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In the article entitled "Intraoperative cerebral oximetry-based management for optimizing perioperative outcomes: a meta-analysis of randomized controlled trials" Can J Anesth 2018; 65: 529-42, we wish to clarify the following items.
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OBJECTIVE: To determine factors associated with nonunion of adult tibial fractures. DESIGN: Retrospective review with data collection for logistic regression and survival analysis. SETTING: Scottish Level I trauma center, 1985-2007. PATIENTS: During this period, 1590 adult tibial fractures were treated by reamed nailing and 1003 fractures met all inclusion criteria for the chosen analysis. INTERVENTION: Reamed intramedullary nailing. MAIN OUTCOME MEASURES: Record of nonunion diagnosis and final union time with characteristics, including age, gender, closed or open injury, OTA/AO classification, Gustilo classification, fasciotomy, infection, polytrauma, smoking, and injury severity score. RESULTS: The overall nonunion rate was 12%, and median time to healing was 18 weeks. Age significantly influenced nonunion, with middle-aged patients at highest risk. Both fracture type (closed/open) and morphology (OTA/AO classification) significantly influenced nonunion risk and time to union. Among closed injuries, the highest nonunion rate was for OTA/AO type B fractures (15%). Among open injuries, the highest nonunion rate was for OTA/AO type C (61%). Both compartment syndrome and smoking did not significantly influence nonunion risk but did significantly extend time to union. CONCLUSIONS: Injury characteristics including fracture morphology and severity of soft tissue injury were strong predictors of compromised fracture healing. Age also influenced nonunion risk in an unexpected way, with highest rates in the middle decades of adulthood. Future studies should consider the possibility of similar age-related effects and clinical studies should seek to identify explanations for why this may arise, including both physiological and socio-behavioral factors. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fixação Intramedular de Fraturas/efeitos adversos , Consolidação da Fratura/fisiologia , Fraturas não Consolidadas/cirurgia , Reoperação/métodos , Fraturas da Tíbia/cirurgia , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Feminino , Seguimentos , Fixação Intramedular de Fraturas/métodos , Fraturas não Consolidadas/diagnóstico por imagem , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fraturas da Tíbia/diagnóstico por imagem , Fatores de Tempo , Centros de Traumatologia , Reino UnidoRESUMO
PURPOSE: Although evidence from observational studies in a variety of clinical settings supports the utility of cerebral oximetry as a predictor of outcomes, prospective clinical trials thus far have reported conflicting results. This systematic review and meta-analysis was designed to evaluate the influence of management associated with intraoperative cerebral oximetry on postoperative outcomes. The primary outcome was postoperative cognitive dysfunction (POCD), with secondary outcomes that included postoperative delirium, length of intensive care unit (ICU) stay, and hospital length of stay (LOS). SOURCE: After searching the PubMed, EMBASE, Cochrane Library, Scopus, and Google Scholar databases, all randomized controlled trials (RCTs) assessing the impact of intraoperative cerebral oximetry-guided management on clinical outcomes following surgery were identified. PRINCIPAL FINDINGS: Fifteen RCTs comprising 2,057 patients (1,018 in the intervention group and 1,039 in control group) were included. Intraoperative management guided by the use of cerebral oximetry was associated with a reduction in the incidence of POCD (risk ratio [RR] 0.54; 95% confidence interval [CI], 0.33 to 0.90; P = 0.02; I2 = 85%) and a significantly shorter length of ICU stay (standardized mean difference [SMD], -0.21 hr; 95% CI, -0.37 to -0.05; P = 0.009; I2 = 48%). In addition, overall hospital LOS (SMD, -0.06 days; 95% CI, -0.18 to 0.06; P = 0.29; I2 = 0%) and incidence of postoperative delirium (RR, 0.69; 95% CI, 0.36 to 1.32; P = 0.27; I2 = 0%) were not impacted by the use of intraoperative cerebral oximetry. CONCLUSIONS: Intraoperative cerebral oximetry appears to be associated with a reduction in POCD, although this result should be interpreted with caution given the significant heterogeneity in the studies examined. Further large (ideally multicentre) RCTs are needed to clarify whether POCD can be favourably impacted by the use of cerebral oximetry-guided management.
