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Let us leave to the side for the moment some of the needless complexity and conflicting information in Adobe certifications (covered in my ultimate piece in this series). Today they shall focus on how to become an Adobe Certified Expert, or ACE.
Our Adobe.com page reference for today's post is this one:
Adobe.com: Become an Adobe Certified Expert in four smooth steps
According to Adobe, those four steps are as follows:
Adobe divides their ACE program into three categories:
* solitary product certification
* Specialist certification
* Master certification
A single-product ACE is an Adobe professional who wants to validate his or her expertise with a solitary Adobe product, such as the following:
On the other hand, a specialist ACE is geared toward using multiple Adobe applications by virtue of his or her job role (i.e., Print specialist, Web specialist, or Video specialist).
Please visit the The Become an Adobe Certified Expert page to view Adobe's requirement's matrix for the three ACE specialist tracks.
For example, if I wanted to rate my ACE as a Web specialist, I would believe to pass the following three exams:
Finally, there is the ACE Master certification. Here you must pass utter exams in an entire Adobe product suite.
The key issue here, friends, is versioning. You may be an expert in, say, Adobe Dreamweaver CS3, but how would you feel about taking a certification exam on MACROMEDIA Dreamweaver?
As I mentioned in my ultimate post, in my humble or no-so-humble opinion, Adobe is doing a dreadful job in maintaining their certification program--just dreadful. In a future post this week I will inspirit you design out how to ensure that you are taking the "latest and greatest" version of your desired Adobe certification exams.
Femoral shaft fractures are common following major traumas, such as motor vehicle accidents.1 In fact, a femoral shaft fracture occurs in approximately 1 in every 10 road injuries.2 A recent study estimated that the incidence of femoral shaft fractures is approximately 1 to 2.9 million per year worldwide.2 The preferred treatment option of these stern injuries is intramedullary nails.3–5 This surgery has been shown to believe wonderful healing and recovery.6
Often, fractures are not isolated injuries, and identifying associated injuries is necessary for patient care, especially for seriously injured patients.7 For given injuries, there are often specific known patterns of associated injuries that can inspirit direct patient workups and management. For example, such patterns of associated injuries believe been described for calcaneus fractures (which believe a known association with lumbar fractures)8,9 and clavicle fractures (which believe a known association with lung injuries).10 Along with comorbidities and the patient's common condition, associated injuries can repercussion the fracture management, time to surgery, and outcomes.
Because femoral shaft fractures typically result from major trauma, they are frequently seen in polytrauma patients.11 However, to the best of the authors' knowledge, no study has identified the associated injury profile for femoral shaft fractures.
To address the need of literature in this area, the current study sought to consume the National Trauma Data Bank (NTDB), the largest multicenter trauma repository, to define a large cohort of patients with femoral shaft fractures and to assess associated injury profiles. Furthermore, to assess the repercussion of such associated injuries, the correlations of such associated injuries with mortality were defined and compared with other factors believed to strike mortality in this patient population.Materials and Methods
The NTDB, created by the American College of Surgeons, is the largest national, multicenter trauma database and includes registrar distraught and administratively coded data.12 It was established as a “repository of trauma related data voluntarily reported by participating trauma centers.”13 The current study used the NTDB to identify adult patients (18 years and older) with femoral shaft fractures from 2011 and 2012. This was based on International Classification of Diseases, Ninth Revision (ICD-9) codes for either open or closed femoral shaft fractures (821.01, 821.11).
Patients' age, sex, and comorbidities were characterized. Age was stratified into the following groups: 18 to 39 years, 40 to 64 years, and 65+ years. The following comorbidities contained in the NTDB were used to reckon a modified Charlson Comorbidity Index (CCI): hypertension, alcoholism, diabetes mellitus, respiratory disease, obesity, congestive heart failure, coronary artery disease, prior cerebrovascular accident, liver disease, functionally conditional status, cancer, renal disease dementia, and peripheral vascular disease. These variables were used to reckon CCI based on a previously described algorithm.14 Of note, this modified CCI did not involve an age component, and any mention of “CCI” in this article always refers to this modified CCI.
