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Acute critical illness is often preceded by deterioration of routinely measured clinical parameters, e.g., blood pressure and heart rate. Early clinical prediction is typically based on manually calculated screening metrics that simply weigh these parameters, such as early warning scores (EWS). The predictive performance of EWSs yields a tradeoff between sensitivity and specificity that can lead to negative outcomes for the patient. Previous work on electronic health records (EHR) trained artificial intelligence (AI) systems offers promising results with high levels of predictive performance in relation to the early, real-time prediction of acute critical illness. However, without insight into the complex decisions by such system, clinical translation is hindered. Here, we present an explainable AI early warning score (xAI-EWS) system for early detection of acute critical illness. xAI-EWS potentiates clinical translation by accompanying a prediction with information on the EHR data explaining it. Acute critical illness is often preceded by deterioration of routinely measured clinical parameters, e.g., blood pressure and heart rate. Here, the authors develop an explainable artificial intelligence early warning score system for its early detection.

ObjectivesTo identify and synthesise available evidence on the impact of transitional care interventions with both predischarge and postdischarge elements on readmission rates in older medical patients.DesignA systematic review.MethodInclusion criteria were: medical patients ≥65 years or mean age in study population of ≥75 years; interventions were transitional care interventions between hospital and home with both predischarge and postdischarge components; outcome was hospital readmissions. Studies were excluded if they: included other patient groups than medical patients, included patients with only one diagnosis or patients with only psychiatric disorders. PubMed, The Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science were searched from January 2008 to August 2019. Study selection at title level was undertaken by one author; the remaining selection process, data extraction and methodological quality assessment were undertaken by two authors independently. A narrative synthesis was performed, and effect sizes were estimated.ResultWe identified 1951 records and included 11 studies: five randomised trials, four non-randomised controlled trials and two pre–post cohort studies. The 11 studies represent 15 different interventions and 29 outcome results measuring readmission rates within 7–182 days after discharge. Twenty-two of the 29 outcome results showed a drop in readmission rates in the intervention groups compared with the control groups. The most significant impact was seen when interventions were of high intensity, lasted at least 1 month and targeted patients at risk. The methodological quality of the included studies was generally poor.ConclusionTransitional care interventions reduce readmission rates among older medical patients although the impact varies at different times of outcome assessment. High-quality studies examining the impact of interventions are needed, preferably complimented by a process evaluation to refine and improve future interventions.PROSPERO registration numberCRD42019121795.

Background Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases. Purpose The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery. Methods The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed. Results A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery. Conclusion ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.

Limited information is available regarding the treatment strategy and prognosis of non-selected patients treated for chronic periprosthetic hip joint infection. Such information is important as no head-to-head studies on treatment strategies are available. The purpose of this study is to report on the treatment strategy and prognosis of a non-selected, consecutive patient population. We identified 130 patients in the National Patient Registry, consecutively treated for a chronic periprosthetic hip joint infection between 2003-2008 at 11 departments of orthopaedic surgery. We extracted information regarding patient demographics, treatment and outcome. 82 patients were re-implanted in a two-stage revision (national standard), the remaining 48 were not re-implanted in a two-stage revision. We were able to collect up-to-date information on all patients to date of death or medical chart review with a minimum of 5 years follow-up by the nationwide electronic patient record system. After primary revision surgery, 53 patients (41%) had a spacer in situ, 64 (50%) had a resection arthroplasty and 13 (9%) did not have the infected implant removed. 63% were re-implanted in a two-stage revision. Re-implantation was performed after an interim period of 14 weeks (IQR 10-18). Patients re-implanted were younger (p-value 0.0006), had a lower CCS score (p-value 0.005), a lower ASA score (p-value 0.0001) and a 68% lower mortality risk in the follow-up period (p-value <0.00001). After adjusting for selected confounders, the mortality risk was no longer significantly different. The 5-year re-infection rate after re-implantation was 14.6% (95%CI 8.0-23.1). Re-infections occurred mainly within 3 years of follow-up. The overall 1-year survival rate was 92% (95%CI 86-96) and the overall 5-year survival rate was 68% (95%CI 59-75). The 5-year survival rate after a two-stage revision was 82% (95%CI 71-89) and in those not re-implanted 45% (95%CI 30-58). We found that patients who receive a two-stage revision after a chronic periprosthetic hip joint infection are younger and healthier when compared to those who do not receive a two-stage revision in a non-selected patient population, indicating a clear selection of patients into this treatment strategy. Re-infection rates following two-stage revision were comparable to international results. We found a high mortality rate in our study population, but the causality of death and chronic periprosthetic hip joint infection cannot be established in this study and this needs further attention.

