bluuebunny/crossref_metadata_2025 huggingface dataset:
Knee Disarticulations Versus Transfemoral Amputations: Functional Outcomes
Authors: Polfer Elizabeth M. , Hoyt Benjamin W. , Bevevino Adam J. , Forsberg Jonathan A. , Potter Benjamin K.
Published: February 2019

Objectives:

To determine whether there is a patient-reported functional difference between combat-related knee disarticulations (KDs) and transfemoral amputations (TFAs).

Setting:

Role 3 Military Trauma Centers.

Patients:

We identified and contacted all KDs and TFAs performed at the Walter Reed National Military Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center from January 2003 until July 2012 to participate in a retrospective functional cohort analysis. Ten KD patients were available for study completion and were matched against 18 patients in the TFA group.

Intervention:

Knee disarticulation versus transfemoral amputation.

Main Outcome Measurements:

The following surveys were obtained from the participants—AAOS Lower Limb Outcome Questionnaire (LLQ), Tegner Activity Scale, SF-36, and Prosthetic Evaluation Questionnaires (PEQs).

Results:

Ten KD patients agreed to participate in the study, and 18 TFA matched controls were interviewed. Patients were followed up at an average of 66 months (interquartile range 50–79 months) after injury. There were no significant differences with regard to the SF-36, PEQ, LLQ, and Tegner Activity Scale scores.

Conclusions:

We detected no functional differences measured on the PEQ, LLQ, SF-36, and Tegner Activity Scale scores between KDs and TFAs. In the absence of a proven functional difference, we advocate performing trauma-related amputations at the most distal level the osseous and soft tissue injuries permit.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Standardized Hospital-Based Care Programs Improve Geriatric Hip Fracture Outcomes: An Analysis of the ACS NSQIP Targeted Hip Fracture Series
Authors: Arshi Armin , Rezzadeh Kevin , Stavrakis Alexandra I. , Bukata Susan V. , Zeegen Erik N.
Published: February 2019

Objective:

To determine relative complication rates and outcome measures in patients treated under a standardized hip fracture program (SHFP).

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who underwent operative fixation of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures in 2016. Cohorts of patients who were and were not treated under a documented SHFP were identified. Relevant perioperative clinical and outcomes data were collected. Multivariate regression was used to assess risk-adjusted complication rates and outcomes for patients treated in SHFPs.

Results:

A total of 9360 hip fracture patients were identified of whom 5070 (54.2%) were treated under a documented SHFP. Median age was 84 years, and 69.9% of patients were women. Patients in an SHFP had a lower risk-adjusted incidence of postoperative deep vein thrombosis [odds ratio (OR) 0.48 (0.32–0.72), P < 0.001]. Rates of other medical and surgical complications and 30-day mortality were statistically comparable. Risk-adjusted evaluation showed that SHFP patients were less likely to be discharged to an inpatient facility versus home [OR 0.72 (0.63–0.81), P < 0.001] and had a lower 30-day readmission rate [OR 0.83 (0.71–0.97), P = 0.023]. Furthermore, the SHFP patients had higher rates of immediate postoperative weight-bearing as tolerated [OR 1.23 (1.10–1.37), P < 0.001], adherence to deep vein thrombosis prophylaxis at 28 days [OR 1.27 (1.16–1.38), P < 0.001], and initiation of bone protective medications [OR 1.79 (1.64–1.96), P < 0.001].

Conclusions:

Care in a modern hospital-based SHFP is associated with improved short-term outcome measures. Further development and widespread implementation of organized, multidisciplinary orthogeriatric hip fracture protocols is recommended.

Level of Evidence:

Therapeutic Level III.
Certified and Advanced Degree Critical Care Nurses Improve Patient Outcomes
Authors: Conley Patricia
Published: January 2019

The need for highly skilled and knowledgeable critical care nurses continues to evolve today and will in the future. Demands in critical care medicine for nurses with advanced degrees (master's in nursing: clinical nurse specialist; or doctorate in nursing: doctorate of philosophy in nursing or doctor of nursing practice) working in intensive care units or progressive care units can help meet these challenges. Nurses with certification and advanced degrees in nursing can be employed to work in 1 or combined roles such as nurse leaders and nurse researcher or intermittently fulfill roles as bedside nurses. These nurses working in critical care units have the ability to provide expertise that extends to staff, families, as well as patients. In addition, they are positioned to conduct relevant clinical research for evidence-based best practices. Evidence-based practice promotes excellence in nursing care and cost containment. Data on numbers of critical care beds in the United States increased 17% between 2000 and 2010.
Increasing Light Exposure for the Prevention of Delirium
Authors: Groves Rachel L.
Published: January 2019

Background

Delirium is a neurological disorder with correlations to increased hospital length of stays and higher morbidity and mortality rates, particularly in the growing elderly population, making prevention strategies key in improving patient outcomes and health care systems.

Objectives

Does increased exposure to light, by artificial or natural means, decrease the incidence of delirium?

Methods

A systematic review was conducted of 4 revered databases, CINAHL, PubMed, PsycINFO, and Scopus, for articles related to key words “delirium” and “lighting” or “daylight” or “natural light” or “bright light” or “sunlight.” Results were narrowed to adult inpatients, defined as age older than 18 years. After limiting for quality of the study and content that addressed the objective, 7 articles were selected for review: 4 related to artificial means of light therapy and 3 consistent with increased exposure to natural light.

