bluuebunny/crossref_metadata_2025 huggingface dataset:
Radiographic Results and Complications of 3 Guided Growth Implants
Authors: Shin Yong-Woon , Trehan Samir K. , Uppstrom Tyler J. , Widmann Roger F. , Green Daniel W.
Published: July 2016

Background:

Temporary, implant-mediated hemiepiphysiodesis (ie, guided growth) is an effective and popular treatment method for lower extremity angular deformities. The purpose of this study was to retrospectively evaluate the safety profile of 3 different implants used to correct lower extremity angular deformities in pediatric patients.

Methods:

We retrospectively reviewed a consecutive series of pediatric patients with lower extremity angular deformities who underwent implant-mediated guided growth by 2 surgeons at our institution between 2004 and 2014. Implants were selected according to surgeon preference and included the Biomet peanut plate, Orthofix eight-plate, and Pega Medical hinge plate. Medical records and radiographs were reviewed to assess deformity correction, implant integrity, and complications.

Results:

During the study period, 115 plates (63 Biomet peanut plates, 30 Orthofix eight-plates, and 22 Pega Medical hinge plates) were implanted in 52 patients (24 males, 28 females). Average age at implantation was 11.7 years (12.3 y in males, 11.1 y in females). Average length of follow-up was 18.4 months. There was no significant difference in rate of deformity correction between the implant types (P=0.08).

Three broken screws (2.6%) were observed, all of which involved cannulated screws in peanut plates. Four peanut plates (6.3%) had an implant-related complication: 3 broken screws and 1 screw pullout. Three eight-plates (10.0%) had screw pullout. No complications were observed within either the hinge plate or solid screw groups. Implant-related complications were significantly associated with increased body weight and cannulated screw use (P=0.02 and 0.03, respectively), but not bone age, sex, plate type, or rate of deformity correction. No deep infections, premature growth arrests, or plate breakages were observed.

Conclusions:

Implant-mediated guided growth is a safe technique for pediatric lower extremity angular deformity correction with a low complication rate. This study demonstrated that overweight patients had a significantly higher rate of implant-related complications. Screw breakages were only observed with cannulated screws in peanut plates. Thus, we recommend using solid, noncannulated screws in overweight children who are at an increased risk of implant failure.

Level of Evidence:

Level IV—retrospective case series.
Joint Salvage Procedures for Failed First Metatarsal Phalangeal Joint Cheilectomy
Authors: Liechti Daniel J. , Backus Jonathon D. , Clanton Thomas O.
Published: July 2016

Hallux rigidus is a painful arthritic condition of the first metatarsal phalangeal joint. For over 40 years, cheilectomy has been considered a first-line surgical treatment for mild and moderate cases of hallux rigidus. Despite successful results in the majority of cases, cheilectomy sometimes fails. Therefore, a number of revision surgical treatment options are available including joint-salvaging procedures such as repeat cheilectomy, dorsal osteotomy of the proximal phalangeal base, or interposition arthroplasty with allograft tissue. These revision surgical procedures will be discussed along with factors such as patient age, activity level, reason for primary failure, and severity of hallux rigidus that aid in decision-making.

Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
Prognostic Value of Secretoneurin in Critically Ill Patients With Infections
Authors: Røsjø Helge , Stridsberg Mats , Ottesen Anett H. , Nygård Ståle , Christensen Geir , Pettilä Ville , Linko Rita , Karlsson Sari , Varpula Tero , Ruokonen Esko , Omland Torbjørn
Published: July 2016

Objectives:

Secretoneurin is produced in neuroendocrine cells, and the myocardium and circulating secretoneurin levels provide incremental prognostic information to established risk indices in cardiovascular disease. As myocardial dysfunction contributes to poor outcome in critically ill patients, we wanted to assess the prognostic value of secretoneurin in two cohorts of critically ill patients with infections.

Design:

Two prospective, observational studies.

Setting:

Twenty-four and twenty-five ICUs in Finland.

Patients:

A total of 232 patients with severe sepsis (cohort #1) and 94 patients with infections and respiratory failure (cohort #2).

Interventions:

None.

Measurements and Main Results:

We measured secretoneurin levels by radioimmunoassay in samples obtained early after ICU admission and compared secretoneurin with other risk indices. In patients with severe sepsis, admission secretoneurin levels (logarithmically transformed) were associated with hospital mortality (odds ratio, 3.17 [95% CI, 1.12–9.00]; p = 0.030) and shock during the hospitalization (odds ratio, 2.17 [1.06–4.46]; p = 0.034) in analyses that adjusted for other risk factors available on ICU admission. Adding secretoneurin levels to age, which was also associated with hospital mortality in the multivariate model, improved the risk prediction as assessed by the category-free net reclassification index: 0.35 (95% CI, 0.06–0.64) (p = 0.02). In contrast, N-terminal pro–B-type natriuretic peptide levels were not associated with mortality in the multivariate model that included secretoneurin measurements, and N-terminal pro–B-type natriuretic peptide did not improve patient classification on top of age. Secretoneurin levels were also associated with hospital mortality after adjusting for other risk factors and improved patient classification in cohort #2. In both cohorts, the optimal cutoff for secretoneurin levels at ICU admission to predict hospital mortality was ≈ 175 pmol/L, and higher levels were associated with mortality also when adjusting for Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores.