Background Insertional hip abductor tendon pathology (tendinopathy or tears of gluteus medius and/or minimus tendons) are increasingly recognized as the main cause of lateral hip pain. This study aims to evaluate generic health status in patients with lateral hip pain due to Magnetic Resonance Imaging (MRI) verified hip abductor tendon pathology using the EQ-5D-5L and compare these findings with a matched national population norm. Methods Data from patients with lateral hip pain, referred to our hospital from 2017-2023, was retrospectively reviewed. Females aged 18+ years, with positive clinical tests and MRI verified hip abductor tendon pathology, who had completed the EQ-5D-5L at relevant timepoints, were included. Our treatment algorithm consisted of a baseline physiotherapist led intervention (patient education followed by 3-months un-supervised training). Surgery was offered to patients who, after the intervention, had recalcitrant lateral hip pain and MRI verified tendon tears. Post hoc two treatment groups were identified. The EQ-index scores were calculated from individual health profiles using a national value set. The student’s t-test was used to compare groups. Summary statistics are used, including numbers of patients and proportions of categorical responses for the five EQ-5D dimensions. To compare responses between groups, the Fisher’s exact test was used. Results Ninety-seven female patients were included; 48 (57±12 years) received rehabilitation only (REHAB) and 49 (59±11 years) underwent subsequent surgery (SURG). At baseline, the mean EQ-index was inferior to population norms. After 3 months of rehabilitation, EQ-index ( p <0.0001) and EQ-VAS ( p =0.004) improved in REHAB, but not in SURG (EQ-index: p =0.32, EQ-VAS: p =0.22). Twelve months after surgery, EQ-index ( p <0.0001) and EQ-VAS ( p <0.0001) improved and, notably, the dimension “pain/discomfort” was comparable to population norms ( p =0.788). Conclusion Generic health status in female patients suffering from lateral hip pain due to hip abductor tendon pathology is severely affected compared to a national population norm measured with the EQ-5D-5L. Generic health status may improve after three months of patient education and rehabilitation in some cases, while surgery may improve health status three months postoperative in the remaining cases. Trial registration The study is registered at the Central Denmark Region List of Research Projects (Jr nr: 1-16-02-761-17 and 1-16-02-125-19). Key points Findings The overall generic health status of female patients experiencing lateral hip pain, due to MRI-confirmed hip abductor tendon pathology, is significantly impaired when compared to a national age and gender matched population norm, as assessed by the EQ-5D-5L instrument. Our findings suggest that rehabilitation and patient education can enhance generic health status in some patients and potentially defer the need for a surgical intervention, whereas surgical intervention may be necessary to achieve similar improvements in the remaining cases. Implications Further studies are needed to establish whether supervised rehabilitation in patients with advanced hip abductor tendon pathology are beneficial in terms of pain reduction and improved physical function. Surgical reconstruction is a viable option for patients with MRI verified gluteal tendon tears who do not show sufficient progress with rehabilitation. Cautions Patients were recruited from a secondary hospital setting, which may indicate a higher level of impairment compared to those typically seen in primary care. Participants were part of a tax-supported healthcare system, ensuring universal and free access to hospitals and primary medical care, which could influence generalizability of the study findings.