Results

Two studies examined the effects of bright light therapy and reported a decreased incidence of delirium. Two studies researched whether increased lighting via a lighting system with varying degrees of intensity throughout the day would prevent delirium, and neither reported a decrease in delirium. The remaining 3 studies focused on whether increased natural light via windows decreased the occurrence of delirium and uncovered no correlation.

Discussion

It is recommended that the study by Potharajaroen et al, which demonstrated significant findings for bright light therapy preventing delirium, be replicated as well as new pilot studies to enrich the growing body of research. Bright light therapy is a low-cost and easy-to-institute intervention that should be utilized on a case-to-case basis.
Abnormal medial prefrontal cortex functional connectivity and its association with clinical symptoms in chronic low back pain
Authors: Tu Yiheng , Jung Minyoung , Gollub Randy L. , Napadow Vitaly , Gerber Jessica , Ortiz Ana , Lang Courtney , Mawla Ishtiaq , Shen Wei , Chan Suk-Tak , Wasan Ajay D. , Edwards Robert R. , Kaptchuk Ted J. , Rosen Bruce , Kong Jian
Published: February 2019

Accumulating evidence has shown that complicated brain systems are involved in the development and maintenance of chronic low back pain (cLBP), but the association between brain functional changes and clinical outcomes remains unclear. Here, we used resting-state functional magnetic resonance imaging (fMRI) and multivariate pattern analysis to identify abnormal functional connectivity (FC) between the default mode, sensorimotor, salience, and central executive brain networks in cLBP and tested whether abnormal FCs are related to pain and comorbid symptoms. Fifty cLBP patients and 44 matched healthy controls (HCs) underwent an fMRI scan, from which brain networks were identified by independent component analysis. Multivariate pattern analysis, graph theory approaches, and correlation analyses were applied to find abnormal FCs that were associated with clinical symptoms. Findings were validated on a second cohort of 30 cLBP patients and 30 matched HCs. Results showed that the medial prefrontal cortex/rostral anterior cingulate cortex had abnormal FCs with brain regions within the default mode network and with other brain networks in cLBP patients. These altered FCs were also correlated with pain duration, pain severity, and pain interference. Finally, we found that resting-state FC could discriminate cLBP patients from HCs with 91% accuracy in the first cohort and 78% accuracy in the validation cohort. Our findings suggest that the medial prefrontal cortex/rostral anterior cingulate cortex may be an important hub for linking the default mode network with the other 3 networks in cLBP patients. Elucidating the altered FCs and their association with clinical outcomes will enhance our understanding of the pathophysiology of cLBP and may facilitate the development of pain management approaches.
Explosive Growth in British Physician Associate Education Since 2008
Authors: Ritsema Tamara S. , Roberts Karen A. , Watkins Jeannie S.
Published: February 2019

Physician associate (PA) education in the United Kingdom has grown substantially since the establishment of 4 PA education programs in the late 2000s. From those 4 programs in 2008, the number of universities educating PAs fell to a nadir of 2 programs in 2012 and then rose to 29 by the end of 2017. Due to program closures, the number of students enrolled in the early years fluctuated substantially. In 2008, 43 students entered PA education; in 2010, only 17 students started PA training, but in 2017, the number of students enrolled in PA programs soared to 853. Early in the course of PA education, programs were only offered in the greater London and West Midlands areas of England. As of 2017, PAs were being educated in all 4 countries of the United Kingdom, although the explosive growth in the number of programs is expected to slow as 2020 nears.
A case report of crystalline light chain inclusion-associated kidney disease affecting podocytes but without Fanconi syndrome
Authors: Ito Kiyoaki , Hara Satoshi , Yamada Kazunori , Zoshima Takeshi , Mizushima Ichiro , Fujii Hiroshi , Miyazaki Ryoichi , Kawai Yasukazu , Yachie Akihiro , Nagata Michio , Izui Shozo , Yamagishi Masakazu , Kawano Mitsuhiro
Published: January 2019

Rationale:

Crystalline light chain inclusion-associated kidney disease affects mainly tubular epithelial cells and is often clinically manifested as Fanconi syndrome. However, only very few case reports about the crystalline deposits within the podocytes are available, and the nature of the pathogenic monoclonal light chain implicated in these cases is still unknown. We report a case of crystalline inclusion-associated kidney disease manifested as crystalline podocytopathy in which we identified the complete structure of the pathogenic monoclonal light chain as belonging to the germ-line gene of Vκ1-39.

Patient concerns:

We describe a 65-year-old woman with crystalline light chain inclusion-associated kidney disease showing mild proteinuria and renal insufficiency with monoclonal gammopathy of undetermined significance without Fanconi syndrome. She had crystalline inclusions mainly within podocytes, tubular epithelial cells and histiocytes in the kidney. Light microscopy showed vacuolation of podocytes and tubular epithelial cells, while eosin negative pale needle-like crystals were present within these cells. Electron microscopy showed accumulation of club-like crystals with high electron density in podocytes, proximal tubular epithelial cells and interstitial histiocytes. Clonal analysis revealed that a pathogenic monoclonal light chain was derived from germline gene, Vκ1-39.

