bluuebunny/crossref_metadata_2025 huggingface dataset:
The Division Between Sense Perception and Non-Sensory Doxa in the Interlude
Authors: Rowett Catherine
Published: May 2018

This chapter investigates the famous passage at Theaetetus 184–186, widely discussed for its distinction between aisthesis and doxa. Past interpretations of this passage are discussed, and a deflationary interpretation is offered, whereby Socrates’ proposed distinction relates solely to whether the soul uses bodily organs in observing the properties it is detecting. In the light of this simple interpretation, it emerges that both aisthesis (in its new technical sense) and doxa (which was formerly part of a broader notion of aisthesis) are ways of observing simple properties—that is, tropes (not propositions or concepts)—and that neither can access ‘being’ in the special sense that belongs only to knowing the ‘what it is’ about some concept. In fact, Socrates’ hint that the observations made without organs might be the ones that include being and therefore attain to truth was misleading.
Queer Historiography in The Bridge
Authors: Lurie Peter
Published: May 2018

This chapter culminates my earlier discussion of several works’ regretful looks back on U.S. history with Hart Crane’s plaintive lament over the country’s signal historical events, tempered by his hopefulness for the republic’s future. It uses sexuality theory to argue against a teleological, progressive sequencing—both in my study’s rhetorical structure and in ways of tracing history’s unfolding. It suggests the importance of textual erotics of painful empathy in the reader’s encounter with an indigenous past in its early sections, before turning to in The Bridge’s critique of U.S. aerial history and maritime trade. The poem’s account of displaced historical subjects encompasses this alterity in the figure of its peripatetic speaker across its several sections and historical eras. The chapter ends with a coda about Crane’s suicide as a response to his New Critical peers’ rejection of his nonironic, non-Eliotonian vision and of what they saw as his “undisciplined” style and sexuality.
The use of deep learning to automate the segmentation of the skeleton from CT volumes of pigs1
Authors: Kvam Johannes , Gangsei Lars Erik , Kongsro Jørgen , Schistad Solberg Anne H
Published: May 2018

Computed tomography (CT) scanning of pigs has been shown to produce detailed phenotypes useful in pig breeding. Due to the large number of individuals scanned and corresponding large data sets, there is a need for automatic tools for analysis of these data sets. In this paper, the feasibility of deep learning for fully automatic segmentation of the skeleton of pigs from CT volumes is explored. To maximize performance, given the training data available, a series of problem simplifications are applied. The deep-learning approach can replace our currently used semiautomatic solution, with increased robustness and little or no need for manual control. Accuracy was highly affected by training data, and expanding the training set can further increase performance making this approach especially promising.
Inherent Resistance to 14α-Demethylation Inhibitor Fungicides in Colletotrichum truncatum Is Likely Linked to CYP51A and/or CYP51B Gene Variants
Authors: Chen Shuning , Wang Yunyun , Schnabel Guido , Peng Congyue Annie , Lagishetty Satyanarayana , Smith Kerry , Luo Chaoxi , Yuan Huizhu
Published: May 2018

Anthracnose disease, caused by Colletotrichum truncatum, affects marketable yield during preharvest production and postharvest storage of fruits and vegetables worldwide. Demethylation inhibitor (DMI) fungicides are among the very few chemical classes of single-site mode of action fungicides that are effective in controlling anthracnose disease. However, some species are inherently resistant to DMIs and more information is needed to understand this phenomenon. Isolates of C. truncatum were collected from the United States and China from peach, soybean, citrus, and begonia and sensitivity to six DMIs (difenoconazole, propiconazole, metconazole, tebuconazole, flutriafol, and fenbuconazole) was determined. Compared with DMI sensitive isolates of C. fructicola, C. siamense, and C. fioriniae (EC50 value ranging from 0.03 to 16.2 µg/ml to six DMIs), C. truncatum and C. nymphaeae were resistant to flutriafol and fenbuconazole (with EC50 values of more 50 µg/ml). Moreover, C. truncatum was resistant to tebuconazole and metconazole (with resistance factors of 27.4 and 96.0) and displayed reduced sensitivity to difenoconazole and propiconazole (with resistance factors of 5.1 and 5.2). Analysis of the Colletotrichum spp. genome revealed two potential DMI targets, CYP51A and CYP51B, that putatively encode P450 sterol 14α-demethylases. Both genes were identified and sequenced from C. truncatum and other species and no correlation between CYP51 gene expression levels and fungicide sensitivity was found. Four amino acid variations L208Y, H238R, S302A, and I366L in CYP51A, and three variations H373 N, M376L, and S511T in CYP51B correlated with the DMI resistance phenotype. CYP51A structure model analysis suggested the four alterations may reduce azole affinity. Likewise, CYP51B structure analysis suggested the H373 N and M376L variants may change the conformation of the DMI binding pocket, thereby causing differential sensitivity to DMI fungicides in C. truncatum.
Photobiomodulation or low-level laser therapy in the management of cancer therapy-induced mucositis, dermatitis and lymphedema
Authors: Bensadoun René-Jean
Published: May 2018

Purpose or review

There is a large body of evidence supporting the efficacy of low-level laser therapy (LLLT) also known as PhotoBioModulation (PBM) when used for the prevention and/or treatment of oral mucositis in patients undergoing radiotherapy for head and neck cancer, or high-dose chemotherapy regimens. This review aims at giving the state of the art of this technique in this indication.

