bluuebunny/crossref_metadata_2025 huggingface dataset:
Epidemiology
Authors: Dalbeth Nicola
Published: March 2016

The aetiopathogenesis of gout is initiated by urate overproduction and uric acid under-excretion, leading to hyperuricaemia. Foods such as seafood, red meat, beer, and sugar-sweetened beverages contribute to overproduction. Under-excretion is mediated by renal and gut uric acid transporters such as SLC2A9, ABCG2, and URAT1. In hyperurcaemia, there is formation of monosodium urate (MSU) crystals in joints, with acute gouty arthritis mediated by the innate immune system occurring in response to these crystals. Factors such as urate concentration, proteins present in synovial fluid, temperature, and pH control crystal nucleation and growth. Activation of the inflammasome by MSU crystals and production of interleukin-1ß‎ is central to acute gouty arthritis. Advanced gout occurs when there is persistent gouty arthritis and tophus with the tophus being an organized immune tissue response to MSU crystals that involves both innate and adaptive immune cells. Progression through the gout checkpoints (hyperuricaemia, MSU crystal formation, and immune response) is governed by inherited genetic variants, lifetime environmental exposures, and their interaction.
Principles of gout management
Authors: Dalbeth Nicola
Published: March 2016

The main goal of therapy is to achieve ‘remission’—the absence of gout attacks and tophi. A sustained reduction in serum urate is critical to the long-term management of gout and will ultimately result in cessation of gout attacks and resolution of tophi. Target serum urate is <0.36 mmol/L for everyone, although a lower target of <0.30 mmol/L may be required for those with severe tophaceous disease. Patient and physician education about the causes and effective management of gout are required to improve adherence to therapy and thereby long-term outcomes.
Anti-inflammatory agents for prophylaxis and flares
Authors: Dalbeth Nicola
Published: March 2016

Acute gout requires rapid, effective treatment. Colchicine, non-steroidal anti-inflammatories, and corticosteroids are all effective; the choice of agent is dictated by the patient’s co-morbidities and concomitant medications. Interleukin-1 inhibitors are effective, but the high cost precludes routine use, and long-term safety data for repeated use are lacking.
Management of co-morbid conditions in people with gout
Authors: Dalbeth Nicola
Published: March 2016

Co-morbidities—particularly hypertension, cardiovascular disease, renal impairment, diabetes, obesity, and hyperlipidaemia—are common in gout. Patients with gout should be screened for co-morbidities. Co-morbidities will influence choice of therapy for acute gout flares and urate lowering.
Becoming blind in one eye
Authors: Dobson Ruth , Giovannoni Gavin
Published: March 2016

This case describes a young woman initially presenting with symptoms suggestive of optic neuritis. She later develops transverse myelitis, and a diagnosis of neuromyelitis optica (NMO; Devic’s disease) is made following investigation. The clinical features and investigative findings associated with NMO are discussed, and are related to the underlying pathology. Differential diagnoses for both optic neuropathy and transverse myelitis are given in the accompanying tables. Treatment options for both acute relapses and long-term immunosuppression are given.
Seeing double
Authors: Shah Anish N. , Riordan-Eva Paul
Published: March 2016

This case provides a thorough exploration of the nuances of assessing, investigating, and treating patients with idiopathic intracranial hypertension (IIH). It starts by considering a patient presenting with raised intracranial pressure in the context of a recent external ear infection and a sixth cranial nerve paresis, who wishes to become pregnant during her subsequent treatment. It explores in detail the steps required to exclude secondary causes of intracranial hypertension before labelling the condition IIH. It discusses the complexities of managing IIH in pregnancy, and describes common neuro-ophthalmologic diagnostic tests that are normally performed in eye clinics including perimetry, Hess charts for ocular motility, and the detection, imaging, and monitoring of optic disc oedema. Finally, it reviews the evidence for current medical and surgical treatments for IIH including weight loss, various medications, optic nerve sheath fenestration, cerebrospinal fluid diversion procedures, transverse sinus stenting, and bariatric surgery.
Getting your head out of a spin
Authors: Kaski Diego , Bronstein Adolfo M.
Published: March 2016