Diagnoses:

The diagnosis of crystalline light chain inclusion-associated kidney disease was made.

Interventions and outcomes:

Bortezomib and dexamethasone were started and her renal function improved to eGFR 36 mL/min/1.73 m2 after 9 courses of therapy.

Lessons:

Patients with light chain crystalline podocytopathy may have a similar pathogenic monoclonal light chain derived from the same germline gene, Vκ1–39, to that of patients with light chain proximal tubulopathy.
Extrauterine epithelioid trophoblastic tumors presenting as lung mass
Authors: Li Jia-Wen , Hu Chang-Chang , Shi Hai-Yan , Wu Rui-Jin
Published: January 2019

Rationale:

Extrauterine epithelioid trophoblastic tumors (ETT) is a rare variant of gestational trophoblastic neoplasms. Here we aim to learn more clinical and pathological characteristics of ETT patient with an isolated pulmonary mass without uterine lesions, through a rare case of extra-uterine ETT and 7 cases published in English periodicals literature.

Patient concerns:

A 31-year-old Chinese woman, presented with low-level elevation of serum human chorionic gonadotropin (HCG) for more than 2 years without abnormal symptoms. Dilation and curettage (D&C) was performed and histopathology revealed a secretory phase of endometrium. Chest computed tomography (CT) scan showed a 0.8 cm nodular lesion in the upper left lobe. Then a thoracotomy with left upper lobe segmentectomy was performed.

Diagnosis:

After pathological and immunohistochemistry diagnosis, the case was confirmed as ETT (III).

Interventions:

According to FIGO guideline, the patient took 3 cycles of multivalent chemotherapy consisting of cisplatin and etoposide, alternating with etoposid, methotrexate dactinomycin (EP-EMA).

Outcomes:

The patient had no obvious signs of recurrence after 13 months of follow-up.

Lessons:

When a fertile age woman persistently shows abnormal low-level escalation of HCG, ETT should be taken into consideration, especially lung X-ray or CT showing lesions without apparent abnormality of the uterus.
Adjuvant chemotherapy improves oncological outcomes of resectable intrahepatic cholangiocarcinoma
Authors: Ma Ka Wing , Cheung Tan To , Leung Brian , She Brian Wong Hoi , Chok Kenneth Siu Ho , Chan Albert Chi Yan , Dai Wing Chiu , Lo Chung Mau
Published: January 2019

Objective:

To define the role of adjuvant chemotherapy in the management of resectable intrahepatic cholangiocarcinoma (ICC) by performing a meta-analysis.

Summary background data:

Oncological benefit of adjuvant chemotherapy in resectable ICC remains controversial, high-level evidence in such context is lacking.

Method:

A comprehensive search using Pubmed, EMbase, and Web of Science was performed from inception to October 2018. Studies compared the survival of patients receiving adjuvant chemotherapy versus surgery alone were included. Data were analyzed using random effect model. Quality of each study and presence of publication bias were assessed by Newcastle–Ottawa score (NOS) and funnel plot with Egger test respectively.

Results:

The present meta-analysis included 15 studies (all were retrospective series) and 5060 patients. Adjuvant chemotherapy was administered either intravenously or intra-arterially in the form of trans-arterial chemo-embolization (TACE). The average NOS for the included studies was 6.5. Pooled analysis of the included studies demonstrated significant advantage in the adjuvant chemotherapy group (HR 0.66, 0.55–079,P <.001, I-square [I2] = 20.8%). After 2 studies were removed for heterogeneity, advantage of adjuvant chemotherapy remained (HR 0.72, 0.62–0.84,P <.001, I2 = 0%). Funnel plot suggested no significant publication bias (Egger test, 2-tailedP = .203). Subgroup analyses suggested that intravenous route of chemotherapy injection (P <.001) and use of gemcitabine base regimen (P = .004) are associated with improved overall survival. Adjuvant chemotherapy did not improve disease-free survival in subgroup analysis (P = .94).

Conclusion:

Adjuvant chemotherapy is associated with improved overall survival and should be considered in patients with ICC following curative resection and in particular to patients with advance disease.
Clinical effects of pulsed radiofrequency to the thoracic sympathetic ganglion versus the cervical sympathetic chain in patients with upper-extremity complex regional pain syndrome
Authors: Park JungHyun , Lee Yun Jae , Kim Eung Don
Published: January 2019

Pulsed radiofrequency (PRF) to the thoracic sympathetic ganglion (TSG PRF) or to the cervical sympathetic chain (CSC PRF) can be performed to overcome transient effects of single sympathetic blocks in patients with upper-extremity complex regional pain syndrome (CRPS).

We retrospectively compared the clinical effects of TSG PRF and CSC PRF. Seven TSG PRF cases and 10 CSC PRF cases were enrolled in the present analysis. We assessed effectiveness with multiple clinical measurements: a numerical rating scale (NRS) of pain before and 1 week after the procedure, postprocedure temperature, effect duration, and a self-described patient satisfaction score.

The temperature was significantly higher in TSG PRF cases than in CSC PRF cases. Pain values (according to the NRS) 1 week after the procedure were significantly lower, and the effect duration was significantly longer, after TSG PRF than after CSC PRF.