Conclusions:

Secretoneurin levels provide incremental information to established risk indices for the prediction of mortality and shock in critically ill patients with severe infections.
Application of a MABEL Approach for a T-Cell-Bispecific Monoclonal Antibody: CEA TCB
Authors: Dudal Sherri , Hinton Heather , Giusti Anna M. , Bacac Marina , Muller Magali , Fauti Tanja , Colombetti Sara , Heckel Tobias , Giroud Nicolas , Klein Christian , Umaña Pablo , Benincosa Lisa , Bachl Juergen , Singer Thomas , Bray-French Katharine
Published: July 2016

CEA TCB is a novel T-cell-bispecific (TCB) antibody targeting the carcinoembryonic antigen (CEA) expressed on tumor cells and the CD3 epsilon chain (CD3e) present on T cells, which is currently in Phase 1 clinical trials (NCT02324257) for the treatment of CEA-positive solid tumors. Because the human CEA (hCEA) binder of CEA TCB does not cross-react with cynomolgus monkey and CEA is absent in rodents, alternative nonclinical safety evaluation approaches were considered. These included the development of a cynomolgus monkey cross-reactive homologous (surrogate) antibody (cyCEA TCB) for its evaluation in cynomolgus monkey and the development of double-transgenic mice, expressing hCEA and human CD3e (hCEA/hCD3e Tg), as a potential alternative species for nonclinical safety studies. However, a battery of nonclinical in vitro/ex vivo experiments demonstrated that neither of the previous approaches provided a suitable and pharmacologically relevant model to assess the safety of CEA TCB. Therefore, an alternative approach, a minimum anticipated biological effect level (MABEL), based on an in vitro tumor lysis assay was used to determine the starting dose for the first-in-human study. Using the most conservative approach to the MABEL assessment, a dose of 52 μg was selected as a safe starting dose for clinical study.
A Clinical Evaluation of Efficacy and Safety of Hyaluronan Sponge with Vitamin C Versus Placebo for Scar Reduction
Authors: Amirlak Bardia , Mahedia Monali , Shah Nilay
Published: July 2016

Background:

Scar formation after injury or surgery is a major clinical problem. Individually, hyaluronan, or hyaluronic acid (HA), and vitamin C have been shown to reduce scarring by means of different mechanisms. The authors evaluated the efficacy and safety of an HA sponge system containing an active derivative of vitamin C to determine whether the use of this product promotes healing and reduces inflammation and scarring after surgery.

Methods:

This double-blind, randomized, prospective study was approved by the local institutional review board. Participants who had unilateral or bilateral surgical scars more than 1 month but less than 18 months old were enrolled. Surgical scars were randomly assigned to receive placebo or HA sponge with vitamin C. Three blinded evaluators reviewed photographs of the incision lines and assessed the scars using a visual analog scale. A patient satisfaction survey was also administered. Participants were followed up at 4 weeks, 12 weeks, and 1 year.

Results:

Twenty-three patients were enrolled in the study. Six patients dropped out of the study, for a total of 17 patients included in final analysis. Mean (range) age of patient was 43.5 (25–67) years. Mean (range) body mass index was 27.4 (18–36.9) kg/m2. The mean visual analog scale score for scars receiving HA sponge with vitamin C was slightly lower than the scars receiving placebo, but the difference was not statistically significant (t test; P = 0.9). The HA sponge with vitamin C was found to have significant positive findings on a patient satisfaction survey.

Conclusions:

The HA sponge system with vitamin C is safe to use in any scars older than 4 weeks. It has high patient satisfaction in achieving a better scar after surgery. The micro-roller used to apply the product was easy to use to potentially increase the spread of the medication in older scars.
Supraorbital Rim Syndrome: Definition, Surgical Treatment, and Outcomes for Frontal Headache
Authors: Hagan Robert R. , Fallucco Michael A. , Janis Jeffrey E.
Published: July 2016

Background:

Supraorbital rim syndrome (SORS) is a novel term attributed to a composite of anatomically defined peripheral nerve entrapment sites of the supraorbital rim region. The SORS term establishes a more consistent nomenclature to describe the constellation of frontal peripheral nerve entrapment sites causing frontal headache pain. In this article, we describe the anatomical features of SORS and evidence to support its successful treatment using the transpalpebral approach that allows direct vision of these sites and the intraconal space.

Methods:

A retrospective review of 276 patients who underwent nerve decompression or neurectomy procedures for frontal or occipital headache was performed. Of these, treatment of 96 patients involved frontal surgery, and 45 of these patients were pure SORS patients who underwent this specific frontal trigger site deactivation surgery only. All procedures involved direct surgical approach through the upper eyelid to address the nerves of the supraorbital rim at the bony rim and myofascial sites.

Results:

Preoperative and postoperative data from the Migraine Disability Assessment Questionnaire were analyzed with paired t test. After surgical intervention, Migraine Disability Assessment Questionnaire scores decreased significantly at 12 months postoperatively (P < 0.0001).

Conclusions:

SORS describes the totality of compression sites both at the bony orbital rim and the corrugator myofascial unit for the supraorbital rim nerves. Proper diagnosis, full anatomical site knowledge, and complete decompression allow for consistent treatment. Furthermore, the direct, transpalpebral surgical approach provides significant benefit to allow complete decompression.
Atypical Rapidly Enlarging Orbital Schwannoma
Authors: Ma Kevin K. , Callahan Alison B. , Wang Shih-Hsiu J. , Goldman James E. , Kazim Michael
Published: July 2016

Orbital schwannomas are typically slow-growing benign tumors that can cause gradual loss of vision, proptosis, and limitation of ocular motility. The authors present an atypical case of a rapidly growing orbital apex schwannoma in a patient with preexisting vision loss secondary to presumed sarcoidal optic neuritis. Contrary to the slowly progressive nature of a typical orbital schwannoma, the lesion was observed to enlarge from radiologically undiscernible to 3.5 cm over 4 years.
Effect of Manuka Honey on Eyelid Wound Healing: A Randomized Controlled Trial
Authors: Malhotra Raman , Ziahosseini Kimia , Poitelea Cornelia , Litwin Andre , Sagili Suresh
Published: July 2016

Purpose:

To report outcomes of a randomized trial on the role of “active” Manuka honey on eyelid surgical wound healing.