Mechanism of injury was then determined from ICD-9 e-codes. Patients were categorized into fall, motor vehicle accident (MVA), or other. Patients with a topple mechanism of injury were determined based on the following ICD-9 e-code ranges: 880.00 to 889.99; 833.00 to 835.99; 844.7; 881; 882; 917.5; 957.00 to 957.99; 968.1; and 987.00 to 987.99. These primarily contained falls from a standing height, ladders, buildings, and sports. Patients with an MVA mechanism of injury were determined based on the following ICD-9 e-code ranges: 800 to 826; 829 to 830; 840 to 845; 958.5; and 988.5. These included patients who were involved in accidents such as motor vehicle drivers, motorcyclists, bicyclists, and pedestrians. utter other e-codes were counted as other; these included firearm and machinery-related injuries, among others.
Injury severity score (ISS) and mortality were data elements directly distraught from NTDB. Associated injuries were identified by ICD-9 codes. The diagnosis codes that were used to identify associated bony and internal organ injuries are circumstantial elsewhere.15
For analysis, Adobe Photoshop CS3 (Adobe Systems, San Jose, California) was used to visually demonstrate the associated injury frequencies by shadings on the skeleton and internal organ figures. The purview of shadings from white to black represented increasing injury frequency. Multivariate logistic regression was used to determine the association of age, modified CCI, and various associated injuries with mortality. utter statistical analyses were conducted using Stata version 13.0 statistical software (Stata-Corp LP, College Station, Texas). utter tests were 2-tailed, and a 2-sided α flush of 0.05 was taken as statistically significant. A waiver for this study was issued by the Human Investigations Committee at the authors' institution.ResultsPatient Demographics
For 2011 and 2012, the NTDB included 26,357 adult patients (16,717 men and 9640 women) who had femoral shaft fractures. The age distribution of utter adult patients with femoral shaft fractures is shown in Figure 1. The highest incidences were between the ages of 18 and 39 years. The primary incidence peak was around 20 years. It was establish that the younger patients were predominantly men (10,448 men and 3220 women in the 18–39 years age group), whereas the older patients were predominantly women (3823 women and 1586 men in the 65+ years age group). The middle group (40–65 years) included 4683 men and 2597 women.
Distribution of ages of patients with femoral shaft fractures by sex.Comorbidity Index and Injury Severity
The median modified CCI scores for age categories 18 to 39, 40 to 64, and 65+ years were utter 0 (Table 1). However, comorbidity tribulation did generally multiply with age for this cohort.
Distribution of Modified Charlson Comorbidity Index
The median ISS for these 3 age groups were between 10 and 19 for the younger 2 age groups and between 0 and 9 for the 65+ age group (Table 2). This is consistent with decreasing injury severity with increasing age for this cohort.
Distribution of Injury Severity ScoreMechanism of Injury
Mechanism of injury distribution by age group is shown in Figure 2. Younger adults sustained femur fractures and had predominantly been involved in MVAs, whereas older adults had predominantly been involved in falls. The middle age category (40–64 years) had a distribution more similar to the younger adults than the older adults, with MVAs dominating the distribution.
Distribution of patients with femoral shaft fractures by mechanism of injury and age groups. Abbreviation: MVA, motor vehicle accident.Associated Injuries by Age
On average, younger adults (ages 18–39 years, who as a group had a predominate MVA mechanism of injury) sustained higher frequencies of bony and internal organ associated injuries across the board compared to the older adults (65+ years). The middle age group (40–64 years) had associated injury frequencies more comparable to the younger group (ages 18–39) than the older age group (age 65+ years). Table 3 summarizes the associated injury frequencies by age category.