This case describes a patient with acute vertigo and discusses the differential diagnoses to consider, with a specific focus on the common presentations including benign paroxysmal positional vertigo (BPPV), vestibular neuritis, vestibular migraine, and posterior circulation stroke. We highlight the importance of obtaining a clear description of what the patient means by the terms ‘dizziness’ or ‘vertigo’ to narrow the differential diagnosis (e.g. vestibular versus, for example, postural hypotension, anaemia, syncope, or anxiety). We describe and illustrate important clinical manoeuvres, including the Dix-Hallpike manoeuvre for the diagnosis of BPPV and the head impulse test to explore the integrity of the vestibulo-ocular reflex (VOR). Finally, one of the greatest challenges for clinicians dealing with acute dizziness is the differentiation between peripheral and central causes of vertigo. We provide a practical framework to address this issue.
A painful oculomotor nerve palsy
Authors: Siva Vino , Papadopoulos Marios C. , Walsh Daniel C.
Published: March 2016

This case presents the case of a posterior communicating artery (PCom) aneurysm manifesting as a pupil-sparing oculomotor nerve palsy. In addition to the clinical presentation, it reviews the role and timing of different investigative tools in the diagnosis and management of subarachnoid haemorrhage (CT, lumbar puncture, angiography, transcranial Doppler ultrasound). The case discusses the neurological sequelae of aneurysmal subarachnoid haemorrhage, paying particular attention to the diagnosis and management of delayed cerebral ischaemia. It highlights the multifaceted approach needed in managing such patients, with peri-operative medical care playing a pivotal role in preserving neurological function. It also reviews the evidence surrounding the treatment of incidental cerebral aneurysms.
A complex sleep disorder
Authors: Winston Joel S. , Eriksson Sofia H.
Published: March 2016

The apparent simplicity of sleep belies enormous neurobiological complexity. Clinical complaints about sleep difficulties must be tackled with a careful history and may require specialist investigation. Here we discuss the challenging case of a 42-year-old woman referred with a two-year history of sleep-related problems that had proved difficult to treat in primary care. Appropriate investigation led to the diagnosis of narcolepsy with cataplexy and rapid eye movement (REM) sleep behaviour disorder. Adequate control of the sleep disorders proved difficult despite trials of multiple medication regimes. The underlying neurophysiology of these conditions is discussed together with a summary of current approaches to treatment. Critically, the presence of two diagnoses renders treatment substantially more complicated, and it is proposed that improved understanding of the neurobiology of sleep will lead to more rational and successful treatment of sleep disorders.
Symptoms come and go but the lesions get bigger
Authors: Paling David , Chard Declan
Published: March 2016

This case describes the case of a young woman with a relapsing and remitting neurological disorder but with features atypical of multiple sclerosis, including prominent cognitive features during relapses, large lesions on MRI, and continuing expansion of lesions despite treatment. We outline her clinical journey, including complications of an early lumbar puncture, through to a brain biopsy which was able to confirm her diagnosis. We then discuss the rationale for our eventual choice of treatment and discuss monitoring for the development of progressive multifocal leucoencephalopathy. Finally, we discuss her likely future prognosis based upon case series of patients with similar clinical features.
Symptoms falling on deaf ears
Authors: Chinthapalli Krishna , Warner Graham
Published: March 2016

This case describes the case of a person with unexplained bilateral sensorineural deafness, intracranial calcification, and a sensory peripheral neuropathy. She was found to have maternally inherited diabetes and deafness (MIDD), a mitochondrial disease. The discussion reviews mitochondrial diseases, which may present at any age with symptoms varying from ataxia to seizures. An overview of mitochondrial genetics and the currently described spectrum of mitochondrial diseases is given, before the diagnostic algorithms, investigations, and potential complications are discussed. Interpretation of common test findings is also discussed, particularly audiograms and intracranial calcification. The case is aimed at medical trainees, especially in neurology, cardiology, or clinical genetics.
Difficulty breathing and moving
Authors: Spillane Jennifer , Kullmann Dimitri M.
Published: March 2016