Method:

Prospective, randomized, single-blinded study was performed for patients undergoing bilateral upper blepharoplasty. Vaseline was applied 4 times a day to both sides for 6 weeks and in addition, one eyelid was randomized to receive Manuka honey twice daily. Postoperative wounds were graded by a masked observer at 1 week, 1 month, and 4 months using Manchester scar scale and a modified eyelid scar grading scale. Patients scored symptoms, expressed preferred side, and of any problems they experienced using honey. Standard photographs were graded by 2 independent assessors.

Results:

Fifty-five patients were randomized. One week after surgery, 46 (29 women, 17 men, mean age 68 years, median 69, range 49–85) were available for analysis. There was a trend toward distortion of the surrounding skin being less (1.6 vs. 1.8,p= 0.07) and the scar being less palpable (1.8 vs. 2.0,p= 0.08) on the Manuka-treated side. Patients reported the scar on the Manuka side to have less stiffness (1.3 vs. 1.6,p= 0.058). At 1 month, all 3 grading scales showed no difference between the 2 sides. At 4 months, scar grading scales showed no differences; however, patients reported scar pain to be significantly less on the Manuka-treated side than control (0.48 vs. 1.9,p= 0.005). Thirty-one of 46 patients believed the scars were similar on both sides, 11 preferred the honey-treated side, and 4 preferred the control.

Conclusion:

Upper eyelid scars treated with or without Manuka honey heal well, without significant difference when assessed by validated scar grading scales; however, honey may provide subjective benefits early, postoperatively.
A Key to Success: Building an Internal Trauma Education Program
Authors: Pirrung Joan Marie
Published: July 2016

Developing an internal education program that specifically meets the needs of your trauma center's nurses is fundamentally an optimal method in educating. This article offers an overview of an internally developed trauma educational series that was created for novice and experienced nurses who work in a Level 1 trauma center.
Epidemiological Characteristics and Overall Burden of Accidental Injuries in Navarra, Spain: Epidemiology of Injuries in Children
Authors: Ferraz-Torres Marta , Belzunegui-Otano Tomás , Martínez-García Oscar , Iriarte-Cerdán Laura , Salgado-Reguero Esther
Published: July 2016

Injuries caused by accidents or violent situations in pediatric patients are a serious social problem where prevention plays a key role. The aim of this study was to describe the epidemiological situation of pediatric injuries in Spain. A prospective study of pediatric patients receiving care in the Emergency Service of the Complejo Hospitalario de Navarra due to for reasons of accidental injury was conducted. The study covered a period of 1 year and assessed a total of 16 variables. There were a total of 8,876 patients, of whom 56.4% were males. Traumatic injuries such as fractures and craniocerebral trauma were identified as the most frequent injuries, occurring as a result of injuries mainly in the home. In females, there was a decrease in the incidence of injuries related to age. There was a greater incidence at the end of the day, during the weekend, and in the months of March to October. The epidemiological profile of pediatric patients who met with accidents in Navarra, Spain, is described. The knowledge of the main areas and factors related to injuries allows us to improve preventive measures, which would contribute to better control in this region of Spain.
Changes in the response to treatment against chronic hepatitis C between 1999 and 2015: data from a prospective cohort
Authors: Mancebo María , Real Luis M. , Mira José A. , Recio Eva , Pérez Elisabet , Monje-Agudo Patricia , Merchante Nicolás , Macías Juan , Neukam Karin , Pineda Juan A.
Published: July 2016

Background

The drug options and strategies for treatment against hepatitis C virus (HCV) infection have changed considerably in the last few years. The aim of this study was to compare the changes in the proportion of nonresponders and patients who achieved a sustained virologic response (SVR) from 1999 to 2015 in one single cohort.

Patients and methods

A total of 522 patients treated against chronic hepatitis C were included prospectively. The time periods were 1999–2002 [interferon (IFN)/ribavirin (RBV)], 2002–2009 (pegylated-IFN/RBV), 2010–2011 (use of IL28B genotype), 2012–2014 (pegylated-IFN/RBV/direct-acting antivirals) and 2015 (IFN-free direct-acting antiviral-based therapy).

Results

The numbers of nonresponders in the study periods in chronological order were as follows: 14 (40%), 76 (21.3%), 7 (8%), 10 (13%), and 0; P=1.1×10–7 and r
2=0.837. The corresponding numbers of patients who achieved SVR were 9 (25.7%), 14 (40.9%), 44 (50.6%), 51 (66.2%), and 64 (90.1%), P=3.3×10–15 and r
2=0.997. Characteristics that may impair SVR, such as advanced fibrosis, genotype 1 infection, HIV coinfection, or treatment experience, did not decrease in the last time periods.