Incidence of Injuries for Each Age Group
Figure 3 and Figure 4 exhibit the associated bony and internal organ injury profiles for the total adult femoral shaft fracture population (18 years and older). The darker shadings correspond to higher frequencies. Overall, among associated bony injuries, the top 3 were tibia/fibula (20.5%), ribs/sternum (19.1%), and non-shaft femur (18.9%, of which 5.8% of the total cohort were femoral neck) fractures. Among associated internal organ injuries, the top 3 were lung (18.9%), intracranial (13.5%), and liver (6.2%) injuries. In general, the most common associated injuries were establish in the thoracic region (lungs and ribs) and in the lower extremity, especially near the femoral shaft fracture.
Schematic representation of percentages of adult patients (18 years and older) with a femoral shaft fracture with an incidence of associated bony injuries in different regions of the skeleton. Darker shadings in gray scale correspond with higher frequencies of associated injuries.
Schematic representation of percentages of adult patients (18 years and older) with a femoral shaft fracture with an incidence of associated internal organ injuries in different regions of the body. Darker shadings in gray scale correspond with higher frequencies of associated injuries. Abbreviation: GI, gastrointestinal.Effects of Associated Injuries on Mortality
Overall mortality after femoral shaft fractures was 4.3%. Multivariate analysis was used to determine the independent effects of age, modified CCI, and specific associated injuries on mortality (Table 4).
Multivariate Mortality Analysis
Regarding age (while controlling for modified CCI and associated injuries), compared with the 18 to 39 age group, the 40 to 64 age group had a 1.92 times increased odds of death and the 65+ age group had a 4.29 increased odds of death. Regarding the modified CCI (while controlling for age and associated injuries), values of 2 and above utter had increased odds of death compared with a modified CCI of 0. Both age and modified CCI had a statistically significant correlation with mortality (P<.05).
Lastly, the effects of associated injuries (by anatomic region) on the odds of death were assessed (while controlling for age and modified CCI). These are shown in the order of increasing odds of mortality in Table 4. The associated injuries by anatomic region that correlated with the greatest multiply in odds of death were thoracic organ injuries (adjusted odds ratio [AOR]=3.53), head injuries (AOR=2.93), abdominal organ injuries (AOR=2.78), and pelvic fractures (AOR=1.80).Discussion
Femoral shaft fractures are relatively common injuries that can result from high-energy trauma. Noting that there can be associated injuries with femoral shaft fractures, traditional teaching demands a solicitous evaluation of the femoral neck because the incidence of this concomitant injury with femoral shaft fractures has been documented anywhere from 2.5% to 9%.16–19 However, to the current authors' knowledge, there has been no reported compelling data defining the likelihood of the overall spectrum of injuries that can be associated with femoral shaft fractures.
The current study used the NTDB to identify a cohort of 26,357 adult femoral shaft fractures patients. This is a much large sample size than those establish in previous femoral shaft studies.20,21 That said, the demographics of the identified cohort were in line with the prior studies. For example, the majority of these femoral shaft fractures occurred in patients between 18 and 39 years of age, which is comparable to previously identified peak incidences between 15 and 24 years of age.21 As another example, the identified cohort had a male:female ratio of 1.7:1, which is comparable to a previously reported ratio of 1.4:1.20 Furthermore, consistent with what would be anticipated, modified CCI was establish to multiply with age, and the predominant mechanism of injury was establish to transition from MVAs to falls with increasing age.
Injury Severity Score provides an overview of the severity of both the femoral shaft fracture and the associated injuries. In the current study, ISS was higher in younger patients than in older patients, which is consistent with the expected higher-energy mechanisms and greater overall injury flush for younger patients.22 However, importantly, ISS lonely does not define the specific injuries associated with femoral shaft fractures, which was the focus of the current work. Specific associated injuries were evaluated, and results are presented in tabular and lifelike formats in the current article.