Recent findings

Recent advances in LLLT/PBM technology, together with a better understanding of mechanisms involved and dosimetric parameters may lead to the management of a broader range of complications associated with cancer treatment. This could enhance patient adherence to cancer therapy, and improve quality of life and treatment outcomes.

The article discusses LLLT/PBM mechanisms of action, dosimetry, and safety, and aims to identify some cancer treatment side-effects for which LLLT/PBM may prove to be effective (oral mucositis, radiation dermatitis, lymphedema). In addition, LLLT/PBM parameters for each of these complications are suggested and future research directions are discussed.
Acromegalic Cardiomyopathy
Authors: Goldberg Michael D. , Vadera Natasha , Yandrapalli Srikanth , Frishman William H.
Published: May 2018

Acromegaly is a rare endocrine disorder that carries a significant burden of cardiovascular morbidity and mortality. Abnormalities of the growth hormone/insulin-like growth factor-1 axis in acromegaly lead to the characteristic cardiovascular manifestations of this disease. One hallmark feature of the disease is acromegalic cardiomyopathy, a syndrome of progressive cardiac dysfunction characterized by left ventricular hypertrophy, diastolic dysfunction, and combined systolic and diastolic dysfunction in the very advanced stage. In this article, we review the current concepts regarding the pathophysiology of acromegalic cardiomyopathy and discuss the various risk factors for its development. We also explore the question of whether the alterations in cardiac function are reversible with successful biochemical control of growth hormone excess either medically or surgically.
Supporting Development During Military Deployment and After April 2018
Authors: Trier Katherine A. , Pappas Demetra , Bovitz Bryan , Augustyn Marilyn
Published: May 2018

CASE: Ryan is a 6-year-old child new to your primary care practice after relocating from out of state with his father and younger sister. Ryan's grandmother recently expressed concerns about Ryan's social skills and behavior. He was subsequently diagnosed by a developmental and behavioral pediatrician with autism spectrum disorder, global developmental delay, and attention deficit hyperactivity disorder. At your first visit with Ryan, his father provides the following history: When Ryan was 3 years old, he was living with his mother and infant sister while his father was serving his fourth tour of duty with the marines in Afghanistan. One night, while Ryan was sleeping in bed with his mother, she died suddenly from a pulmonary embolism. Ryan's father was then called home from Afghanistan to take care of the children.

Ryan's father explains that this was his first time serving as a primary caregiver for any prolonged period. He felt overwhelmed and unprepared, both cognitively and emotionally, to return from a combat zone and assume full-time, single-parent responsibilities. Ryan's father admitted knowing little about child development and had not had sustained interactions with his own children because of frequent deployments. He did not appreciate the delays and atypicalities in Ryan's development until he moved back home with his own mother and she expressed concerns. Ryan's father had his own psychological, emotional, and physical challenges from participating in active combat, including chronic pain in his shoulder from multiple gunshot wounds. Despite moving back home to be close to his family, Ryan's father admits feeling isolated and reports that “no one knows what it feels like.”

How would you provide unique support to Ryan and his family? What treatment modalities are particularly important to emphasize?
Limbal Stem Cell Deficiency Secondary to Diffuse Non-necrotizing Anterior Scleritis: A Clinicopathological Report
Authors: Khoo Lin Wei , Attzs Michelle , Srinivasan Sathish , Roberts Fiona
Published: May 2018

Purpose:

To report a case of limbal stem cell deficiency (LSCD) secondary to diffuse non-necrotizing anterior scleritis (DNNAS).

Method:

Interventional case report with clinicopathologic correlation. A 69-year-old white woman with known Crohn disease presented with DNNAS. The acute inflammatory phase was treated with topical and systemic steroids. After DNNAS, she developed secondary LSCD with loss of limbal palisades of Vogt and conjunctivalization of the corneal surface and corneal haze. She underwent superficial keratectomy combined with autologous limbal stem cell grafting from the fellow eye. The keratectomy specimen was sent for pathological examination.

Results:

There were no intraoperative or post-operative complications. Histopathology and immunohistochemistry showed a cytokeratin 19–positive and cytokeratin 3– and cytokeratin 12 negative epithelium in keeping with a conjunctival phenotype on the corneal surface.

Conclusions:

LSCD can be a rare complication of DNNAS. After control of ocular surface inflammation, autologous limbal stem cell grafting and amniotic membrane transplantation can be effective in normalizing the ocular surface.
Changes in Physical and Occupational Therapy Students' Self-efficacy Using an Interprofessional Case-based Educational Experience
Authors: Ivey Carole K. , Bowman Dixie H. , Lockeman Kelly S.
Published: May 2018

Introduction.

The Commission on Accreditation in Physical Therapy Education and the Accreditation Council for Occupational Therapy Education require the integration of interprofessional education (IPE) into their respective educational programs. This follows reports from the Institute of Medicine and the World Health Organization that highlight the importance of IPE to prepare professionals for interprofessional collaborative practice. However, information related to practical strategies to incorporate learning experiences into the curriculum is sparse. The purpose of this study was to examine the impact of an interprofessional simulation on the self-efficacy of physical therapy (PT) and occupational therapy (OT) students and to explore student perceptions of the IPE experience to better understand their engagement in learning.

