and functional outcome scores; however, the retear rate is high. Existing research on massive rotator cuff repair is limited to poor- to fair-quality studies. Level of Evidence Level IV, systematic review including Level IV studies.
Purpose To (1) define the cumulative recurrence rate after primary anterior shoulder dislocation in Level I and II comparative studies and (2) to pool risk ratios for common risk factors to provide a ...clinically practical hierarchy of modifiable and nonmodifiable risk factors for recurrence. Methods Level I and II prognostic studies were identified using the electronic databases CINAHL, Embase, and MEDLINE from inception to December 2014. Included studies (n = 15) had recurrent dislocation as the main outcome, and a minimum 2-year follow-up. The cumulative odds ratio of prognostic factors was calculated where appropriate. Bias was assessed in each study using the Quality in Prognosis Studies (QUIPS) tool. Results The reported rate of recurrence ranged from 19% to 88% (pooled overall = 21%; pooled Level I only = 47%). The pooled time to recurrence was 10.8 months (standard deviation 0.42). Male sex (n = 6 studies) conferred a 2.68 (1.66-4.31; P < .001) and patient age <20 years (n = 4 studies) conferred a 12.76 (5.77-28.2; P < .001; v >20 years) increased odds of recurrence. An associated greater tuberosity fracture (n = 7 studies) decreased the odds of recurrence by 3.8 times (2.94-5.00; P < .001). The quality of evidence was moderate for age, low for sex, and very low for all other prognostic variables. Conclusions The pooled rate of recurrence after primary anterior shoulder instability was found to be 21% among moderate- to high-quality prognostic studies. Male sex and younger age predicted a significantly higher risk of recurrent instability (approaching 80%), whereas concurrent fracture of the greater tuberosity significantly decreased the risk of subsequent recurrent dislocation. However, considering the quality of available evidence for these predictors, there remains a clear need for further high-quality prospective studies. Level of Evidence Level II, systematic review of Level I and II prognostic studies.
A medieval Islam historian's incisive portrait of ISIS,
revealing the group's deep ideological and intellectual roots in
the earliest days of Islam With tremendous speed, the
Islamic State has moved ...from the margins to the center of life in
the Middle East. Despite recent setbacks, its ability to conquer
and retain huge swaths of territory has demonstrated its skillful
tactical maneuvering, ambition, and staying power. Yet we still
know too little about ISIS, particularly about its deeper ideology.
In this eye-opening book, David J. Wasserstein offers a penetrating
analysis of the movement, looking closely at the thousand-year-old
form of Islamic apocalyptic messianism the group draws upon today.
He shows how ISIS is not only a military and political movement but
also, and primarily, a religious one with a coherent worldview, a
patent strategy, and a clear goal: the re-creation of a medieval
caliphate. Connecting the group's day-to-day activities and the
writings and sayings of its leaders with the medieval Islamic past,
Wasserstein provides an insightful and unprecedented perspective on
the origins and aspirations of the Islamic State.
Background:
There is a lack of high-quality population-based literature describing the epidemiology of primary anterior shoulder dislocation.
Purpose:
To (1) calculate the incidence density rate ...(IDR) of primary anterior shoulder dislocation requiring closed reduction (CR; “index event”) in the general population and demographic subgroups, and (2) determine the rate of and risk factors for repeat shoulder CR.
Study Design:
Cohort study (prognosis); Level of evidence, 2.
Methods:
All patients who underwent shoulder CR by a physician in Ontario between April 2002 and September 2010 were identified with administrative databases. Exclusion criteria included age <16 and >70 years, posterior dislocation, and prior shoulder dislocation or surgery. Index event IDR was calculated for all populations/subgroups, and IDR comparisons were made. Repeat shoulder CR was sought until September 2012. Risk factors for repeat shoulder CR were identified with a Prentice, Williams, and Peterson proportional hazards model.
Results:
There were 20,719 persons (median age, 35 years; 74.3% male) who underwent a shoulder CR after a primary anterior shoulder dislocation (23.1/100,000 person-years). The IDR was highest among young males (98.3/100,000 person-years). A total of 3940 (19%) patients underwent repeat shoulder CR after a median of 0.9 years, of which 41.7% were ≤20 years of age. Less than two-thirds of all first repeat shoulder CR events occurred within 2 years; in fact, 95% occurred within 5 years. The risk of repeat shoulder CR was lowest if the primary reduction had been performed by an orthopaedic surgeon (hazard ratio HR, 0.76; 95% CI: 0.64, 0.90; P = .002) or was associated with a humeral tuberosity fracture (HR, 0.71; CI, 0.53, 0.95; P = .02). Older age (HR, 0.97; CI, 0.97, 0.98; P < .0001) and higher medical comorbidity score (HR, 0.92; CI, 0.87, 0.98; P = .009) were also protective. Risk was highest among males (HR, 1.26; CI, 1.16, 1.36; P < .0001) and patients from low-income neighborhoods (HR, 1.23; CI, 1.13, 1.34; P < .0001).
Conclusion:
Young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. Patient, provider, and injury factors all influence repeat shoulder CR risk. A comprehensive understanding of the epidemiology of primary anterior shoulder dislocation will aid management decisions and injury prevention initiatives.