This case describes a patient who presented with neuromuscular weakness culminating in respiratory failure and admission to the ICU. He was subsequently diagnosed with Lambert-Eaton myasthenic syndrome (LEMS), a rare autoimmune disease that presents with skeletal muscle weakness and autonomic dysfunction. Approximately 50 per cent of cases of LEMS are paraneoplastic; most frequently it is associated with a small-cell lung cancer. The diagnosis of LEMS is based on characteristic neurophysiological findings of small compound muscle action potential amplitudes that increase following maximal exercise or high-frequency stimulation, a process known as facilitation. In addition, approximately 85 per cent of patients have antibodies to voltage-gated calcium channels detectable on serology The treatment of LEMS depends on the presence of an underlying malignancy. If a tumour is present, treatment must be directed towards this. 3, 4-Diaminopyridine may provide symptomatic relief in both tumour and non-tumour LEMS and immunmodulatory therapy may also be required.
Paroxysmal sensory and motor events
Authors: Paterson Ross W. , Sztriha Laszlo K.
Published: March 2016

This case discusses the clinical approach to the patient with paroxysmal sensory and motor events. Transient ischaemic attacks (TIAs) are a common cause of paroxysmal neurological events, yet up to 60 per cent of patients referred to the TIA clinic have an alternative final diagnosis. This case illustrates the importance of history-tak ing, imaging, and other paraclinical investigations for accurately assessing and managing the TIA patient whilst exploring a comprehensive range of alternative diagnostic possibilities including epilepsy and amyloid spells.
Does Increased Experience with Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Lead to Decreased Flap Loss? The Learning Effect
Authors: Koolen Pieter G. L. , Vargas Christina R. , Ho Olivia A. , Ibrahim Ahmed M. S. , Ricci Joseph A. , Tobias Adam M. , Winters Hay A. H. , Lin Samuel J. , Lee Bernard T.
Published: March 2016

Background:

Early studies have shown that near-infrared monitoring with tissue oximetry shows promise in providing earlier detection of free flap vascular compromise. However, large-scale clinical evaluation of this technology on flap outcome has not previously been established. This study examines the effect of tissue oximetry on flap reexploration rates and salvage over a 10-year period. The learning curve for this new technology is also assessed.

Methods:

A retrospective review was performed of prospectively maintained data on all microsurgical breast reconstructions performed at an academic institution from 2004 to 2014. Patients were divided into two separate cohorts—standard clinical monitoring and standard clinical monitoring plus tissue oximetry—and rates of reexploration and flap salvage were compared. Subgroup analysis (tertiles) was performed to assess outcomes with increasing experience.

Results:

A total of 380 flaps (36.2 percent) received standard clinical monitoring, and 670 flaps (63.8 percent) received additional tissue oximetry monitoring. The rate of flap salvage before implementation of tissue oximetry monitoring was 57.7 percent and increased to 96.6 percent (p < 0.001). The number of complete flap losses decreased from 11 (2.9 percent) to one (0.1 percent) with the use of tissue oximetry (p < 0.001). Subgroup analysis demonstrated significantly fewer reexplorations in the third tertile.

Conclusions:

Inclusion of continuous tissue oximetry in the postoperative monitoring protocol of microsurgical breast reconstruction is associated with significantly improved salvage rates and fewer flap losses. Furthermore, learning curve assessment demonstrates that use of tissue oximetry can decrease the rate of reexploration over time.
Seroma in Prosthetic Breast Reconstruction
Authors: Jordan Sumanas W. , Khavanin Nima , Kim John Y. S.
Published: March 2016

Background:

Seroma, as a complication of prosthetic breast reconstruction, results in patient distress, increased office visits, undesirable aesthetic outcomes, and—importantly—may escalate to infection and frank prosthesis loss. Herein, the authors review the pathophysiology and risk factors and attempt to collate published practices for avoidance and management of seroma.