Methods.

The study sample included 51 first-year PT students and 36 third year OT students, all enrolled in a case-based class, respectively. A quasi-experimental pretest–posttest design was used to examine changes in self-efficacy for interprofessional learning among participants after an interprofessional simulation activity. Participants completed the Self-Efficacy for Interprofessional Experiential Learning (SEIEL) survey 1 week before the simulation activity (pretest) and 1 week after (posttest.) Qualitative methods were used to gather feedback from participants about the learning activity.

Results.

Self-efficacy scores for OT students and PT students on each SEIEL subscale were calculated. For the interprofessional interaction subscale, there was a significant main effect between pretest and posttest scores, with posttest scores higher than pretest scores. There was no difference based on whether they were an OT or PT student. Similarly, there was a significant main effect between pretest and posttest scores on the interprofessional team evaluation and feedback subscale, whereas there was no significant effect based on student discipline. Both OT and PT students reported they gained knowledge about the other profession's role, scope of practice, goals, and evaluation and treatment activities and described the opportunity to plan and problem solve as the most helpful aspect of this learning activity. Their responses indicated that they perceived the greatest learning through the direct hands-on time with the standardized patients and the rest of the time was not valuable as they were just watching.

Discussion and Conclusion.

Occupational therapy and PT students benefited equally with improved self-efficacy and positive learning outcomes. In a time with many uncertainties in IPE, this study provides evidence that a single, brief learning activity can be beneficial.
Comparison of acoustic radiation force impulse elastography and transient elastography for prediction of hepatocellular carcinoma recurrence after radiofrequency ablation
Authors: Yoon Jun Sik , Lee Yu Rim , Kweon Young-Oh , Tak Won Young , Jang Se Young , Park Soo Young , Hur Keun , Park Jung Gil , Lee Hye Won , Chun Jae Min , Han Young Seok , Lee Won Kee
Published: May 2018

Background

To compare the clinical value of acoustic radiation force impulse (ARFI) elastography and transient elastography (TE) for hepatocellular carcinoma (HCC) recurrence prediction after radiofrequency ablation (RFA) and to investigate other predictors of HCC recurrence.

Patients and methods

Between 2011 and 2016, 130 patients with HCC who underwent ARFI elastography and TE within 6 months before curative RFA were prospectively enrolled. Independent predictors of HCC recurrence were analyzed separately using ARFI elastography and TE. ARFI elastography and TE accuracy to predict HCC recurrence was determined by receiver operating characteristic curve analysis.

Results

Of all included patients (91 men; mean age, 63.5 years; range: 43–84 years), 51 (42.5%) experienced HCC recurrence during the follow-up period (median, 21.9 months). In multivariable analysis using ARFI velocity, serum albumin and ARFI velocity [hazard ratios: 2.873; 95% confidence interval (CI): 1.806–4.571; P<0.001] were independent predictors of recurrence, and in multivariable analysis using TE value, serum albumin and TE value (hazard ratios: 1.028; 95% CI: 1.013–1.043; P<0.001) were independent predictors of recurrence. The area under the receiver operating characteristic curve of ARFI elastography (0.821; 95% CI: 0.747–0.895) was not statistically different from that of TE (0.793; 95% CI: 0.712–0.874) for predicting HCC recurrence (P=0.827). The optimal ARFI velocity and TE cutoff values were 1.6 m/s and 14 kPa, respectively.

Conclusion

ARFI elastography and TE yield comparable predictors of HCC recurrence after RFA.
Here Comes Price Transparency
Authors: Boston-Fleischhauer Carol
Published: May 2018

The public reporting of clinical and operational performance measures is old news for chief nurse executives (CNEs). Since the advent of value-based purchasing and patient experience measures, CNEs have partnered with other executives to ensure organizational readiness and success with the performance measures being publicly shared. In 2018, healthcare organizations face a new wave of public reporting expectations—price. Once again, executives will need to ensure organizational readiness. Chief nurse executives must analyze the impact of this trend on the nursing enterprise and carefully consider how to best prepare for healthcare price transparency.
Keeping the Magnet® Flame Alive With Appreciative Inquiry
Authors: Halm Margo A. , Crusoe Kristen
Published: May 2018

Sustaining a clinical excellence culture for Magnet® redesignation requires continued engagement of frontline nurses, nurse leaders, and executives. Appreciative Inquiry is a strength-based approach emanating from a positive core. From this core, teams discover, dream, design, and create their preferred destiny. This article describes how a Magnet-designated organization used Appreciative Inquiry to revitalize its redesignation preparation and beyond.
Using Motivational Interviewing to Impact Readiness of RNs to Return to the Classroom
Authors: Phifer Lynne , Robeano Karen , Ivey Angela , Blood-Siegfried Jane
Published: May 2018