TSG PRF is a more effective procedure than CSC PRF for managing chronic upper-extremity CRPS.
Identification of key genes and pathways in hepatocellular carcinoma
Authors: Wu Min , Liu Zhaobo , Zhang Aiying , Li Ning
Published: January 2019

Background:

Hepatocellular carcinoma (HCC) is one of the most prevalent cancers worldwide. However, the precise mechanisms of the development and progression of HCC remain unclear. The present study attempted to identify and functionally analyze the differentially expressed genes between HCC and cirrhotic tissues by using comprehensive bioinformatics analyses.

Methods:

The GSE63898 gene expression profile was downloaded from the Gene Expression Omnibus (GEO) and analyzed using the online tool GEO2R to identify differentially expressed genes (DEGs). Gene ontology (GO) functional analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis of the DEGs were performed in DAVID. The STRING database was used to evaluate the interactions of DEGs and to construct a protein-protein interaction (PPI) network using Cytoscape software. Hub genes were selected using the cytoHubba plugin and were validated with the cBioPortal database.

Results:

A total of 301 DEGs were identified between HCC and cirrhotic tissues. The GO analysis results showed that these DEGs were significantly enriched in certain biological processes including negative regulation of growth and cell chemotaxis. Several significant pathways, including the p53 signaling pathway, were identified as being closely associated with these DEGs. The top 12 hub genes were screened and included TTK, NCAPG, TOP2A, CCNB1, CDK1, PRC1, RRM2, UBE2C, ZWINT, CDKN3, AURKA, and RACGAP1. The cBioPortal analysis found that alterations in hub genes could result in significantly reduced disease-free survival in HCC.

Conclusion:

The present study identified a series of key genes and pathways that may be involved in the tumorigenicity and progression of HCC, providing a new understanding of the underlying molecular mechanisms of carcinogenesis in HCC.
Fulminant type 1 diabetes mellitus
Authors: You Wei , Yang Jianming , Liu Yanqun , Wang Wen , Zhu Li , Wang Wei , Yang Jun , Chen Fangyuan
Published: January 2019

Rationale:

Fulminant type 1 diabetes mellitus (FT1DM) is a new subtype of type 1 diabetes mellitus that was first proposed by the Japanese scholar Imagawa in 2000. In the 2 patient cases described in this study, gastrointestinal symptoms were the first symptoms reported, and the initial blood glucose levels were very high. However, the glycosylated hemoglobin (HbA1c) levels were not very high, the islet β-cell function was almost completely lost in a short time, and the metabolic disorder was severe; the patients’ islet β cells demonstrated complete and irreversible functional damage, and the prognosis was poor.

Patient concerns:

We report a 37-year-old and 48-year-old male patients. The first patient was addmited with emesis and diarrhea for 2 days and the second patient had stomachache for 8 days, emesis and dyspnea for half an hour before admission. Both patients had no history of hypertension, coronary heart disease, or hyperglycemia.

Diagnosis:

Two patients had same scenario: acute onset, hyperglycemia, ketoacidosis, β cell function deficiency, and HbA1c <8.5%.

Interventions:

After admission, the administration of adequate liquid infusion, the intravenous injection of regular insulin to reduce the blood glucose levels, and the correction of electrolyte disturbance and acid-base imbalance were conducted.

Outcomes:

Subsequently, the blood glucose level of the patients was gradually reduced, the acidosis was corrected, and the disease conditions gradually stabilized. For both patients, the long-term insulin replacement therapy of “insulin aspart plus insulin glargine” was selected.

Lessons:

FT1DM is a new subtype of type 1 diabetes mellitus. The onset of this disease is rapid, and the function of islet β cells is almost completely lost in a short time period. This metabolic disorder is severe, and the clinical manifestations are nonspecific. Unless a timely and accurate diagnosis is made, and patients receive prompt treatment, it is difficult to control the disease and the risk of death is high.
Rapid Cycle Deliberate Practice Versus Reflective Debriefing for Pediatric Septic Shock Training*
Authors: Cory Melinda J. , Colman Nora , McCracken Courtney E. , Hebbar Kiran B.
Published: February 2019

Objectives:

Rapid cycle deliberate practice is a simulation training method that cycles between deliberate practice and directed feedback to create perfect practice; in contrast to reflective debriefing where learners are asked to reflect on their performance to create change. The aim of this study is to compare the impact of rapid cycle deliberate practice versus reflective debriefing training on resident application and retention of the pediatric sepsis algorithm.

Design:

Prospective, randomized-control study.

Setting:

A tertiary care university children’s hospital simulation room, featuring a high-fidelity pediatric patient simulator.

Subjects:

Forty-six upper-level pediatric residents.

Interventions:

Simulation training using rapid cycle deliberate practice or reflective debriefing.