Background Sonication of removed orthopaedic implants in suspected implant-associated infections (IAI) is widely applied internationally. However, evaluation of the utility of sonication on all implants removed in everyday standard practice is scarce. This exploratory study was performed to evaluate the application of sonication fluid (SF) culture on removed orthopaedic implants, irrespective of the reason for removal. Methods Out of 100 removed orthopaedic implants collected between August 2019 and September 2020, 77 implants with availability of concurrent tissue culture samples were included in the study. Removed implants were categorized into a confirmed or suspected IAI group and a presumed aseptic group based on pre-operative diagnosis by the responsible surgeon. Implants were sonicated and SF culture performed under both aerobic and anaerobic conditions. The significance of all bacterial isolates was evaluated based on the CFU/mL cut-offs of the EBJIS guidelines, except for C. acnes where additional investigations were performed. Results The results of SF culture in the two groups were compared with their corresponding tissue cultures. Out of the 12 cases in the confirmed/suspected IAI group, SF culture was positive in 11 cases and had increased diagnostic yield in two (17%) cases compared to tissue culture. Increased diagnostic yield of SF compared to tissue culture was seen in seven (11%) of the 65 implants in the presumed aseptic group. If growth of Cutibacterium species isolates were interpreted based on EBJIS cut-off for SF culture instead of the study-specific criteria, then two isolates considered to represent infection might have been missed while three other isolates considered contaminants would have fallen under the ‘infection confirmed’ category in the EBJIS guidelines. Conclusion Sonication with SF culture has increased diagnostic yield compared to tissue cultures in all implants irrespective of reason for removal. However, positive SF cultures with Cutibacterium species should always be interpreted with extreme care.

Two-stage revision is regarded by many as the best treatment of chronic infection in hip arthroplasties. Some international reports, however, have advocated one-stage revision. No systematic review or meta-analysis has ever compared the risk of reinfection following one-stage and two-stage revisions for chronic infection in hip arthroplasties. The review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Relevant studies were identified using PubMed and Embase. We assessed studies that included patients with a chronic infection of a hip arthroplasty treated with either one-stage or two-stage revision and with available data on occurrence of reinfections. We performed a meta-analysis estimating absolute risk of reinfection using a random-effects model. We identified 36 studies eligible for inclusion. None were randomized controlled trials or comparative studies. The patients in these studies had received either one-stage revision (n = 375) or two-stage revision (n = 929). Reinfection occurred with an estimated absolute risk of 13.1% (95% confidence interval: 10.0%-17.1%) in the one-stage cohort and 10.4% (95% confidence interval: 8.5%-12.7%) in the two-stage cohort. The methodological quality of most included studies was considered low, with insufficient data to evaluate confounding factors. Our results may indicate three additional reinfections per 100 reimplanted patients when performing a one-stage versus two-stage revision. However, the risk estimates were statistically imprecise and the quality of underlying data low, demonstrating the lack of clear evidence that two-stage revision is superior to one-stage revision among patients with chronically infected hip arthroplasties. This systematic review underscores the need for improvement in reporting and collection of high-quality data and for large comparative prospective studies on this issue.