Supporting nurses with associate degrees in nursing (ADNs) to return to school is challenging for nurse executives. Strategies include tuition reimbursement, scholarships, and flexible scheduling. Despite these measures, it is anticipated that we will fall short of a goal of 80% bachelor's degree–prepared nurses by 2020. The aim of this project was to increase ADN-prepared RN readiness to return to school through motivational interviewing.
Safety of Ovarian Tissue Transplantation in Patients With Borderline Ovarian Tumors
Authors: Masciangelo Rossella , Bosisio Chiara , Donnez Jacques , Amorim Christiani A. , Dolmans Marie-Madeleine
Published: May 2018

(Abstracted from Human Reprod 2018;33:212–219)

Ten percent to 20% of all ovarian epithelial tumors are borderline ovarian tumors (BOTs). These low-grade malignancies rarely metastasize.
Usability of Immunohistochemistry in Forensic Samples With Varying Decomposition
Authors: Lesnikova Iana , Schreckenbach Marc Niclas , Kristensen Maria Pihlmann , Papanikolaou Liv Lindegaard , Hamilton-Dutoit Stephen
Published: May 2018

Immunohistochemistry (IHC) is an important diagnostic tool in anatomic and surgical pathology but is used less frequently in forensic pathology. Degradation of tissue because of postmortem decomposition is believed to be a major limiting factor, although it is unclear what impact such degradation actually has on IHC staining validity. This study included 120 forensic autopsy samples of liver, lung, and brain tissues obtained for diagnostic purposes. The time from death to autopsy ranged between 1 and more than 14 days. Samples were prepared using the tissue microarray technique. The antibodies chosen for the study included KL1 (for staining bile duct epithelium), S100 (for staining glial cells and myelin), vimentin (for endothelial cells in cerebral blood vessels), and CD45 (for pulmonary lymphocytes). Slides were evaluated by light microscopy. Immunohistochemistry reactions were scored according to a system based on the extent and intensity of the positive stain. An overall correlation between the postmortem interval and the IHC score for all tissue samples was found. Samples from decedents with a postmortem interval of 1 to 3 days showed positive staining with all antibodies, whereas samples from decedents with a longer postmortem interval showed decreased staining rates. Our results suggest that IHC analysis can be successfully used for postmortem diagnosis in a range of autopsy samples showing lesser degrees of decomposition.
Bronchiolar Adenoma
Authors: Chang Jason C. , Montecalvo Joseph , Borsu Laetitia , Lu Shaohua , Larsen Brandon T. , Wallace William Dean , Sae-Ow Wichit , Mackinnon Alexander C. , Kim Hyunjae R. , Bowman Anita , Sauter Jennifer L. , Arcila Maria E. , Ladanyi Marc , Travis William D. , Rekhtman Natasha
Published: May 2018

We have identified 25 lesions involving alveolar lung parenchyma characterized by nodular proliferation of bland bilayered bronchiolar-type epithelium containing a continuous layer of basal cells. These lesions shared some histologic features with the recently described entity of ciliated muconodular papillary tumor (CMPT); however, the majority did not fit all diagnostic criteria in that they exhibited only focal or absent papillary architecture, and they had variable number of ciliated and mucinous cells, with some lesions entirely lacking 1 or both of these components. The morphologic and immunohistochemical features ranged from those resembling proximal bronchioles (proximal-type: moderate to abundant mucinous and ciliated cells; negative or weak TTF1 in luminal cells; n=8) to those resembling respiratory bronchioles (distal-type: scant or absent mucinous and ciliated cells; positive TTF1 in luminal cells; n=17). The hallmark of all lesions was a continuous layer of basal cells (p40 and CK5/6-positive). We provisionally designated these lesions as bronchiolar adenomas (BAs) and analyzed their clinicopathologic and molecular features. All BAs were discrete, sharply circumscribed lesions with a median size of 0.5 cm (range, 0.2 to 2.0 cm). Most lesions were either entirely flat (n=14) or contained focal papillary architecture (n=7); only 4 lesions, all proximal-type, were predominantly papillary, fitting the classic description of CMPT. Notably, of 9 lesions submitted for frozen section evaluation, 7 were diagnosed as adenocarcinoma. No postsurgical recurrences were observed for any lesions (median follow-up, 11 mo). Twenty-one BAs underwent next-generation sequencing and/or immunohistochemistry for BRAF V600E, revealing mutation profiles similar to those previously described for CMPTs, including BRAF V600E mutations (n=8, 38%), unusual EGFR exon 19 deletions (n=2, 10%), EGFR exon 20 insertions (n=2, 10%), KRAS mutations (n=5, 24%), and HRAS mutations (n=1, 5%). The mutation profiles were similar in proximal-type and distal-type lesions. In conclusion, we describe a family of putatively benign clonal proliferations with a spectrum of morphology recapitulating various levels of the bronchiolar tree, of which only a minor subset fits the classic description of CMPT. Comparable mutation profiles and partially overlapping morphologic features across the spectrum of these lesions support their nosological relationship. We propose designating this entire family of lesions as BAs, and that lesions currently designated CMPTs represent a subgroup of this family.
Adolescent Seizure in the Emergency Department Due to Concomitant Brugada Syndrome
Authors: Baum Beau , Ingaramo Oscar , Chao David
Published: May 2018