Measurements and Main Results:

Knowledge was assessed with a quiz on core sepsis management topics. The application of knowledge was assessed with a sepsis management checklist during the simulated scenario. The residents were assessed before and after the intervention and again at a follow-up session, 3–4 months later, to evaluate retention. Both groups had similar pre-intervention scores. Post-intervention, the rapid cycle deliberate practice group had higher checklist scores (rapid cycle deliberate practice 18 points [interquartile range, 18–19] vs reflective debriefing 17 points [interquartile range, 15–18]; p < 0.001). Both groups had improved quiz scores. At follow-up, both groups continued to have higher scores compared with the pre-intervention evaluation, with the rapid cycle deliberate practice group having a greater change in checklist score from pre-intervention to follow-up (rapid cycle deliberate practice 5 points [interquartile range, 3.5–7] vs reflective debriefing 3 points [interquartile range, 1.5–4.5]; p = 0.019). Both groups reported improved confidence in diagnosing and managing septic shock.

Conclusions:

Both rapid cycle deliberate practice and reflective debriefing are effective in training pediatric residents to apply the sepsis algorithm and in improving their confidence in the management of septic shock. The rapid cycle deliberate practice method was superior immediately post-training; however, it is unclear if this advantage is maintained over time. Both methods should be considered for training residents.
Voltage-gated Potassium Channel Antibody Autoimmune Encephalopathy Presenting With Isolated Psychosis in an Adolescent
Authors: KAHN DAVID A.
Published: February 2019

Antibody-mediated encephalopathies associated with serum or cerebrospinal fluid antibodies directed against neuronal structures may present with a multitude of neuropsychiatric syndromes. Although some of the antibody-driven conditions are now well recognized in adults (eg, N-methyl-D-aspartate receptor antibody encephalitis), the spectrum of neuropsychiatric manifestations in the pediatric population is less clear. Psychosis, confusion, catatonia, and additional behavioral changes, along with seizures, encephalopathy, and movement disorders, may be initial manifestations or concurrent features in all age groups. Psychosis, when present, is often part of a broader spectrum of neurological and neuropsychiatric symptoms for which the diagnosis of autoimmune encephalitis is considered. The authors present the case of an adolescent with an acute and isolated psychotic presentation of voltage-gated potassium channel antibody encephalitis, further expanding the phenotypic spectrum of this specific antibody-mediated disease and raising the possibility that specific immune-mediated processes may define a biological subgroup of psychoses.
Reward Dysfunction in the Manic Spectrum: Unable to Win? The Use of Biographical Information to Refine Neurobiological Modeling
Authors: GOTTLIEB JOHN F.
Published: February 2019

Objective:

The manic spectrum is thought to be characterized by a hypersensitive biobehavioral reward system, the behavioral activation system. Evidence for this framework comes from questionnaire-based, self-report data collected in cross-sectional and prospective studies of mania, mania in remission, and proneness to hypomania, and from functional neuroimaging investigations of brain reward circuit activity during incentivized choice protocols. Although heightened reward anticipation is consistently documented, the status of later goal attainment activity, hedonic responses, and satiety reactions is less clear. This report examines the status of such reward receipt processes as they operate in the manic spectrum.

Methods:

A case report of a typical subject with bipolar II disorder with a hyperthymic temperament is presented using longitudinal, biographical data.

Results:

Diminished reward receipt, pleasure, and satiety were demonstrated indicating impaired hedonic processing in hyperthymic temperament. This impairment indicates a dissociation between early, intensified reward pursuit processes and later, blunted, reward attainment activity.

Conclusions:

The experience and neural correlates of hedonic processing may be impaired in the manic spectrum. Possible mechanisms for this impairment and its dissociation from the earlier stage of reward processing characterized by hyperactive reward pursuit are considered. Clinical reports and longitudinal, life-based follow-up can provide important data to supplement more experimentally based neurobiological models of reward dysfunction in bipolar disorders.
Use of Rapid Response Teams in Psychiatry: Variables that Impact Safety
Authors: GREYTAK RYAN , WANG JOANNA Y. , HSU YEA-JEN , MARSTELLER JILL , JAYARAM GEETHA
Published: February 2019

Objective:

The addition of rapid response teams (RRTs) has emerged as a treatment option for medically deteriorating psychiatric inpatients. The goal of this study was to identify risk factors for use of RRTs at the time of initial psychiatric evaluation and develop measures to predict use of this emergent medical intervention. We have not located any studies that have previously addressed this issue.

Methods:

We studied the use of RRTs and code teams (CTs) on inpatient general and specialty psychiatric services in a large urban academic psychiatric hospital. RRT or CT calls were made for 60 patients on these units between January, 2010 and December, 2012. Our retrospective chart review study compared the cases of these 60 patients with 120 matched controls. Using χ2 and the Fisher exact tests, we identified variables that differed significantly between the case and control groups. Next, we used a forward stepwise regression model to create prediction tools to risk stratify patients at the time of initial assessment.

Results:

Bivariate analyses identified 14 independent statistically significant patient variables. We created 2 risk prediction tools: (1) an “exhaustive” tool (which used 12 of the total 38 factors we considered) based on a stepwise regression model that yielded an area under the receiver operating curve (AUC) of 0.91, and (2) a simplified tool referred to by the acronym “SCHEME” with 6 factors and an AUC of 0.76.