As an sample of a specific associated injury, femoral neck fractures believe been reported to be associated with femoral shaft fractures, with an incidence ranging from 2.5% to 9%. This was confirmed by the current analysis, which showed that 5.8% of femoral shaft fractures had concomitant femoral neck fractures (completely in line with prior reports).16,23 This is clearly of clinical import for the treating surgeon, who should be awake of this when managing patients with this combination of injuries.
From the current analyses of bony injuries associated with femoral shaft fractures, it was establish that 38.1% had other lower extremity fractures (notably 20.5% had tibia/fibula fractures), whereas 22.4% had upper extremity fractures. These lofty incidences suggest that the extremities need to be thoroughly assessed for concomitant injuries and that there should be a low threshold for imaging any region of question.
In addition, spinal injuries were relatively common in this population (16.8% of patients with femoral shaft fractures had a concomitant spinal fracture). This is notable because this incidence is comparable to that of patients with a known spinal fracture who furthermore believe a noncontiguous spinal fracture (range, 6.4%–19%).24,25 For patients with a spinal fracture, conventional teaching promotes a low threshold to evaluate for noncontiguous fractures. The very appears to be wholehearted for the need to evaluate for any spinal fracture in the femoral shaft fracture patient as well.
From the current analysis of internal organ injuries associated with femoral shaft fractures, it was establish that thoracic (19.5%), abdominal (14.2%), and intracranial (13.5%) injuries were common. This suggests a higher incidence than that from a previous study, which showed concomitant thoraco-abdominal injuries (10.9%) with femoral shaft fractures.21 The lofty incidence of internal organ injuries identified underscores the import of the “pan scan” for patients with high-energy injuries when clinically appropriate to ensure that such associated internal organ injuries are not missed.
Finally, multivariate analysis showed that increasing age, increasing modified CCI, and many of the associated injuries (most notably thoracic organ, head, and abdominal organ injuries) had significant associations with a higher risk of mortality. This underscores the import and repercussion of associated injuries, highlighting the clinical import of appreciating the associated injuries defined in the current study.
The major limitation of the current study deals with the data acquired from the NTDB. Because the NTDB focuses on trauma patients, the studied population may be biased toward femoral shaft fractures, which occur in the setting of more severely injured patients than in the common population. In addition, because the NTDB is a convenience sample, the data “may not be representative of utter hospitals.”13 It is necessary to note that trauma victims who die before transport to a hospital are not included in the NTDB; therefore, the current study does not picture femoral shaft fractures that result in immediate death.13 Finally, although information was gathered for utter patients with a femoral shaft fracture in the NTDB using ICD-9 diagnosis coding, it is crucial that the potential variability within this group is emphasize because fracture classification was not available in the data set.Conclusion