Conclusion

The proportion of nonresponders was significantly reduced using the IL28B genotype as a predictive tool and direct-acting antivirals further improved treatment outcome. Concomitantly, the rates of SVR showed a linear increase.
Therapeutic Modulation of Aortic Stiffness
Authors: Hussein Ahmed Muzhir , Shaaya Ghazwan , Arora Rohit , Al-Khazaali Ali , Al-Khafaji Khalid , Helu Hanan K.
Published: July 2016

Aortic stiffness (AS) is an important predictor of cardiovascular morbidity in humans. The present review discusses the possible pathophysiological mechanisms of AS and focuses on a survey of different therapeutic modalities for decreasing AS. The influence of several nonpharmacological interventions is described: decrease body weight, diet, aerobic exercise training, music, and continuous positive airway pressure therapy. The effects of different pharmacological drug classes on AS are also discussed: antihypertensive drugs—renin–angiotensin–aldosterone system drugs, beta-blockers, alpha-blockers, diuretics, and calcium channel blockers (CCBs)—advanced glycation end product cross-link breakers, statins, oral anti-diabetics, anti-inflammatory drugs, vitamin D, antioxidant vitamins, and endothelin-1 receptor antagonists. All of these have shown some effect in decreasing AS.
Does Pantoprazole Affect the On-Treatment Platelet Reactivity in Patients With Acute STEMI Treated With ADP Receptor Blockers?—A Pilot Prospective Study
Authors: Bolek Tomáš , Samoš Matej , Šimonová Radoslava , Kovář František , Fedor Marián , Galajda Peter , Staško Ján , Kubisz Peter , Mokáň Marián
Published: July 2016

Background:

Proton pump inhibition (PPI) administrated together with adenosine diphosphate (ADP) receptor blockers (ADPRB) significantly reduces the risk of gastrointestinal bleeding. Nevertheless, there is a heated discussion about an interaction between PPI and ADPRB that leads to high on-treatment platelet reactivity (HTPR).

Study Question:

Is there a relationship between pantoprazole PPI and HTPR on ADPRB therapy in patients with acute ST-elevation myocardial infarction (STEMI).

Methods:

Single center pilot study in patients with acute STEMI was performed. This study enrolled totally 87 patients (34 clopidogrel-treated and 53 new ADPRB-treated patients). Pantoprazole was administrated in 33 patients. HTPR was detected with ADP-induced light transmission aggregometry and vasodilator-stimulated phosphoprotein phosphorylation analysis. Samples were taken before coronary angiography (sample 1) and on the next day after the procedure (sample 2).

Results:

No significant differences were found in pantoprazole-treated patients and patients without PPI neither in sample 1 (59.2 ± 29.5% vs. 54.9 ± 22.7%, P = 0.49) nor in sample 2 (43.8 ± 27.2% vs. 37.0 ± 22.9%, P = 0.30). Similarly, there were no significant differences in the platelet reactivity index of vasodilator-stimulated phosphoprotein phosphorylation in both samples (sample 1: 53.3 ± 29.8% vs. 65.0 ± 20.5%, P = 0.11; sample 2: 30.8 ± 27.1% vs. 40.6 ± 27.5%, P = 0.19). A comparison of clopidogrel and new ADP receptor blockers in patients on pantoprazole PPI did not reveal significant differences in on-treatment platelet reactivity.

Conclusions:

This study did not reveal interaction between pantoprazole and ADPRB in patients with acute STEMI.
Primary Care Appointment Availability for Medicaid Patients
Authors: Basseyn Simon , Saloner Brendan , Kenney Genevieve M. , Wissoker Douglas , Polsky Daniel , Rhodes Karin V.
Published: July 2016

Background:

Arkansas and Iowa received waivers from the federal government in 2014 to use federal Medicaid expansion funding to enroll beneficiaries in commercial insurance plans on the Marketplaces. One key hypothesis of these “private option” or “premium assistance” programs was that Medicaid beneficiaries would experience increased access to care. In this study, we compare new patient primary care appointment availability and wait-times for beneficiaries of traditional Medicaid and premium assistance Medicaid.

Methods:

Trained field staff posing as patients, randomized to traditional Medicaid or Marketplace plans, called primary care practices seeking new patient appointments in Arkansas and Iowa in May to July 2014. All calls were made to offices that previously indicated being in-network for the plan. Offices were drawn randomly, within insurance type, based on the county proportion of the population with each insurance type. We calculated appointment rates and wait-times for new patients for traditional Medicaid and Marketplace plans.

Results:

In Arkansas, Marketplace appointment rates were 27.2 percentage points higher than traditional Medicaid appointment rates (83.2% compared with 55.5%, P<0.001), while in Iowa, Marketplace appointment rates were 12.0 percentage points higher (86.3% compared with 74.3%, P<0.001). Conditional on receiving an appointment, median wait-times were roughly 1 week in each state without significant differences by insurance type.

Conclusions:

The experiences of Arkansas and Iowa suggest that enrolling Medicaid beneficiaries into Marketplace plans may lead to higher primary care appointment availability for new patients at participating providers. Further research is needed on whether premium assistance programs affect quality and continuity of care, and at what cost.
Preventive Services Use Among African American and Latino Adult Caregivers in South Los Angeles
Authors: Mendez-Luck Carolyn A. , Walker Kara O. , Luck Jeff
Published: July 2016

Background:

The burden of informal caregiving is significant and well-documented, yet the evidence is mixed as to whether being a caregiver presents an additional barrier to receiving recommended preventive care.

Objectives:

To determine whether (1) caregivers compared with noncaregivers were less likely to receive preventive health services; and (2) higher intensity caregivers were less likely to receive preventive health services than lower intensity caregivers.