Conclusions:

We propose the acronym SCHEME to refer to a tool that can be used to quickly and easily assess medical risk in prospective psychiatric inpatients at the time of admission, which can help reduce the use of RRTs and CTs.
Outcomes of Acute Partial Hospital Treatment: Comparison of Two Programs and a Waiting List Control
Authors: LIEBERMAN PAUL B. , VILLALBA RENDUELES , FARRIS SAMANTHA G.
Published: February 2019

Objective:

To investigate the effectiveness of acute, very brief partial hospital treatment, and the comparative benefits of different types of partial hospitalization programs (PHPs), this exploratory study examined changes in psychiatric symptoms and elements of cognitive functioning during an acute PHP compared with a waiting list control, and also compared such changes in 2 PHPs that treated similar patient groups but used different treatment approaches.

Methods:

Patients were admitted to 2 PHPs, one utilizing cognitive-behavioral therapy and the other interpersonal and existential psychotherapy. Assessments were collected at the start of a waiting list control period, as well as at admission to and discharge from the PHP. In both programs, patients completed self-report assessments of anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory), hopelessness (Beck Hopelessness Scale), and resilience (Dispositional Resilience Scale) at admission and discharge; a subset of cognitive-behavioral therapy patients completed the same measures while on a waiting list.

Results:

During acute partial hospitalization (mean length of stay, 5.3±3.0 d), patients (N=2000) improved significantly (Cohen d=0.39 to 1.1) on all 4 measures of symptom severity and cognitive functioning. Although some changes were observed in the subjects on the 2-week waiting list, they were less than during a 1-week PHP admission. No significant differences in outcomes were found between the 2 PHPs.

Conclusions:

Across 2 different acute PHPs, significant reductions in symptom severity and improvements in elements of cognitive functioning were observed. Findings indicate that acute PHP treatment may produce moderate-sized treatment effects in a 1-week period that seem unrelated to specific psychotherapeutic methods.
Rural Assertive Community Treatment and Telepsychiatry
Authors: SWANSON CHARLIE L. , TRESTMAN ROBERT L.
Published: January 2019

Assertive community treatment (ACT) is an evidence-based treatment for patients with severe and persistent mental illness. ACT has been shown to reduce inpatient hospitalization and is increasingly being used as a mainstay of evidence-based psychiatric practice for these clinical populations. The increasing implementation of evidence-based practices has led to the expansion of ACT in rural areas. Variability in the adaptation of ACT in rural areas has included accommodation by teams to multiple barriers. One way to increase psychiatric professional efficiency in rural areas is with telepsychiatry and possibly with rural ACT, but with unknown effects on fidelity and outcomes. Telepsychiatry has been considered a means of expanding the reach of and access to ACT. Concerns about the use of telepsychiatry by ACT teams include the psychiatrist’s ability to develop a relationship with patients and staff and difficulties observing the patient’s entire living environment via telemedicine. The Piedmont Community Services Board (CSB) Program for Assertive Community Treatment (PACT) serves patients in southwestern Virginia in collaboration with the Virginia Tech Carilion School of Medicine. The Piedmont CSB PACT uses telemedicine to expand the treating psychiatrist’s reach and contact with PACT patients, increasing the efficiency of the psychiatrist’s PACT time. Telemedicine is used for crisis intervention and augmentation of regular ongoing visits. The goals of this project were to measure patient, staff, and psychiatrist comfort and satisfaction with the use of telepsychiatry in ACT in addition to monitoring routine outcome measures.
Impact of Borderline Personality Pathology on Treatment Outcomes in Adolescents in Residential Treatment: The Role of Emotion Regulation
Authors: GRATZ KIM L. , BENTLEY JOHN P. , YOUNG JOHN
Published: January 2019

Despite growing research on the impact of borderline personality pathology (BPP) on treatment outcomes for emotional disorders among adults, no studies have examined this question in adolescents. Moreover, no studies have examined mediators of the relation between BPP and changes in mood and anxiety symptoms during treatment. This study examined the impact of BPP on treatment outcomes in 141 adolescents in psychiatric residential treatment, as well as the mediating role of change in emotion regulation (ie, adaptive responses to emotions) in the relation between baseline BPP and improvements in psychiatric symptoms during treatment. Participants completed questionnaires assessing emotion regulation and depression, anxiety, and posttraumatic stress disorder symptoms at baseline and posttreatment. Although BPP was not directly associated with the magnitude of change in psychiatric symptoms from baseline to posttreatment, it was positively associated with greater improvement in emotion regulation during treatment. Furthermore, results revealed significant indirect effects of BPP on improvements in all psychiatric symptoms through improvement in emotion regulation.
Early Enteral Nutrition Following Gastrointestinal Surgery in Children
Authors: Braungart Sarah , Siminas Sotirios
Published: February 2019

Objective:

To investigate the safety and effectiveness of early enteral feeding versus traditional enteral feeding after gastrointestinal (GI) anastomosis in children in the pediatric literature.

Summary of Background Data:

Prolonged postoperative fasting has been the traditional model of care following pediatric GI surgery. In contrast, early feeding has become well established in the adult population, where meta-analyses have shown early introduction of enteral feeds to be beneficial to hospital stay and patient outcomes.

Methods:

Comprehensive literature searches of the English literature search (PubMed, Ovid, Embase databases) from inception to present according to the PRISMA guidelines. Included studies were assessed according to the MINORS criteria. Outcomes for time to first feed and full feeds, and discharge, and risk of major complications were synthesized.