Brugada syndrome is an increasingly discussed entity in the emergency medicine and cardiology literature. However, there are few cases reported in the pediatric population. Seizure is a presentation common to pediatric emergency departments. This case report describes the clinical course, workup, and differential diagnosis of a 15-year-old male adolescent with first-time seizure and Brugada pattern on electrocardiogram. A brief review of the literature follows the case presentation.
Does Hormone Therapy Use Increase Perioperative Complications in Abdominally Based Microsurgical Breast Reconstruction?
Authors: Tran Bao Ngoc N. , Ruan Qing Z. , Cohen Justin B. , Kamali Parisa , Doval Andres F. , Tobias Adam M. , Singhal Dhruv , Lin Samuel J. , Lee Bernard T.
Published: May 2018

Background:

The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. As breast cancer patients undergoing microsurgical breast reconstruction are often receiving hormone therapy, it is unclear whether this increased thrombotic risk is associated with increased flap loss.

Methods:

A retrospective review was performed on patients undergoing abdominally based microsurgical breast reconstruction at an academic institution from 2004 to 2015. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including complete or partial flap loss and overall complications, were compared and analyzed using univariate and logistic regression models.

Results:

Among a total of 853 patients (1253 flaps), 193 patients (269 flaps) were receiving hormone therapy and 660 patients (984 flaps) were not. Patients on hormone therapy had higher rates of previous breast surgery, advanced cancer stage, chemoradiation before reconstruction, and delayed and unilateral reconstruction. There were no statistically significant differences between hormone therapy patients and nontherapy patients in complete flap loss (1.0 percent versus 1.1 percent) and partial flap loss (2.2 percent versus 1.5 percent). Hypertension and previous breast surgery were the only independent risk factors for minor complications (adjusted OR, 2.1; 95 percent CI, 1.3 to 3.6; p = 0.005; and adjusted OR, 1.8; 95 percent CI, 1.2 to 2.7; p = 0.009, respectively) and overall complications (adjusted OR, 2.2; 95 percent CI, 1.3 to 3.7; p = 0.004; and adjusted OR, 1.9; 95 percent CI, 1.3 to 3.0; p = 0.003, respectively).

Conclusions:

Hormone therapy was not associated with a higher incidence of complete or partial flap loss or overall complications. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Motiva Ergonomix Round SilkSurface Silicone Breast Implants: Outcome Analysis of 100 Primary Breast Augmentations over 3 Years and Technical Considerations
Authors: Huemer Georg M. , Wenny Raphael , Aitzetmüller Matthias M. , Duscher Dominik
Published: May 2018

Background:

Macrotextured anatomical implants are frequently used in aesthetic breast surgery; however, several safety concerns linked to this implant type have been raised recently. In an attempt to address these shortcomings, Motiva Ergonomix implants have been introduced. Here, the authors describe the current world’s largest experience with these novel devices in aesthetic breast surgery and evaluate the postoperative outcome of 100 primary breast augmentations.

Methods:

A retrospective assessment of 100 consecutive primary breast augmentation patients over a period of 3 years was conducted. Patients were followed for a minimum of 6 months postoperatively. Demographics, surgical data, and complications were recorded. In addition, a survey regarding the breast augmentation outcome was performed.

Results:

The reasons for surgery were mainly hypoplasia (52 percent) and ptosis (28 percent). All implants were placed by means of an inframammary approach in a submuscular pocket, and the average implant volume was 370 cc (range, 150 to 700 cc) with mostly full projection (65 percent). The revision rate was 7 percent. The authors observed four cases of implant malpositioning, one implant rupture, one implant exchange for aesthetic reasons, and one hematoma evacuation. Nevertheless, the authors achieved a 100 percent satisfaction rate with the postsurgical outcome among both patients and surgeons.

Conclusions:

Motiva Ergonomix implants provide reliable and satisfying results for both patients and surgeons. They can be used safely and effectively for aesthetic breast surgery. However, like all breast prostheses, Motiva Ergonomix implants are not completely free of complications and should be used only with advanced technique to achieve optimal results.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
The Impact of Mastectomy Weight on Reconstructive Trends and Outcomes in Nipple-Sparing Mastectomy: Progressively Greater Complications with Larger Breast Size
Authors: Frey Jordan D. , Salibian Ara A. , Karp Nolan S. , Choi Mihye
Published: May 2018

Background:

Reconstructive trends and outcomes for nipple-sparing mastectomy continue to be defined. The graduated impact of breast size and mastectomy weight remains incompletely evaluated.

Methods:

All patients undergoing nipple-sparing mastectomy from 2006 to June of 2016 were identified. Demographics and outcomes were analyzed and stratified by mastectomy weight of 800 g or higher (large group), between 799 and 400 g (intermediate group), and less than 400 g (small group).