Overall, this study characterized the distribution of age, comorbidity burden, ISS, mechanism of injury, and associated injuries in adult patients with femoral shaft fractures, as well as identified the associations of such associated injuries with mortality. It was establish that these injuries more commonly occur in younger and healthier patients, who were most likely to believe suffered the injury from a high-energy mechanism. lofty rates of associated bony and internal organ injuries were identified, and rates were defined. Moreover, the mortality associated with femoral shaft fractures is most closely related to such associated injuries and less related to overall health status. This underscores the import for orthopedists and trauma surgeons to treasure these associated injuries when assessing, managing, and treating patients with femoral shaft fractures.References
Distribution of Modified Charlson Comorbidity IndexCharlson Comorbidity IndexAge Group, yTotal18–3940–6465+093.7%a77.8%a56.5%a81.7%15.6%15.5%25.4%12.4%20.6%3.6%10.0%3.3%30.1%1.7%4.2%1.4%≥40.0%1.4%3.9%1.2%Total100%100%100%100%Table 2
Distribution of Injury Severity ScoreInjury Severity ScoreAge Group, yTotal18–3940–6465+0–930.7%41.0%73.0%a42.2%10–1940.1%a33.9%a18.7%34.0%20–2916.6%14.5%5.4%13.7%30+12.6%10.6%3.0%10.1%Total100%100%100%100%Table 3
Incidence of Injuries for Each Age GroupInjuryAge Group, yTotal18–3940–6465+Head injury26.2%21.4%7.0%21.0% Skull fracture14.9%11.2%3.0%11.4% Intracranial injury16.5%14.3%5.0%13.5%Spinal injury18.1%20.9%7.7%16.8% Cervical spine5.4%6.5%2.9%5.2% Thoracic spine5.3%6.7%2.4%5.1% Lumbar spine9.5%11.6%3.8%8.9% Sacral spine4.6%4.8%1.4%4.0%Ribs/sternum18.9%26.5%9.7%19.1%Pelvic fracture15.6%15.2%5.8%13.5% Acetabulum8.4%7.1%2.4%6.8% Pubis5.9%6.2%2.7%5.4% Ilium2.0%2.4%0.7%1.8% Ischium0.5%0.6%0.3%0.5%Upper extremity fracture25.8%24.5%10.8%22.4% Clavicle4.2%4.2%1.6%3.7% Scapula3.6%3.5%1.0%3.0% Humerus5.8%6.6%3.5%5.5% Proximal humerus1.6%2.6%2.0%2.0% Humeral shaft2.7%2.5%0.8%2.2% Distal humerus1.4%1.5%0.7%1.3% Radius/ulna12.7%12.2%5.0%11.0% Proximal radius/ulna2.9%2.7%0.8%2.4% Radial/ulnar shaft4.3%3.6%1.1%3.4% Distal radius/ulna6.1%6.4%3.0%5.6% Hand7.3%5.9%2.3%5.8%Lower extremity fracture38.0%47.1%26.2%38.1% Non-shaft femur fracture15.1%25.6%19.5%18.9% Proximal femur9.5%16.1%10.5%11.6% Femoral neck5.8%6.8%4.5%5.8% Distal femur5.4%10.3%8.7%7.5% Patella5.8%5.0%1.8%4.8% Tibia/fibula fracture22.1%26.6%8.4%20.5% Proximal tibia/fibula6.5%10.9%3.4%7.1% Tibial/fibular shaft8.8%10.6%2.7%8.1% Ankle8.5%9.8%3.3%7.8% Foot10.1%10.2%2.4%8.6%Thoracic organ injury25.3%18.6%6.0%19.5% Heart0.8%1.2%0.4%0.8% Lung24.7%17.8%5.7%18.9% Pneumothorax15.1%12.6%4.3%12.2% Diaphragm0.8%1.0%0.2%0.7%Abdominal organ injury18.4%14.2%3.6%14.2% Gastrointestinal tract4.7%4.5%0.9%3.8% Liver8.7%5.0%1.4%6.2% Spleen7.9%5.5%1.1%5.9% Kidney3.7%2.0%0.5%2.6%Pelvic organ injury1.5%1.4%0.2%1.2%Table 4
Multivariate Mortality AnalysisOutcome: MortalityAdjusted Odds Ratio95% assurance IntervalPAge (reference, 18–39 y)<.001 40–64 y1.921.65–2.23 65+ y4.273.55–5.16Modified Charlson<.001 Comorbidity Index (reference, 0) 10.700.56–0.88 21.451.04–2.03 32.881.95–4.27 4+2.691.78–4.07Associated Injuries (in increasing order of odds of mortality) Lumbar spine0.720.60–0.86<.001 Lower extremity0.960.84–1.10.541 Thoracic spine1.110.90–1.36.342 Upper extremity1.301.13–1.50<.001 Cervical spine1.401.15–1.70.001 Pelvic fracture1.801.55–2.08<.001 Abdominal organ2.782.39–3.23<.001 Head2.932.54–3.38<.001 Thoracic organ3.533.01–4.14<.001
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