Research Design, Subjects, and Measures:

Data were from a telephone survey of Latino and African American adults 50 years or older in South Los Angeles (n=702). Outcomes were flu vaccination, pneumococcal vaccination, and colorectal cancer screening. Logistic regression models adjusted for predisposing, enabling, and need factors according to the Andersen Model of Access to Health Care for Low-income Populations.

Results:

Caregiver type (eg, adult child, nonrelated) was associated with varying odds of receiving a preventive service. Caregivers had lower odds than noncaregivers of receiving preventive services although odds of receiving a flu vaccination improved slightly for caregivers of persons with memory loss compared with other caregivers. More weekly caregiving hours was associated with higher odds of receiving flu vaccination (adjusted odds ratios, 1.1; 95% confidence interval=1.0, 1.1) or colorectal cancer screening (adjusted odds ratios, 1.1; 95% confidence interval=1.0, 1.1). Caregivers and noncaregivers age 65 and older or with chronic conditions were more likely to receive vaccinations.

Conclusions:

Preventive service use was influenced by characteristics of the caregiving situation. An opportunity may exist to leverage care recipients’ ongoing contact with health care providers to increase caregivers’ own access to preventive services.
Constipation and Constipation‐predominant Irritable Bowel Syndrome
Authors: Rajindrajith Shaman , Devanarayana Niranga M. , Benninga Marc A.
Published: July 2016

Objective:

The aim of the present study is to compare functional constipation (FC) and constipation‐predominant irritable bowel syndrome (IBS‐C) in adolescents.

Methods:

A school‐based survey was conducted involving adolescents ages 13 to 18 years. A set of validated questionnaires including Rome III questionnaire for functional gastrointestinal disorders in children/adolescents, somatization inventory, quality of life inventory, and childhood traumatic events inventory were used for data collection. FC and IBS‐C were defined using Rome III criteria.

Results:

A total of 1792 adolescents (975 boys [45.4%]) were included in the analysis. Prevalence of FC and IBS‐C were 7.7% and 1.6%, respectively. Bowel habits such as stool frequency <3 per week (10% vs 44.9%, P < 0.0001), hard stools (20% vs 40.5%, P < 0.05), painful defecation (33.3% vs 56.5%, P < 0.05), large diameter stools (23.3% vs 50.7%, P < 0.01), stool withholding behavior (20% vs 44.2%, P < 0.05), were more commonly associated with FC than did IBS‐C. Occurrence of fecal incontinence (0% vs 8%, P = 0.21), urgency (56.7% vs 66.7%, P = 0.65), and straining (56.7% vs 36.9%, P = 0.47) was not significantly different between IBS‐C and FC. Exposure to physical abuse, emotional abuse, and sexual abuse was equally prevalent among adolescents with FC and IBS‐C. There was no difference between somatization scores, and health‐related quality of life between the 2 groups.

Conclusions:

Although bowel habits related to stool withholding are more prevalent in FC, than in IBS‐C, they are more likely to be a spectrum of a disorder rather than 2 separate entities.
Process Improvement to Enhance Quality in a Large Volume Labor and Birth Unit
Authors: Bell Ashley M. , Bohannon Jessica , Porthouse Lisa , Thompson Heather , Vago Tony
Published: July 2016

Background:

The goal of the perinatal team at Mercy Hospital St. Louis is to provide a quality patient experience during labor and birth. After the move to a new labor and birth unit in 2013, the team recognized many of the routines and practices needed to be modified based on different demands.

Methods:

The Lean process was used to plan and implement required changes. This technique was chosen because it is based on feedback from clinicians, teamwork, strategizing, and immediate evaluation and implementation of common sense solutions. Through rapid improvement events, presence of leaders in the work environment, and daily huddles, team member engagement and communication were enhanced. The process allowed for team members to offer ideas, test these ideas, and evaluate results, all within a rapid time frame. For 9 months, frontline clinicians met monthly for a weeklong rapid improvement event to create better experiences for childbearing women and those who provide their care, using Lean concepts. At the end of each week, an implementation plan and metrics were developed to help ensure sustainment. The issues that were the focus of these process improvements included on-time initiation of scheduled cases such as induction of labor and cesarean birth, timely and efficient assessment and triage disposition, postanesthesia care and immediate newborn care completed within approximately 2 hours, transfer from the labor unit to the mother baby unit, and emergency transfers to the main operating room and intensive care unit.

Results:

On-time case initiation for labor induction and cesarean birth improved, length of stay in obstetric triage decreased, postanesthesia recovery care was reorganized to be completed within the expected 2-hour standard time frame, and emergency transfers to the main hospital operating room and intensive care units were standardized and enhanced for efficiency and safety. Participants were pleased with the process improvements and quality outcomes.