IntroductionLateral hip pain due to hip abductor tendon pathology (ie, gluteal tendinopathy or tendon rupture) is a relatively new diagnosis. This patient group has previously been described as a clinical dilemma due to the often-short-lived effects of treatment. In the process of identifying the underlying pathology, however, more targeted treatment strategies have been explored. Recent research recommends exercise as a first-line treatment for this patient group along with patient education. However, patients seen in a hospital setting (secondary healthcare) often present recalcitrant lateral hip pain, tendon ruptures and multiple comorbidities. Whether patient education and exercise therapy are beneficial for patients in secondary healthcare has only been sparsely investigated. Therefore, this study aims to investigate changes in lateral hip pain following a 3 month physiotherapist-led patient education and exercise intervention in patients with MRI-proven hip abductor tendon pathology seen in a hospital setting.Methods and analysisIn this prospective cohort trial, 60 patients, presenting lateral hip pain and MRI-verified hip abductor tendon pathology at the orthopaedic outpatient clinic at Horsens Regional Hospital, Denmark, a public teaching hospital, are included. Hip abductor tendon pathology will be diagnosed by clinical tests and MRI. The intervention consists of seven physiotherapist-led patient education and exercise sessions at the hospital during 3 months. The instructions will guide the patients in their daily home-based exercise sessions.The primary outcome is change in lateral hip pain measured by the ‘pain’ subscale from the patient-reported outcome measure: the revised Copenhagen Hip And Groin Outcome Score (HAGOS). Secondary outcomes are changes in the remaining subscales of the revised HAGOS, Oxford Hip Score, Victorian Institute of Sports Assessment-Gluteal Questionnaire, European Questionnaire-Five Dimensions Five-Level, lateral hip pain (numeric rating scale score, 0–10), hip muscle strength and the 30 s chair stand test. Also, patient-reported Global Rating of Change in hip condition, as well as adherence and harms, will be reported.Ethics and disseminationThis trial has been accepted by the Central Denmark Regions Ethics Committee (1-10-72-136-22). The study is registered at the Central Denmark Region List of Research Projects (Journal No 1-16-02-180-24) and clinicaltrials.gov (NCT06418217).All results from this study, regardless of the direction, will be published in a peer-reviewed journal and presented at national and international congresses.Trial registration numberNCT06418217.

Problem framing is critical to developing risk prediction models because all subsequent development work and evaluation takes place within the context of how a problem has been framed and explicit documentation of framing choices makes it easier to compare evaluation metrics between published studies. In this work, we introduce the basic concepts of framing, including prediction windows, observation windows, window shifts and event-triggers for a prediction that strongly affects the risk of clinician fatigue caused by false positives. Building on this, we apply four different framing structures to the same generic dataset, using a sepsis risk prediction model as an example, and evaluate how framing affects model performance and learning. Our results show that an apparently good model with strong evaluation results in both discrimination and calibration is not necessarily clinically usable. Therefore, it is important to assess the results of objective evaluations within the context of more subjective evaluations of how a model is framed.

IntroductionInsertional hip abductor tendon pathology (tendinopathy or tear of gluteus medius and/or minimus tendons (GMM)) are increasingly recognized as the main cause of lateral hip pain (LHP). This study aims to evaluate the potential health-state benefits of a non-surgical plus/minus a surgical intervention in patients with LHP by use of the EQ-5D-5L, and compare these findings with a Danish population norm.Material and MethodsIn this retrospective study, we included patients referred to our hospital with LHP from September 2017 to March 2023. Hip abductor tendon pathology were diagnosed clinically and by MRI. All patients recieved patient education and engaged in 3-months un-supervised rehabilitation. Surgery was offered to patients with MRI proven GMM tears that did not, clinically or subjective, improve after the rehabilitation period.Results97 female patients were included, 48 patients (57.1±12.2 years) received rehabilitation only (REHAB group) and 49 patients (58.9±11.2 years) had additionally surgery (SURG group). At baseline, EQ-5L-5D index was lower in SURG compared to REHAB group (0.56 vs 0.67, p<0.001). After 3 months rehabilitation, EQ-5L-5D index improved in REHAB (0.74), but not in SURG (0.59). 12 months post-operatively, SURG EQ-5D-5L index improved to 0.77. 12 months post-operatively, the EQ-5D-5L-dimension ‘pain/discomfort’ was comparable to a Danish population norm for the SURG (p=0.49). ConclusionRehabilitation should be first line of treatment in LHP patients and might aid differentiating between tendinopathy and GMM tears. Patients receiving surgical reconstruction of GMM tears are comparable to a Danish population norm in regards to Pain/discomfort at 12 months follow-up.