Results:

Of 809 nipple-sparing mastectomies, 66 (8.2 percent) had mastectomy weights of 800 g or higher, 328 (40.5 percent) had mastectomy weights between 799 and 400 g, and 415 nipple-sparing mastectomies (51.3 percent) had mastectomy weights less than 400 g. Nipple-sparing mastectomies in the large group were significantly more likely to be associated with major mastectomy flap necrosis (p = 0.0005), complete nipple-areola complex necrosis (p < 0.0001), explantation (p < 0.0001), cellulitis treated with oral (p = 0.0008) and intravenous (p = 0.0126) antibiotics, abscess (p = 0.0254), and seroma (p = 0.0126) compared with those in the intermediate group. Compared with small nipple-sparing mastectomies, patients in the large group had greater major mastectomy flap necrosis (p < 0.0001), complete (p < 0.0001) and partial (p = 0.0409) nipple-areola complex necrosis, explantation (p < 0.0001), cellulitis treated with oral (p < 0.0001) and intravenous (p < 0.0001) antibiotics, abscess (p = 0.0119), and seroma (p < 0.0001). Patients in the intermediate group were more likely to experience major (p < 0.0001) and minor (p < 0.0001) mastectomy flap necrosis, complete (p = 0.0015) and partial (p < 0.0001) nipple-areola complex necrosis, cellulitis treated with oral antibiotics (p = 0.0062), and seroma (p = 0.0248) compared with those undergoing small nipple-sparing mastectomies. Larger mastectomy weights were significant predictors of complications on logistic regression analysis.

Conclusion:

Reconstructive and ischemic complications in nipple-sparing mastectomy are progressively greater as mastectomy weight and breast size increase.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Antifibrinolytic Agents in Plastic Surgery: Current Practices and Future Directions
Authors: Brown Stav , Yao Amy , Taub Peter J.
Published: May 2018

Background:

Prevention of blood loss is a chief consideration in plastic and reconstructive surgery. The antifibrinolytic drugs tranexamic acid and ε-aminocaproic acid have emerged as promising agents to reduce both perioperative blood loss and transfusion requirements. However, published reports in the plastic surgery literature are lacking. The authors sought to summarize the current knowledge of the use of antifibrinolytics in plastic surgery by reviewing the existing literature for clinical outcomes and recommendations.

Methods:

A systematic review of the PubMed, Cochrane, and Google Scholar databases was conducted for publications examining the use of antifibrinolytics in plastic surgery. Studies were abstracted for procedure type, antifibrinolytic dose, time and mode of administration, blood loss, transfusion requirements, and complications.

Results:

Thirty-three studies were deemed eligible for inclusion, comprising a total of 1823 patients undergoing plastic surgical procedures with tranexamic acid (n = 1328) and/or ε-aminocaproic acid (n = 495).

Conclusions:

Tranexamic acid and ε-aminocaproic acid are widely used to reduce blood loss and transfusion requirements in craniofacial and orthognathic surgery, without an increased risk of adverse events. Intravenous administration is most commonly used, although topical formulations show similar efficacy with a reduced systemic distribution. Tranexamic acid has also emerged as a promising agent in aesthetic surgery and burn care, due to its favorable safety profile and role in reducing blood loss, achieving an improved surgical field, and reducing edema and ecchymosis. Further investigation of these agents in the fields of burn care, aesthetic surgery, and microsurgery is warranted to standardize protocols for clinical use.
Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem
Authors: Weissler Jason M. , Cho Eugenia H. , Koltz Peter F. , Carney Martin J. , Itkin Maxim , Laje Pablo , Levin L. Scott , Dori Yoav , Kanchwala Suhail K. , Kovach Stephen J.
Published: May 2018

With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Brain Correlates of Mental Stress-Induced Myocardial Ischemia
Authors: Bremner J. Douglas , Campanella Carolina , Khan Zehra , Shah Majid , Hammadah Muhammad , Wilmot Kobina , Al Mheid Ibhar , Lima Bruno B. , Garcia Ernest V. , Nye Jonathon , Ward Laura , Kutner Michael H. , Raggi Paolo , Pearce Brad D. , Shah Amit J. , Quyyumi Arshed A. , Vaccarino Viola
Published: May 2018

Objective

Coronary artery disease (CAD) is a major cause of morbidity and mortality, and despite important advances in our understanding of this disorder, the underlying mechanisms remain under investigation. Recently, increased attention has been placed on the role of behavioral factors such as emotional stress on CAD risk. Brain areas involved in memory and the stress response, including medial prefrontal cortex, insula, and parietal cortex, also have outputs to the peripheral cardiovascular system. The purpose of this study was to assess the effects of mental stress on brain and cardiac function in patients with CAD.

Methods

CAD patients (N = 170) underwent cardiac imaging with [Tc-99m] sestamibi single-photon emission tomography at rest and during a public speaking mental stress task. On another day, they underwent imaging of the brain with [O-15] water positron emission tomography (PET) during mental stress (arithmetic and public speaking) and control conditions.

Results

Patients with mental stress–induced myocardial ischemia showed increased activation with stress in anterior cingulate, inferior frontal gyrus, and parietal cortex (p < .005). This was seen with both arithmetic stress and public speaking stress. Arithmetic stress was additionally associated with left insula activation, and public speaking with right pre/postcentral gyrus and middle temporal gyrus activation (p < .005).