Purpose The purpose of this systematic review was to synthesize the available Level I and Level II literature on platelet-rich plasma (PRP) as a therapeutic intervention in the management of ...symptomatic knee osteoarthritis (OA). Methods A systematic review of Medline, Embase, Cochrane Central Register of Controlled Trials, PubMed, and www.clinicaltrials.gov was performed to identify all randomized controlled trials and prospective cohort studies that evaluated the clinical efficacy of PRP versus a control injection for knee OA. A random-effects model was used to evaluate the therapeutic effect of PRP at 24 weeks by use of validated outcome measures (Western Ontario and McMaster Universities Arthritis Index, visual analog scale for pain, International Knee Documentation Committee Subjective Knee Evaluation Form, and overall patient satisfaction). Results Six Level I and II studies satisfied our inclusion criteria (4 randomized controlled trials and 2 prospective nonrandomized studies). A total of 577 patients were included, with 264 patients (45.8%) in the treatment group (PRP) and 313 patients (54.2%) in the control group (hyaluronic acid HA or normal saline solution NS). The mean age of patients receiving PRP was 56.1 years (51.5% male patients) compared with 57.1 years (49.5% male patients) for the group receiving HA or NS. Pooled results using the Western Ontario and McMaster Universities Arthritis Index scale (4 studies) showed that PRP was significantly better than HA or NS injections (mean difference, −18.0 95% confidence interval, −28.8 to −8.3; P < .001). Similarly, the International Knee Documentation Committee scores (3 studies) favored PRP as a treatment modality (mean difference, 7.9 95% confidence interval, 3.7 to 12.1; P < .001). There was no difference in the pooled results for visual analog scale score or overall patient satisfaction. Adverse events occurred more frequently in patients treated with PRP than in those treated with HA/placebo (8.4% v 3.8%, P = .002). Conclusions As compared with HA or NS injection, multiple sequential intra-articular PRP injections may have beneficial effects in the treatment of adult patients with mild to moderate knee OA at approximately 6 months. There appears to be an increased incidence of nonspecific adverse events among patients treated with PRP. Level of evidence Level II, systematic review of Level I and II studies.
Postoperative delirium in older adults receiving hip fracture surgery is associated with morbidity and increased health care costs, yet little is known of potential modifiable factors that may help ...limit the risks.
To use population-wide individual-level data on the duration of hip fracture surgery to determine whether prolonged surgical times and type of anesthesia are associated with an increased risk of postoperative delirium.
This retrospective population-based cohort study analyzed patients aged 65 years and older receiving hip fracture surgery between April 1, 2009, and March 30, 2017, at 80 hospitals in Ontario, Canada. Generalized estimated equations with logistic regression analysis were used to determine the relationship between procedure duration, type of anesthesia, and the occurrence of postoperative delirium. Restricted cubic splines were also generated to visualize this relationship. Data analysis was conducted from July to October 2018, revision in January 2019.
Surgery duration, measured as the total time in the operating room.
A diagnosis of postoperative delirium during hospitalization.
Among 68 131 patients with surgically managed hip fracture (median interquartile range age, 84 78-89 years; 72% women) identified, 7150 patients experienced postoperative delirium. In total, 26 853 patients (39.4%) received general anesthesia. Receiving general anesthesia was associated with a slightly higher rate of postoperative delirium compared with not receiving general anesthesia (2943 11.0% vs 4207 10.2%; P = .001). The risk for delirium increased with increased surgical duration-every 30-minute increase in the duration of surgery was associated with a 6% increase in the risk for delirium (adjusted odds ratio, 1.06; 95% CI, 1.03-1.08; P < .001). Prolonged surgical duration was associated with a higher incidence of postoperative delirium, and the risk was higher was in patients who had received general anesthesia (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; P < .001) than in those patients who did not receive GA (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08; P = .01).
Among older adults receiving hip fracture surgery, both an increased duration of surgery and receiving a general anesthetic were associated with an increased risk for postoperative delirium.
The deposition of the last Umayyad, Hishām III al-Mu‘tadd, in Cordoba in 1031 and the banishment of all members of the Umayyad family from the city marked the end of the political unity of the ...peninsula as that had been understood and as it had been since the conquest of 711. It also left a void in the practical and the theoretical aspects of political legitimacy in al-Andalus. Who should be caliph? What did being caliph now mean? What models emerged to legitimize the holding and wielding of ...
The article discusses an autobiographical passage in the life of al-Ṭurṭūshī (ca. 451/1059-520/1126, or Jumādā I 525/April 1131) contained in the Siyar A'lām al-Nubalā' of alDhahabī ...(673/1274-748/1348). The text reports a remarkable set of meteorological phenomena during al-Ṭurṭūshī's visit to Baghdad in 478/1085-86. Fierro interpreted the story as a description of an eclipse, and as lying at the origin of al-Ṭurṭūshī's turn to asceticism, paralleling a similar story about the earlier Muḥammad Iḅn Waḍḍāḥ. I show here, based on astronomical records, that there was no eclipse at that time in Baghdad, consequently that what al-Ṭurṭūshī experienced could not have been one. Further, al-Ṭurṭūshī did not understand it as having been one. It could not, therefore, have been the cause of his turn to asceticism. The description points more naturally instead to a dust-storm, or simoom. There is therefore no link, literary or other, between this aspect of the life of alṬurṭūshī and that of Muḥammad Iḅn Waḍḍāḥ.
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