Results:

Ten studies comprising 451 patients were included in the analysis. All studies aimed at investigating the safety of early feeding in pediatric GI surgery, with or without a fast-track program. Only 4 studies compared the study group to a control group in which patients were fed in a traditional way (traditional feeding).

Most studies defined early feeding as feeds commenced ≤24 hours postoperatively (range 2–72 hours). Mean time to first feed was significantly lower in the early feeding group, but not significantly lower for the mean time to full feeds and mean hospital stay. Bowel obstruction and anastomotic breakdown were classed as major complications. There was no significant difference in their occurrence in both groups.

Conclusions:

Although the studies identified are few and heterogeneous, they demonstrate that there is no clear advantage of keeping children “nil by mouth” and no clear disadvantage of providing early enteral nutrition following elective gastrointestinal surgery. Larger randomized controlled trials are required to assess the true impact on postoperative complications, health care associated costs, and to investigate patient-reported outcome measures.
Alcohol Withdrawal Syndrome
Authors: Glann Judith K. , Carman Margaret , Thompson Julie , Olson David , Nuttall Cynthia , Fleming Holly , Reese Cheryl
Published: January 2019

Alcoholism continues to be a persistent health problem in the United States, accounting for up to 62% of emergency department (ED) visits. This quality improvement (QI) project examined whether identifying the benefit for early use of Alcohol Use Disorders Identification Test (AUDIT C) and Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIW-ar) in the ED would avoid escalation of care and offset poor outcomes of alcohol withdrawal syndrome (AWS). A preimplementation chart review (N= 99) showed an average of 12%–15% of patients requiring escalation of care at the project site. The QI project utilized a single-group, pre-/posttest design. The setting was a Southwest Veterans Affair tertiary care referral center. Thirty-five ED staff members were surveyed for baseline knowledge and attended education sessions, led by an advanced practice nurse, on the use of AUDIT-C and CIWA-ar. Posteducation, patients admitted to the hospital were screened with AUDIT-C and treated with CIWA-ar. Postimplementation, charts were reviewed for admitted patients (N= 42) on the use of AUDIT-C, CIWA-ar, length of stay (LOS), and area patient treated. Although the test scores after didactic education were statistically significant (p≤ 0.050), there was no significant difference in the use of AUDIT-C or CIWA-ar in the ED, nor a significant decrease in LOS for those patients with CIWA-ar ordered. However, the potential for clinical benefit could not be disavowed. Barriers to implementation included survey fatigue, inability to embed AUDIT-C in the electronic medical record, inconsistency in completing AUDIT-C, interrater reliability, and patient fear of stigmatization. Advanced practice nurses provide an integral role to augment early identification and treatment of AWS in the ED.
Alternatives to tokamaks: a faster-better-cheaper route to fusion energy?
Authors: Clery Daniel
Published: February 2019

The use of thermonuclear fusion as a source for energy generation has been a goal of plasma physics for more than six decades. Its advantages are many: easy access to fuel and virtually unlimited supply; no production of greenhouse gases; and little radioactive waste produced. But heating fuel to the high temperature necessary for fusion—at least 100 million degrees Celsius—and containing it at that level has proved to be a difficult challenge. The ring-shaped magnetic confinement of tokamaks, which emerged in the 1960s, was quickly identified as the most promising approach and remains so today although a practical commercial reactor remains decades away. While tokamaks have rightly won most fusion research funding, other approaches have also been pursued at a lower level. Some, such as inertial confinement fusion, have emerged from nuclear weapons programs and others from academic efforts. A few have been spun out into start-up companies funded by venture capital and wealthy individuals. Although alternative approaches are less well studied, their proponents argue that they could provide a smaller, cheaper, and faster route to fusion energy production. This article will survey some of the current efforts and where they stand.

This article is part of a discussion meeting issue ‘Fusion energy using tokamaks: can development be accelerated?’.
The European roadmap towards fusion electricity
Authors: Donné A. J. H.
Published: February 2019

The European roadmap to the realization of fusion electricity breaks the quest into eight missions. For each mission, it reviews the current status of research, identifies open issues, and proposes a research and development programme. ITER is the key facility on the roadmap as it is expected to achieve most of the important milestones on the path to fusion power. The Fusion Roadmap is tightly connected to the ITER schedule and the vast majority of resources in fusion research are presently dedicated to ITER and its accompanying experiments. Parallel to the ITER exploitation in the 2030s, the construction of the demonstration power plant DEMO needs to be prepared. DEMO will for the first time supply fusion electricity to the grid and it will have a self-sufficient fuel cycle. The design, construction and operation of DEMO require full involvement of industry to ensure that, after a successful DEMO operation, industry can take responsibility for commercial fusion power. The European fusion roadmap provides a coherent path towards the fusion power plant, and it proposes in an integrated way to find solutions for all challenges that still need to be addressed.