Clinical Implications:

Working together as a team using the Lean process, frontline clinicians identified areas that needed improvement, developed and implemented successful strategies that addressed each gap, and enhanced the quality and safety of care for a large volume perinatal service.
Engaging Transgender People in NIH-Funded HIV/AIDS Clinical Trials Research
Authors: Siskind Rona L. , Andrasik Michele , Karuna Shelly T. , Broder Gail B. , Collins Clare , Liu Albert , Lucas Jonathan Paul , Harper Gary W. , Renzullo Philip O.
Published: July 2016

In 2009, the National Institutes of Health recognized the need to expand knowledge of lesbian, gay, bisexual, and transgender (LGBT) health and commissioned the Institute of Medicine to report on the health of these populations in the United States. The resulting Institute of Medicine publication called for more knowledge of the health of LGBT populations, as well as improved methodologies to reach them, more LGBT-focused research, and enhanced training programs and cultural competency of physicians and researchers. Several of the National Institutes of Health–funded HIV/AIDS clinical trials networks, including the Adolescent Medicine Trials Network for HIV/AIDS Interventions, HIV Prevention Trials Network, HIV Vaccine Trials Network, and Microbicide Trials Network, have focused attention on engaging transgender (TG) individuals in research. They have identified issues that transcend the nature of research (ie, treatment or prevention, adult or adolescent) and have adopted various approaches to effectively engage the TG community. Each network has recognized the importance of developing partnerships to build trust with and seek input from TG individuals on research plans and policies. They have established standing advisory groups and convened consultations for this purpose. To ensure that trial data are reflective of the participants they are seeking to enroll, they have reviewed and revised data collection forms to incorporate the 2-step method of collecting sex at birth and gender identity as 2 independent variables, and some have also revised research protocol templates and policies for concept development to ensure that they are appropriate for the inclusion of TG participants. The networks have also initiated trainings to enhance cultural sensitivity and developed a range of materials and resources for network and clinical research site staff. They continue to identify TG-specific research needs in an effort to be more responsive to and improve the health of TG individuals, particularly related to HIV/AIDS.
Transgender Women in Clinical Trials of Pre-Exposure Prophylaxis
Authors: Grant Robert M. , Sevelius Jae M. , Guanira Juan V. , Aguilar Jana Villayzan , Chariyalertsak Suwat , Deutsch Madeline B.
Published: July 2016

Lessons were learned with trans women who participated (as volunteers and investigators) in trials of HIV pre-exposure prophylaxis (PrEP). Trans women are not men. Compared with men who have sex with men, trans women trial participants were more likely to be involved with transactional sex, had more sexual partners, and were less likely to have PrEP medications detected in blood. Trans women define themselves differently in different cultures. One best practice is to ask at least 2 gender questions: sex assigned at birth and current gender. More information is needed to fully situate PrEP efficacy for trans women, including analysis of drug–drug interactions between PrEP medications and feminizing hormones and PrEP drug penetration into neovaginal tissues. Including trans women in studies is helpful only if their participation is specifically reported, as could occur in a table of baseline characteristics of the enrolled cohort. Gender-affirming care is important to foster appropriate uptake and use of PrEP. Such care includes use of preferred pronouns and names, safety to use the bathroom of choice, and access to gender-affirming hormone therapy and surgery. The consistent finding that PrEP works when taken across diverse populations having diverse practices related to gender, sexual intercourse, and hormone use provides a basis for offering PrEP to people at substantial risk of acquiring HIV although some subgroups may not have been fully represented in trials. Nonetheless, specific PrEP implementation science for trans women (and men) is essential to develop best practices for PrEP delivery and use.
Expanded Cheek-Shaped Flap for Aesthetic Cheek Reconstruction in the Cervicoperiauricular Area
Authors: Tian Jia , Fan Jincai , Liu Liqiang , Gan Cheng , Yang Zengjie , Chen Wenlin , Yin Zhuming
Published: July 2016

Background

The cervical area is well acknowledged as an ideal donor site for aesthetic reconstruction of the cheek, and tissue expansion may play an important role for maximally achieving such a purpose. However, the conventional design of the expanded cervical flap generally results in unsightly morbidity of the donor site. The aim of this study is to evaluate the results of using an improvised cervical expanded flap in aesthetic reconstruction of the cheek.

Methods

From July 2004 to October 2012, a total of 23 burn sequelae patients (30 cheeks) underwent cheek reconstruction with an expanded flap that originated from the cervicoperiauricular area. The procedures were initially carried out with the insertion of a round tissue expander in the cervicoperiauricular area, followed by serial inflation of the expander, and finally, transplantation of the expanded flap to the cheek in a rotation advancement fashion. The donor site closure was along the auricular sulcus.

Results

The average area of the harvested flaps was 9.7 × 8.1 cm. All the flaps completely survived, only one major complication occur-a dome exposure of the tissue expander after the expansion was completed. The flap was salvaged, and the transfer stage was done without intact. Minor complications after flap transfer include: widened scar at the donor site, a “dog-ear” needing additional minor surgery, distal part of the flap transient congestion. The patients achieved very satisfactory results functionally and aesthetically.

Conclusions

Using the expanded cheek-shaped flap technique can provide a safe, thin, and color-matched flap in aesthetic reconstruction of the cheek with minimal donor site morbidity.
Using a Low Fluence Q-Switched 532/1064-nm Nd
Authors: Shen Jen-Hsiang , Chang Chang-Cheng , Chen Yu-Tsung , Hsih Chao-Jen , Huang Hsin , Lin Bor-Shyh
Published: July 2016

Background and Objectives

Low fluence Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers are widely applied for facial depigmentation. Nonetheless, few reports analyze the general outcome, complications, of single and combined therapy of 532/1064-nm Nd:YAG lasers in Asian patients with Fitzpatrick type IV skin.