Conclusions

These findings suggest that mental stress–induced myocardial ischemia is associated with activation in brain areas involved in the stress response and autonomic regulation of the cardiovascular system. Altered brain reactivity to stress could possibly represent a mechanism through which stress leads to increased risk of CAD-related morbidity and mortality.
Tofacitinib 5 mg Twice Daily in Patients with Rheumatoid Arthritis and Inadequate Response to Disease-Modifying Antirheumatic Drugs
Authors: Bird Paul , Bensen William , El-Zorkany Bassel , Kaine Jeffrey , Manapat-Reyes Bernadette Heizel , Pascual-Ramos Virginia , Witcombe David , Soma Koshika , Zhang Richard , Thirunavukkarasu Krishan
Published: May 2018

Background

Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). We performed a comprehensive review of phase 3 studies of tofacitinib 5 mg twice daily (BID) (approved dose in many countries) in patients with moderate to severe RA and inadequate response to prior disease-modifying antirheumatic drugs.

Methods

A search of PubMed and ClinicalTrials.gov identified 5 studies: ORAL Solo (NCT00814307), ORAL Sync (NCT00856544), ORAL Standard (included adalimumab 40 mg once every 2 weeks; NCT00853385), ORAL Scan (NCT00847613), and ORAL Step (NCT00960440). Efficacy and safety data for tofacitinib 5 mg BID, placebo, and adalimumab were analyzed.

Results

Across the 5 studies, 1216 patients received tofacitinib 5 mg BID, 681 received placebo, and 204 received adalimumab. At month 3, tofacitinib demonstrated significantly higher 20%, 50%, and 70% improvement in American College of Rheumatology response criteria (ACR20, ACR50, and ACR70, respectively) response rates, greater improvement in Health Assessment Questionnaire-Disability Index, and a higher proportion of Disease Activity Score-defined remission than placebo. Frequencies of adverse events (AEs), serious AEs, and discontinuations due to AEs were similar for tofacitinib and placebo at month 3; serious infection events were more frequent for tofacitinib. In ORAL Standard, although not powered for formal comparisons, tofacitinib and adalimumab had numerically similar efficacy and AEs; serious AEs and serious infection events were more frequent with tofacitinib.

Conclusions

Tofacitinib 5 mg BID reduced RA signs and symptoms and improved physical function versus placebo in patients with inadequate response to prior disease-modifying antirheumatic drugs. Tofacitinib 5 mg BID had a consistent, manageable safety profile across studies, with no new safety signals identified.
Prognostic Value of Lymph Node Yield on Overall Survival in Esophageal Cancer Patients
Authors: Visser Els , Markar Sheraz R. , Ruurda Jelle P. , Hanna George B. , van Hillegersberg Richard
Published: May 2018

Objective:

This meta-analysis determines whether increased lymph node yield improves survival in patients with esophageal cancer undergoing esophagectomy with or without neoadjuvant therapy.

Background:

Esophagectomy involves resection of the esophagus and surrounding lymph nodes, which are commonly the first stations of cancer spread. The extent of lymphadenectomy during esophagectomy remains controversial, with several studies publishing conflicting results, especially in the era of neoadjuvant therapy.

Methods:

An electronic literature search was undertaken using Embase, Medline, and the Cochrane library databases (2000 to 2017). Articles with esophageal cancer patients undergoing esophagectomy with lymphadenectomy and investigating the effects of low and high lymph node yield on overall survival and disease-free survival were included. Meta-analysis of data was conducted using a random effects model. If the study divided the cohort into multiple groups based on lymph node yield, survival was compared between the lowest and highest lymph node yield groups. In addition to analysis of the entire cohort, subset analysis of only those patients receiving neoadjuvant therapy was also performed.

Results:

A total of 26 studies were included in this meta-analysis with a follow-up ranging from 15 to 94 months. For the analysis of overall survival, 23 studies were included. A meta-analysis showed that overall survival significantly improved in the high lymph node yield group [hazard ratio (HR) = 0.81; 95% confidence interval (95% CI) = 0.74–0.87; P < 0.01]. In the 10 studies describing disease-free survival, this was significantly improved in the high lymph node yield group (HR = 0.72; 95% CI = 0.62–0.84; P < 0.01). Subset analysis of neoadjuvant-treated patients demonstrated a survival benefit of high lymph node yield on overall survival (HR = 0.82; 95% CI = 0.73–0.92; P < 0.01).

Conclusion:

This meta-analysis demonstrates the benefit of an increased lymph node yield from esophagectomy on overall and disease-free survival. In addition, a survival benefit of a high lymph node yield was demonstrated in patients receiving neoadjuvant therapy followed by esophagectomy.
Background selection and the statistics of population differentiation: consequences for detecting local adaptation
Authors: Matthey-Doret Remi , Whitlock Michael C.
Published: May 2018

Background selection is a process whereby recurrent deleterious mutations cause a decrease in the effective population size and genetic diversity at linked loci. Several authors have suggested that variation in the intensity of background selection could cause variation inFSTacross the genome, which could confound signals of local adaptation in genome scans. We performed realistic simulations of DNA sequences, using parameter estimates from humans and sticklebacks, to investigate how variation in the intensity of background selection affects different statistics of population differentiation. We show that, in populations connected by gene flow, Weir & Cockerham’s (1984) estimator ofFSTis largely insensitive to locus-to-locus variation in the intensity of background selection. UnlikeFST, however,dXYis negatively correlated with background selection. We also show that background selection does not greatly affect the false positive rate inFSToutlier studies. Overall, our study indicates that background selection will not greatly interfere with finding the variants responsible for local adaptation.
Mapping molecular HLA typing data to UNOS antigen equivalents for improved virtual crossmatch
Authors: Kaur Navchetan , Kransdorf Evan P. , Pando Marcelo J , Maiers Martin , Ray Bryan , Lee Jar-How , Lalli Peter , Murphey Cathi L , Bray Robert A , Gragert Loren
Published: May 2018