This article is part of a discussion meeting issue ‘Fusion energy using tokamaks: can development be accelerated?’
The impact of plasma physics on the timescale to a tokamak fusion power plant
Authors: Wilson Howard
Published: February 2019

Some of the main plasma physics challenges associated with achieving the conditions for commercial fusion power in tokamaks are reviewed. The confinement quality is considered to be a key factor, having an impact on the size of the reactor and exhaust power that has to be managed. Plasma eruptions can cause excessive erosion if not mitigated, with implications for maintenance and availability. Disruptions are a major concern—one large disruption could terminally damage the reactor so it is important to understand the loads they impart to the structure, and put in place appropriate protection and an effective avoidance/mitigation strategy. Managing the exhaust of heat and particles from the plasma is likely to be a significant issue, which may be mitigated if an advanced confinement regime can be identified. The advanced divertor structures that may be required to handle the exhaust have a significant impact on the design of a fusion reactor. Three strategies can be identified to take account of the physics challenges, with different implications for the timescale to fusion power: (1) a staged approach with the size of each step determined by our confidence in the predictive capability of our models; (2) a single, big step with contingency built into the design where possible to accommodate the uncertainty in physics predictions and (3) a single big step with optimistic physics assumptions and no contingency, accepting the increased financial and reputational risk that comes with such an approach.

This article is part of a discussion meeting issue ‘Fusion energy using tokamaks: can development be accelerated?’.
On the size of tokamak fusion power plants
Authors: Zohm Hartmut
Published: February 2019

Figures of merit for future tokamak fusion power plants (FPPs) are presented. It is argued that extrapolation from present-day experiments to proposed FPPs must follow a consistent development path, demonstrating the largest required leaps in intermediate devices to allow safe extrapolation to an FPP. This concerns both plasma physics and technology. At constant plasma parameters, the figures of merit depend on both major radius
R
and magnetic field
B
. We propose to use the term ‘size’ for a combination of
R
and
B
to avoid ambiguities in scaling arguments. Two routes to FPPs are discussed: the more conventional one increasing
R
, based on the assumption that
B
is limited by present technology; and an alternative approach assuming the availability of new technology for superconducting coils, allowing higher
B
. It is shown that the latter will lead to more compact devices, and, assuming a criterion based on divertor impurity concentration, is in addition more favourable concerning the exhaust problem. However, in order to obtain attractive steady-state tokamak FPPs, the required plasma parameters still require considerable progress with respect to present experiments. A credible strategy to arrive at these must hence be shown for both paths. In addition, the high-field path needs a demonstration of the critical technology items early on.

This article is part of a discussion meeting issue ‘Fusion energy using tokamaks: can development be accelerated?’.
Smaller and quicker with spherical tokamaks and high-temperature superconductors
Authors: Windridge Melanie
Published: February 2019

Research in the 1970s and 1980s by Sykes, Peng, Jassby and others showed the theoretical advantage of the spherical tokamak (ST) shape. Experiments on START and MAST at Culham throughout the 1990s and 2000s, alongside other international STs like NSTX at the Princeton Plasma Physics Laboratory, confirmed their increased efficiency (namely operation at higher beta) and tested the plasma physics in new regimes. However, while interesting devices for study, the perceived technological difficulties due to the compact shape initially prevented STs being seriously considered as viable power plants. Then, in the 2010s, high-temperature superconductor (HTS) materials became available as a reliable engineering material, fabricated into long tapes suitable for winding into magnets. Realizing the advantages of this material and its possibilities for fusion, Tokamak Energy proposed a new ST path to fusion power and began working on demonstrating the viability of HTS for fusion magnets. The company is now operating a compact tokamak with copper magnets,
R
0
 ∼ 0.4 m,
R
/
a
 ∼ 1.8, and target
I
p
 = 2MA,
B
t0
 = 3 T, while in parallel developing a 5 T HTS demonstrator tokamak magnet. Here we discuss why HTS can be a game-changer for tokamak fusion. We outline Tokamak Energy's solution for a faster way to fusion and discuss plans and progress, including benefits of smaller devices on the development path and advantages of modularity in power plants. We will indicate some of the key research areas in compact tokamaks and introduce the physics considerations behind the ST approach, to be further developed in the subsequent paper by Alan Costley.

This article is part of a discussion meeting issue ‘Fusion energy using tokamaks: can development be accelerated?’.
Towards a compact spherical tokamak fusion pilot plant
Authors: Costley A. E.
Published: February 2019

The question of size of a tokamak fusion reactor is central to current fusion research especially with the large device, ITER, under construction and even larger DEMO reactors under initial engineering design. In this paper, the question of size is addressed initially from a physics perspective. It is shown that in addition to size, field and plasma shape are important too, and shape can be a significant factor. For a spherical tokamak (ST), the elongated shape leads to significant reductions in major radius and/or field for comparable fusion performance. Further, it is shown that when the density limit is taken into account, the relationship between fusion power and fusion gain is almost independent of size, implying that relatively small, high performance reactors should be possible. In order to realize a small, high performance fusion module based on the ST, feasible solutions to several key technical challenges must be developed. These are identified and possible design solutions outlined. The results of the physics, technical and engineering studies are integrated using the Tokamak Energy system code, and the results of a scoping study are reviewed. The results indicate that a relatively small ST using high temperature superconductor magnets should be feasible and may provide an alternative, possibly faster, ‘small modular’ route to fusion power.

This article is part of a discussion meeting issue ‘Fusion energy using tokamaks: can development be accelerated?’.