Study Design/Materials and Methods

We retrospectively reviewed all consecutive patients who completed 5 consecutive sessions at 1-month intervals of treatment with 1064-nm (spot size: 5–7 mm, 1.5–2.0 J/cm2) or combined with 532-nm (spot size, 2–3 mm; 0.5–1.5 J/cm2) Nd:YAG laser (Laseroptek, Korea) from October 2011 to March 2013. The patients, laser surgeon, and 3 blinded reviewers assessed the outcomes and complications. Improvement was graded as follows: 1, 0%–25%; 2, 26%–50%; 3, 51%–75%; 4, 76–90%; and 5, greater than 90%. Postinflammatory hyperpigmentation (PIH) was documented according to the severity (1, slight; 2, moderate; 3, severe; and 4, extreme). Other post-laser side effects were also documented (eg, scaling, dryness, erythema, and pruritus).

Results

Four male patients and 37 female patients were included with a mean age of 38.5 years (SD, 10.1 years). There were no significant differences on patients', surgeon's, or blinded reviewers' improvement gradings. (4.11 ± 0.62 vs 4.30 ± 0.46, P = 0.54; 3.88 ± 0.66 vs 3.89 ± 0.31, P = 0.50; 3.30 ± 0.69 vs 3.74 ± 0.38, P = 0.34). Transient minor side effect occurred as follows: erythema in 9 (22%), pruritus in 7 (17%), dryness in 6 (15%), and scaling in 6 (15%). There was no risk difference in these side effects between groups. The PIH scores were slight in 10 patients (4 in single and 6 in combined), severe in 4 (3 in single and 1 in combined), and extreme in 1 (single therapy). The PIH incidence also did not differ (33.3%, 35.3%; P = 0.58).

Conclusions

We reported satisfactory outcomes after low-fluence Q-switched sole 1064-nm or combined 532/1064-nm therapy. The outcome and complication profiles did not differ between the groups. The PIH incidence was not low, but usually transient. The incidence of severe or extreme PIH was rare.
Comparison of Short-term Outcomes After Laparoscopic Versus Open Hartmann Reversal: A Case-matched Study
Authors: Onder Akin , Gorgun Emre , Costedio Meagan , Kessler Hermann , Stocchi Luca , Benlice Cigdem , Remzi Feza
Published: July 2016

Purpose:

The aim of this study is to compare short-term outcomes of laparoscopic versus open Hartmann reversal.

Materials and Methods:

Patients who underwent Hartmann reversal between January 2005 and September 2014 were identified and matched for age, sex, body mass index, American Society of Anesthesiologists score, and creation of diverting ileostomy to open counterparts. Patient characteristics and postoperative outcomes (30 d) were evaluated.

Results:

Eighteen patients with laparoscopic Hartmann reversal were matched to 18 open patients. There were no differences between laparoscopic versus open groups in terms of operative time (157.7±52.2 vs. 151.5±49.3 min,P>0.05) or overall complication rates [6 (33.3%) vs. 6 (33.3%) (P>0.05)]. No anastomotic leaks or mortality occurred in either group. However, the laparoscopic group was associated with significantly decreased estimated blood loss (114±103 vs. 217±125 mL,P<0.05), faster return of bowel function (3.2±0.6 vs. 4±0.6 d,P<0.05), and reduced hospital stay (5.4±3.1 vs. 8.3±4.8 d,P<0.05).

Conclusions:

Laparoscopic Hartmann reversal can be safely performed with better short-term outcomes in carefully selected patients.
Triathlete Risk of Pelvic Floor Disorders, Pelvic Girdle Pain, and Female Athlete Triad
Authors: Yi Johnny , Tenfelde Sandi , Tell Dina , Brincat Cynthia , Fitzgerald Colleen
Published: July 2016

Objectives

Our primary objective was to describe the prevalence of pelvic floor disorders (PFDs), pelvic girdle pain (PGP), and the female athlete triad (disordered eating, menstrual irregularities, and osteoporosis) in a female triathlete population. We also evaluated for an association between these conditions.

Methods

We administered an online survey to women who self-identified as female triathletes. Using validated questionnaires, Epidemiology of Prolapse and Incontinence Questionnaire and Pelvic Girdle Questionnaire, along with the female athlete triad questionnaire, we identified the prevalence of PFDs, PGP, and female athlete triad in this specific population. Demographic and exercise intensity were also queried to characterize these female triathletes.

Results

Three hundred eleven female triathletes responded to the Internet survey. There was a significant prevalence of PFDs with stress urinary incontinence and anal incontinence symptoms being most common (37.4% and 28%, respectively). Urgency urinary incontinence and pelvic organ prolapse were less common (16% and 5%, respectively). Stress urinary incontinence and pelvic organ prolapse were more common in parous triathletes (P = 0.001, P = 0.05). Pelvic girdle pain was noted in 18% of these triathletes but was not disabling. Twenty-four percent of participants screened positive for at least 1 arm of the female athlete triad. No association was found between the female athlete triad and PFDs.

Conclusions

Pelvic floor disorders are common and bothersome in female triathletes. Pelvic girdle pain, while present, does not limit these athletes from their training. These female triathletes may be at risk for the female athlete triad. Female triathletes may be at risk for both metabolic and PFDs and should be screened when identified.
Persistent Postoperative Pain: Pathophysiology, Risk Factors, and Prevention
Authors: Butrick Charles W.
Published: July 2016

Objective

Persistent postoperative pain (PPOP) is the second most common reason for a patient to seek care at a chronic pain center. Many of the patients seen with prolapse or incontinence are at risk for developing PPOP as a result of the surgeries done for these problems. The pathophysiology of this disabling pain disorder is well understood, and the risk factors are easy to identify. Once identified, perioperative interventions can be offered to attempt to prevent PPOP.

