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Operative management of acetabular fractures is technically challenging, but there is little data regarding how surgeon experience affects outcomes. Previous efforts have focused only on reduction quality in a single surgeon series. We hypothesized that increasing surgeon experience would be associated with improved acetabular surgical outcomes in general.Retrospective cohort study.Urban academic level-I trauma center.Seven hundred ninety-five patients who underwent an open reduction internal fixation for an acetabular fracture.There was a significant association between surgeon experience and certain outcomes, specifically reoperation rate (16.9% overall), readmission rate (13.9% overall), and reduction quality. Deep infection rate (9.7% overall) and secondary displacement rate (3.7% overall) were not found to have a significant association with surgeon experience. For reoperation rate, the time until 50% peak performance was 2.4 years in practice.Surgeon experience had a significant association with reoperation rate, quality of reduction, and readmission rate after open reduction internal fixation of acetabular fractures. Other patient outcomes were not found to be associated with surgeon experience.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

ImportanceThe gold-standard treatment for laryngeal dystonia (LD) and essential tremor of the vocal tract (ETVT) is botulinum toxin (BoNT) chemodenervation. Although safe and effective, it is not curative, and periodic injections are required. Some medical insurance companies only cover injections at a 3-month interval, though some patients benefit from injections more frequently.ObjectiveTo determine the proportion and characteristics of patients who receive BoNT chemodenervation treatment in intervals shorter than 90 days.Design, Setting, and ParticipantsThis retrospective cohort study across 3 quaternary care neurolaryngology specialty practices in Washington and California recruited patients who underwent at least 4 consecutive laryngeal BoNT injections for LD and/or ETVT in the past 5 years. Data were collected from March through June 2022 and analyzed from June through December 2022.ExposureLaryngeal BoNT treatment.Main Outcomes and MeasuresBiodemographic and clinical variables, injection characteristics, evolution during the 3 interinjection intervals, and lifetime laryngeal BoNT treatment data were collected from patient medical records. Logistic regression was used to assess association to the short-interval outcome, defined as an average injection interval shorter than 90 days.ResultsOf 255 patients included from the 3 institutions, 189 (74.1%) were female, and the mean (SD) age was 62.7 (14.3) years. The predominant diagnosis was adductor LD (n = 199 [78.0%]), followed by adductor dystonic voice tremor (n = 26 [10.2%]) and ETVT (n = 13 [5.1%]). Seventy patients (27.5%) received short-interval injections (Conclusions and RelevanceThis cohort study demonstrated that while insurance companies often mandate a 3-month or greater interval for BoNT chemodenervation financial coverage, there is a considerable subset of patients with LD and ETVT who receive short-interval treatment to optimize their vocal function. Short-interval chemodenervation injections demonstrate a similar adverse effect profile and do not appear to predispose to resistance through antibody formation.

Although D2-gastrectomy is the most effective treatment for resectable gastric cancer (GC), it is unclear whether elderly patients have increased risk of morbidity and worse survival. This study aimed to compare the short- and long-term outcomes of older age (OA) patients with those of less advanced age (LAA).GC patients undergoing curative gastrectomy were retrospectively analyzed and divided into two groups: OA (75 years) and LAA (75 years). Propensity score-matching (PSM) analysis using seven variables was conducted to reduce selection bias.Among 586 patients, 494 (84.3%) were classified as LAA and 92 (15.7%) as OA. OA patients had worse clinical status, higher rates of D1-lymphadenectomy, subtotal gastrectomy, and Lauren type; higher mortality and worse survival. No difference in pathological tumor-node-metastasis (pTNM) stage was observed between groups. Preoperative chemotherapy was performed more frequently in the LAA group. After PSM (92 OA: 92 LAA), all variables included in PSM were matched, and mortality rates and survival became similar between groups. In multivariate analysis, American Society of Anaesthesiologists score III/IV was an independent factor associated with a 90-day mortality after PSM.Gastrectomy in elderly GC patients has similar outcomes compared with younger ones. Clinical status and disease stage are more important than the patient's age.

Chemotherapy (CMT) followed by surgery is recommended by Western countries for advanced gastric cancer (GC). However, cT4 GC usually undergoes upfront surgery, due to symptoms. This study aimed to evaluate if preoperative CMT is a better strategy than upfront surgery in cT4 GC.All cT4 GCs who underwent curative gastrectomy were included. Patients were divided according to their initial treatment: upfront surgery (SURG) or CMT + SURG.Among the 226 GC initially staged as cT4, 150 underwent SURG and 76 CMT + SURG. Groups were similar concerning age, comorbidities, American Society of Anesthesiologists, gastrectomy performed, and postoperative complications. The CMT + SURG group had less advanced pTNM. Median overall survival (OS) was 32 and 58.5 months for SURG and CMT + SURG, respectively (p = 0.04). Patients who received perioperative or adjuvant CMT had better OS compared to surgery alone (49.4 vs. 15.9 months, p 0.001). OS was similar for those receiving preoperative and adjuvant CMT. Non-CMT, pN+, and R1 resection were independent risk factors for worse OS.Multimodal treatment associating CMT with surgery, regardless of whether the approach is pre- or postoperative, is essential to improve the survival of cT4 GC. As tolerance to adjuvant treatment is reduced, preoperative CMT is a better strategy than upfront surgery in these patients.