Background

Virtual crossmatch utilizes HLA typing and antibody screen assay data as a part of organ offers in deceased donor allocation systems. Histocompatibility labs must convert molecular HLA typings to antigen equivalencies for entry into the United Network for Organ Sharing (UNOS) UNet system. While an Organ Procurement and Transplantation Network (OPTN) policy document provides general guidelines for conversion, the process is complex because no antigen mapping table is available. We present a UNOS antigen equivalency table for all IMGT/HLA alleles at the A, B, C, DRB1, DRB3/4/5, DQA1, and DQB1 loci.

Methods

An automated script was developed to generate a UNOS antigen equivalency table. Data sources used in the conversion algorithm included the World Marrow Donor Association(WMDA) antigen table, the HLA Dictionary, and UNOS-provided tables. To validate antigen mappings, we converted National Marrow Donor Program (NMDP) high resolution allele frequencies to antigen equivalents and compared with the UNOS Calculated Panel Reactive Antibodies (CPRA) reference panel.

Results

Normalized frequency similarity scores between independent NMDP and UNOS panels for 4 US population categories (Caucasian, Hispanic, African American and Asian/Pacific Islander) ranged from 0.85 to 0.97, indicating correct antigen mapping. An open source web application (ALLele to ANtigen (“ALLAN”)) and web services were also developed to map unambiguous and ambiguous HLA typing data to UNOS antigen equivalents based on NMDP population-specific allele frequencies (http://www.transplanttoolbox.org).

Conclusions

This tool sets a foundation for using molecular HLA typing to compute the virtual crossmatch and may aid in reducing typing discrepancies in UNet.
Photoacoustic imaging for the prediction and assessment of response to radiotherapyin vivo
Authors: Martinho Costa Márcia , Shah Anant , Rivens Ian , Box Carol , O’Shea Tuathan , Bamber Jeffrey , Haar Gail ter
Published: May 2018

Radiotherapy is commonly used for cancer therapy, although its efficacy is reduced in hypoxic regions of tumours. Photoacoustic imaging (PAI) is an emergent, non-invasive imaging technique that allows the measurement of blood oxygen saturation (sO2) which inversely correlates with hypoxia in tissue. The potential use of PAI as a prognostic tool for radiotherapy outcome was investigated in a head and neck cancer modelin vivo. PAI was performed before delivering a single fraction (10, 20 or 30 Gy) treatment. The results show that tumours with pre-treatment higher blood sO2responded better than those with lower levels in the 10 and 20 Gy groups. For the 30 Gy group, treatment response was independent of blood sO2. The haemoglobin content of the tumours was not correlated with their response to any of the radiation doses studied. Changes in sO2, monitored at 24 h and 96 h following 10 and 20 Gy doses, showed that tumours that were subsequently unresponsive to treatment had an increase in blood sO2at both time points compared to those which subsequently regressed after radiotherapy. The results suggest that sO2values measured by photoacoustic imaging can be used before, and shortly after, irradiation to predict subsequent treatment response.
Physiological starvation increases EGF-Ras-MAPK pathway activity duringC. elegansvulval induction
Authors: Grimbert Stéphanie , Vargas Velazquez Amhed Missael , Braendle Christian
Published: May 2018

Studying how molecular pathways respond to ecologically relevant environmental variation is fundamental to understand organismal development and its evolution. Here we characterize how starvation modulatesCaenorhabditis elegansvulval cell fate patterning – an environmentally sensitive process, with a nevertheless robust output. Past research has shown many vulval mutants affecting EGF-Ras-MAPK, Delta-Notch and Wnt pathways to be suppressed by environmental factors, such as starvation. Here we aimed to resolve previous, seemingly contradictory, observations on how starvation modulates levels of vulval induction. Using the strong starvation suppression of the Vulvaless phenotype oflin-3/egfreduction-of-function mutations as an experimental paradigm, we first tested for a possible involvement of the sensory system in relaying starvation signals to affect vulval induction: mutation of various sensory inputs, DAF-2/Insulin or DAF-7/TGF-βsignaling did not abolishlin-3(rf)starvation suppression. In contrast, nutrient deprivation induced by mutation of the intestinal peptide transporter genepept-1or the TOR pathway componentrsks-1(the orthologue of mammalian P70S6K) very strongly suppressedlin-3(rf)mutant phenotypes. Therefore, physiologically starved animals induced by these mutations tightly recapitulated the effects of external starvation on vulval induction. While both starvation andpept-1RNAi were sufficient to increase Ras and Notch pathway activities in vulval cells, the highly penetrant Vulvaless phenotype of a tissue-specific null allele oflin-3was not suppressed by either condition. This and additional results indicate that partiallin-3expression is required for starvation to affect vulval induction. These results suggest a cross-talk between nutrient deprivation, TOR-S6K and EGF-Ras-MAPK signaling duringC. elegansvulval induction.