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Disfunção Cognitiva/prevenção & controle , Oximetria , Complicações Pós-Operatórias/prevenção & controle , Delírio/prevenção & controle , Humanos , Unidades de Terapia Intensiva , Período Intraoperatório , Tempo de Internação , Garantia da Qualidade dos Cuidados de Saúde , Ensaios Clínicos Controlados Aleatórios como AssuntoAssuntos
Humanos , Masculino , Feminino , Adulto , Fraturas Ósseas/classificação , Fraturas Ósseas/epidemiologia , Ortopedia , TraumatologiaRESUMO
A largely unanswered question in the study of arboviruses is the extent to which virus can overwinter in adult vectors during the cold winter months and resume the transmission cycle in summer. Buggy Creek virus (BCRV; Togaviridae, Alphavirus) is an unusual arbovirus that is vectored primarily by the swallow bug (Hemiptera: Cimicidae: Oeciacus vicarius) and amplified by the ectoparasitic bug's main avian hosts, the migratory cliff swallow (Petrochelidon pyrrhonota) and resident house sparrow (Passer domesticus). Bugs are sedentary and overwinter in the swallows' mud nests. We evaluated the prevalence of BCRV and extent of infection in swallow bugs collected at different times in winter (October-early April) in Nebraska and explored other ecological aspects of this virus's overwintering. BCRV was detected in 17% of bug pools sampled in winter. Virus prevalence in bugs in winter at a site was significantly correlated with virus prevalence at that site the previous summer, but winter prevalence did not predict BCRV prevalence there the following summer. Prevalence was higher in bugs taken from house sparrow nests in winter and (in April) at colony sites where sparrows had been present all winter. Virus detected by reverse transcription (RT)-polymerase chain reaction in winter was less cytopathic than in summer, but viral RNA concentrations of samples in winter were not significantly different from those in summer. Both of the BCRV lineages (A, B) overwintered successfully, with lineage A more common at sites with house sparrows and (in contrast to summer) generally more prevalent in winter than lineage B. BCRV's ability to overwinter in its adult vector probably reflects its adaptation to the sedentary, long-lived bug and the ecology of the cliff swallow and swallow bug host-parasite system. Its overwintering mechanisms may provide insight into those of other alphaviruses of public health significance for which such mechanisms are poorly known.
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Arbovírus , Controle Biológico de VetoresRESUMO
Most arthropod-borne viruses (arboviruses) show distinct serological subtypes or evolutionary lineages, with the evolution of different strains often assumed to reflect differences in ecological selection pressures. Buggy Creek virus (BCRV) is an unusual RNA virus (Togaviridae, Alphavirus) that is associated primarily with a cimicid swallow bug (Oeciacus vicarius) as its vector and the Cliff Swallow (Petrochelidon pyrrhonota) and the introduced House Sparrow (Passer domesticus) as its amplifying hosts. There are two sympatric lineages of BCRV (lineages A and B) that differ from each other by > 6% at the nucleotide level. Analysis of 385 BCRV isolates all collected from bug vectors at a study site in southwestern Nebraska, USA, showed that the lineages differed in their peak times of seasonal occurrence within a summer. Lineage A was more likely to be found at recently established colonies, at those in culverts (rather than on highway bridges), and at those with invasive House Sparrows, and in bugs on the outsides of nests. Genetic diversity of lineage A increased with bird colony size and at sites with House Sparrows, while that of lineage B decreased with colony size and was unaffected by House Sparrows. Lineage A was more cytopathic on mammalian cells than was lineage B. These two lineages have apparently diverged in their transmission dynamics, with lineage A possibly more dependent on birds and lineage B perhaps more a bug virus. The long-standing association between Cliff Swallows and BCRV may have selected for immunological resistance to the virus by swallows and thus promoted the evolution of the more bug-adapted lineage B. In contrast, the recent arrival of the introduced House Sparrow and its high competence as a BCRV amplifying host may be favoring the more bird-dependent lineage A.
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Animais , Humanos , Alphavirus , Interações Hospedeiro-Parasita , Doenças Transmissíveis , PardaisAssuntos
Humanos , Masculino , Feminino , Adulto , Fraturas Ósseas/classificação , Fraturas Ósseas/epidemiologia , Luxações ArticularesRESUMO
Tomado del Jou. Med. Assn., jul. 24, 1937, p. 268