Methods and Results

Evaluation of articles obtained using a MEDLINE search involving chronic pain and PPOP, including prevalence, pathophysiology, and prevention was reviewed. The concept of central censitization and the key role it plays in chronic pain disorders were also reviewed. A history of chronic pain (anywhere) as well as findings of levator myalgia, allodynia, and hypertonic pelvic floor disorders is critical in identifying patients at risk for PPOP.

Conclusions

Identification of patients at risk allows the clinician to educate the patient about the risk of PPOP and the various perioperative interventions that can be used to prevent its development. Further studies will be required to determine how effective these interventions are in patients undergoing surgery for incontinence and/or pelvic organ prolapse.
Outpatient Narcotic Use After Minimally Invasive Urogynecologic Surgery
Authors: Swenson Carolyn W. , Kelley Angela S. , Fenner Dee E. , Berger Mitchell B.
Published: July 2016

Objectives

To quantify outpatient narcotic use in the first 2 weeks after urogynecologic surgery.

Methods

Using a convenience sample, women who underwent minimally invasive urogynecologic surgery between May and October 2014 were contacted by telephone 2 weeks postoperatively and given a questionnaire regarding their postoperative pain experience. To quantify narcotic use, patients were asked to count the tablets remaining from their discharge narcotic prescription. Postoperative pain scores and pain expectations were also assessed. Women using more than 30 narcotics were in the top quartile for use; therefore, those using 30 or fewer versus more than 30 were compared. Logistic regression was used to identify independent factors associated with women in the top quartile for postoperative narcotic use.

Results

Fifty women were included in the study. Median number of narcotics used was 13 (interquartile range (IQR), 1-30) versus 40 (IQR, 35-60) prescribed. Compared to women who used 30 or fewer narcotics (n=38), those using more than 30 (n=12) more frequently were taking narcotics before surgery (13.2% vs 41.7%; P=0.03) and had a chronic pain diagnosis (15.8% vs 58.3%; P=0.003). Although pain scores were similar, women who took more than 30 narcotics more frequently reported their postoperative pain to be much worse or worse than expected (7.9% vs 33.3%; P=0.048). In logistic regression, chronic pain remained the only factor associated with using more than 30 narcotics (odds ratio, 7.36; 95% confidence interval, 1.00-54.03; P=0.0496).

Conclusions

Women used one third of the narcotics they were prescribed after minimally invasive urogynecologic surgery. These data may be useful for establishing narcotic prescription guidelines.
Modelling tree growth taking into account carbon source and sink limitations
Authors: Hayat Amaury , Hacket-Pain Andrew J. , Pretzsch Hans , Rademacher Tim Tito , Friend Andrew D.
Published: July 2016

Increasing CO2concentrations are strongly controlled by the behaviour of undisturbed forests, which are believed to be a major current sink of atmospheric CO2. There are many models which predict forest responses to environmental changes but they are almost exclusively carbon source (i.e. photosynthesis) driven. Here we present a model for an individual tree that takes into account also the intrinsic limits of meristems and cellular growth rates, as well as control mechanisms within the tree that influence its diameter and height growth over time. This new framework is built on process-based understanding combined with differential equations solved by the Runge-Kutta-Fehlberg (RKF45) numerical method. It was successfully tested for stands of beech trees in two different sites representing part of a long-term forest yield experiment in Germany. This model provides new insights into tree growth and limits to tree height, and addresses limitations of previous models with respect to sink-limited growth.

Author Summary

Greenhouse gas emissions, in particular of CO2, have emerged as one of the most important global concerns, and it is therefore important to understand the behaviour of forests as they absorb and store a very large quantity of carbon. Most models treat forests as boxes with growth only driven by photosynthesis, while their actual growth depends also on many other important processes such as the maximal rate at which individual cells can grow, the influences of temperature and soil moisture on these cells, and the control that the tree has on itself through endogenous signalling pathways. Therefore, and with inspiration from process-based understanding of the biological functioning of trees, we have developed a model which takes into account these different factors. We first use this knowledge and additional basic assumptions to derive a system of several equations which, when solved, enable us to predict the height and the radius of an individual tree at a given time, provided that we have enough information about its initial state and its surroundings. We use the Runge-Kutta-Fehlberg mathematical method to obtain a numerical solution and thus predict the development of the height and radius of an individual tree over time under specified conditions.
Inference of epistatic effects leading to entrenchment and drug resistance in HIV-1 protease
Authors: Flynn William F. , Haldane Allan , Torbett Bruce E. , Levy Ronald M.
Published: July 2016

Understanding the complex mutation patterns that give rise to drug resistant viral strains provides a foundation for developing more effective treatment strategies for HIV/AIDS. Multiple sequence alignments of drug-experienced HIV-1 protease sequences contain networks of many pair correlations which can be used to build a (Potts) Hamiltonian model of these mutation patterns. Using this Hamiltonian model we translate HIV protease sequence covariation data into quantitative predictions for the probability of observing specific mutation patterns which are in agreement with the observed sequence statistics. We find that the statistical energies of the Potts model are correlated with the fitness of individual proteins containing therapy-associated mutations as estimated by in vitro measurements of protein stability and viral infectivity. We show that the penalty for acquiring primary resistance mutations depends on the epistatic interactions with the sequence background. Primary mutations which lead to drug resistance can become highly advantageous (or entrenched) by the complex mutation patterns which arise in response to drug therapy despite being destabilizing in the wildtype background. Anticipating epistatic effects is important for the design of future protease inhibitor therapies.