Multivisceral resection (MVR) in locally advanced gastric cancer (GC) is a morbid procedure. However, the precise impact of removing additional organs remains controversial. This study aimed to compare the outcomes of MVR versus standard gastrectomy (SG) in an unbiased cohort.Patients who underwent curative-intent surgery for gastric adenocarcinoma were considered. Those submitted to SG were compared to the ones who received MVR using Propensity Score Matching (PSM) analysis.A total of 685 GC patients were included (621 SG and 64 MVR). Groups were distinct concerning the extent of the gastrectomy, tumor size, pTNM, R0, postoperative complications, and 90-day mortality. After PSM, 57 patients were matched in each group. All variables assigned in the score were well matched. Postoperative complication, 90-day mortality, and overall survival (OS) became similar among groups. Age65 years old and resection of two or more organs, besides the stomach, were factors associated with 90-day mortality. R1 and not received multimodal therapy were independent prognostic factors for worse OS.After PSM, the difference in morbidity, mortality, and survival of MVR compared to SG was no longer statistically significant, suggesting that MVR is an acceptable therapeutic strategy to patients with advanced GC.

Malignancy is a well-known complication in patients after kidney transplantation (KT), but its effect on posttransplant outcomes, allograft, and patient survival remains unexplored. The aim of this study is to report the impact of the comorbidity on clinical outcome, function, and failure of an allograft kidney.This case-control study included 101 KT patients. Twenty-six patients who developed cancer (CA) were assigned to the case group and 75 to the control group. Statistical analysis was performed using logistic regression models, and graft survival was analyzed using the Kaplan-Meier curve.Non-melanoma skin CA was the most common malignancy, accounting for almost 60% of cases, followed by stomach CA, prostate CA, and lymphoproliferative diseases (7.70% each). Difference in graft and patient survival was not significant between the two groups (P.05). A tumor in nonfunctioning in the first nonfunctioning KT was identified in 1 KT patient with a second allograft and by anatomopathological was detect Fuhrman grade II renal cell carcinoma. This KT patient was in good clinical condition with serum creatinine level of 1.5 mg/dL.No association was observed between CA development and risk factors, including family history and smoking habit, and no differences in allograft and patient survival were found. Nevertheless, in our data, CA in KT patients occurred early after transplantation. Renal cell carcinoma in allograft failure was identified in a patient; that suggested that nephrectomy of kidney failure must be performed to avoid patient allosensitization and neoplasia. Thus, we suggest continuous screening of malignancy diseases for KT patients.

Introduction Femoral neck fractures in the young patient present a unique challenge. Most surgeons managing these injuries prefer a fixed angle implant, however these devices are fraught with problems. A dynamic hip screw (DHS) is one such fixed angle device that risks malreduction through rotational torque during screw insertion. To avoid this risk some surgeons utilize a dynamic helical hip system (DHHS), however little is known about the complication profile of this device. We hypothesized that the complication rate between these two devices would be similar. Patients and Methods All patients presenting to a single tertiary referral center with a femoral neck fracture were identified from a prospectively collected trauma database over an 11-year period. Patients were included if they were less than 60 years of age, treated with a DHS or DHHS, and had at least 6 months of follow-up. Demographic data, injury characteristics, and post-operative complications were obtained through chart review. Standard statistical comparisons were made between groups. A total of 77 patients met inclusion criteria. Results Average age of patients was 38 years (range: 18–59) and 56 (73%) were male. The DHS was used in 37 (48%) patients and the DHHS was used in 40 (52%) patients. Demographic data including average age, gender, body mass index, and smoking status did not differ between the groups. There were 29 (39%) total complications of interest (femoral neck shortening >5 mm, non-union requiring osteotomy, conversion to THA, and osteonecrosis. There were 19 (51%) complications in the DHS group and 10 (25%) in the DHHS group (p = 0.01, risk difference 25%, 95% CI 7–43). Comparisons of the individual complications about the DHS and DHHS cohort did not reach statistical significance for non-union (8% vs 3%) or THA (16% vs 13%) (p = 0.33, p = 0.64, respectively) but a difference was detected in the rate of shortening (27% vs 10%; p = 0.05). Conclusion This study demonstrates a high risk of complication when managing young femoral neck fractures in line with prior literature. The major complication rate of non-union requiring osteotomy or fixation failure resulting in THA was no different between the two groups, but the rate of shortening was greater the DHS group. This data suggests the DHHS may be a suitable device to manage the young femoral neck fracture and without increased risk of complication.

OBJECTIVES: Laser-assisted Indocyanine Green Angiography (LA-ICGA) is a novel method for objectively quantifying soft tissue perfusion. The primary aim of this study was to determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study SETTING: Academic trauma centre PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients that underwent open reduction internal fixation MAIN OUTCOME MEASUREMENTS: Skin perfusion (fluorescence units) as measured by LA-ICGA RESULTS: Six patients were classified as Tscherne grade 0, nine as grade 1, ten as grade 2, and two as grade 3. Perfusion decreased by 14 fu (95% CI: −21, −6, p

Low dietary energy and decreased intake of herbage have been attributed to the reduced performance of grazing dairy cattle. We hypothesized that grasses with inherently greater energy would interact in a complementary way with condensed tannins (CT) in birdsfoot trefoil to increase herbage intake by grazing dairy heifers. Eight pasture treatments comprising high-sugar perennial ryegrass (Lolium perenne L.), orchardgrass (Dactylis glomerata L.), meadow bromegrass (Bromus riparius Rehmann), and tall fescue [Schendonorus arundinaceus (Schreb.) Dumort] were established in Lewiston, Utah as monocultures and binary mixtures with birdsfoot trefoil (Lotus corniculatus L.; BFT). Pasture treatments were rotationally stocked by Jersey heifers for 105 d in 2017 and 2018, and herbage samples were collected pre- and postgrazing for each 7-d grazing period and analyzed for herbage mass, nutritive value, and apparent herbage intake. We observed differences among pasture treatments in herbage quantity and nutritive value, as well as differences in herbage intake by grazing Jersey heifers. On average, grass-BFT mixtures had greater herbage intake than grass monocultures, and every grass-BFT treatment individually had greater herbage intake than their respective grass monocultures. Using multivariate analyses, we determined that approximately 50% of the variation in herbage intake was due to nutritive and physical herbage characteristics, with the most explanatory being characteristics related to fiber and energy, followed by those related to the percent of BFT in the herbage. Grass monocultures exhibited a range of inherent dietary energy, but there was indication that an imbalance of energy to crude protein (e.g., protein deficient) reduced intake of grass monocultures. Moreover, there was some evidence of a complementary effect between increased dietary energy and CT; however, low CT levels made it impossible to determine the effect of CT on herbage intake per se. This study confirmed that chemical and physical characteristics inherent to different pasture species have a large effect on herbage intake by grazing cattle. Pastures planted to binary mixtures of nutritious grasses and birdsfoot trefoil increase herbage intake of temperate pastures by grazing Jersey heifers.

Dairy heifers developed in certified organic programs, especially those utilizing pasture-based management schemes, have lower rates of gain than heifers raised in nonorganic confinement production systems in temperate climates, such as in the Intermountain West region of the United States. This study investigates the effects that different forages in a rotational grazing system have on development of organically raised Jersey heifers. Over 3 years, 210 yearling Jersey heifers were randomly assigned to one of 9 treatments, including a conventional confinement control where animals were fed a total mixed ration or one of 8 pasture treatments: Cache Meadow bromegrass (Bromus riparius Rehmann), QuickDraw orchard grass (Dactylis glomerata L.), Amazon perennial ryegrass (Lolium perenne L.), or Fawn tall fescue (Schendonorus arundinaceus [Schreb.] Dumort) and each individual grass interseeded with birdsfoot trefoil (Lotus corniculatus L., BFT). Each treatment had 3 blocks/yr over the 3-yr period, with each block having a 0.4 ha pasture of each treatment. Every 35 d, over a 105-d period, heifers were weighed and measured for hip height, and blood samples were collected to determine serum insulin-like growth factor-1 and blood urea nitrogen concentrations. Fecal egg counts were also assessed. Heifer body weight (BW), blood urea nitrogen, and insulin-like growth factor-1 concentrations were affected by treatment when analyzed over time. Heifers on grass-BFT pastures had increased BW compared with heifers on monoculture grass pastures. Heifers receiving a total mixed ration or perennial ryegrass+BFT had increased BW gain over the 105-d period compared with heifers grazing tall fescue+BFT, orchard grass, perennial ryegrass, meadow bromegrass, or tall fescue. Individually for all grass species, heifers grazing +BFT pastures had greater ending BW and weight gain than heifers grazing the respective grass monocultures. Furthermore, weight gain for heifers on perennial ryegrass+BFT, meadow bromegrass+BFT, and orchard grass+BFT were not different from those on a total mixed ration. Heifers grazing grass-BFT pastures had increased blood urea nitrogen compared with heifers grazing monoculture grass pastures. Heifer hip height and fecal egg counts were not affected by treatment. These results show that the addition of BFT to organic pasture improves growth of grazing replacement heifers. Economic analyses also demonstrate that interseeding grass pastures with BFT results in an increased economic return compared with grazing monoculture grass pastures. Grass pastures interseeded with BFT may be a sustainable option to achieve adequate growth of Jersey heifers raised in an organic pasture scenario in a temperate climate.