Methods:

A systematic literature review was performed using MEDLINE, Web of Science, Embase, and Cochrane Library for studies published between 2000 and January of 2015. Random-effects meta-analysis was used to estimate the overall pooled incidence of seroma and to examine the effect of drain number and acellular dermal matrix use.

Results:

Seventy-two relevant primary articles and three systematic reviews were identified. Fifty-one citations met inclusion criteria, including two randomized controlled trials. The overall pooled incidence was 5.4 percent (95 percent CI, 4.1 to 6.7 percent). Obesity, acellular dermal matrix, and preoperative irradiation were cited risk factors. Pooled relative risk for acellular dermal matrix was 1.83 (95 percent CI, 1.28 to 2.62). Drain practices were collated from 34 articles.

Conclusions:

Seromas following prosthetic breast reconstruction are complicated by the hypovascular, proinflammatory milieu of the mastectomy skin flap, the geometrically complex dead space, and the presence of a foreign body with potential contamination and biofilm. There is reasonable evidence to suggest that these factors contribute to a progression of seroma to infection and prosthesis loss. These findings have motivated this summary article on current practice guidelines and strategies to prevent and treat seromas.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
What Is the Best Way to Measure Surgical Quality? Comparing the American College of Surgeons National Surgical Quality Improvement Program versus Traditional Morbidity and Mortality Conferences
Authors: Zhang Jacques X. , Song Diana , Bedford Julie , Bucevska Marija , Courtemanche Douglas J. , Arneja Jugpal S.
Published: March 2016

Background:

Morbidity and mortality conferences have played a traditional role in tracking complications. Recently, the American College of Surgeons National Surgical Quality Improvement Program Pediatrics (ACS NSQIP-P) has gained popularity as a risk-adjusted means of addressing quality assurance. The purpose of this article is to report an analysis of the two methodologies used within pediatric plastic surgery to determine the best way to manage quality.

Methods:

ACS NSQIP-P and morbidity and mortality data were extracted for 2012 and 2013 at a quaternary care institution. Overall complication rates were compared statistically, segregated by type and severity, followed by a subset comparison of ACS NSQIP-P-eligible cases only. Concordance and discordance rates between the two methodologies were determined.

Results:

One thousand two hundred sixty-one operations were performed in the study period. Only 51.4 percent of cases were ACS NSQIP-P eligible. The overall complication rates of ACS NSQIP-P (6.62 percent) and morbidity and mortality conferences (6.11 percent) were similar (p = 0.662). Comparing for only ACS NSQIP-P–eligible cases also yielded a similar rate (6.62 percent versus 5.71 percent; p = 0.503). Although different complications are tracked, the concordance rate for morbidity and mortality and ACS NSQIP-P was 35.1 percent and 32.5 percent, respectively.

Conclusions:

The ACS NSQIP-P database is able to accurately track complication rates similarly to morbidity and mortality conferences, although it samples only half of all procedures. Although both systems offer value, limitations exist, such as differences in definitions and purpose. Because of the rigor of the ACS NSQIP-P, we recommend that it be expanded to include currently excluded cases and an extension of the study interval.
Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?
Authors: Dion Sarah , Wong Jessica J. , Côté Pierre , Yu Hainan , Sutton Deborah , Randhawa Kristi , Southerst Danielle , Varatharajan Sharanya , Stern Paula J. , Nordin Margareta , Chung Chadwick , D’Angelo Kevin , Dresser Jocelyn , Brown Courtney , Menta Roger , Ammendolia Carlo , Shearer Heather M. , Stupar Maja , Ameis Arthur , Mior Silvano , Carroll Linda J. , Jacobs Craig , Taylor-Vaisey Anne
Published: March 2016

Objective:

To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow.

Methods:

We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis.

Results:

We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis.

Discussion:

Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.
Development and Preliminary Testing of a Screening Measure of Acceptance and Willingness in Relation to Pain, Fatigue, and Sadness in Chronic Pain
Authors: Vowles Kevin E. , Johnson Linea E. , Gertz Kevin J. , Jensen Mark P.
Published: March 2016

Background:

The manner in which one responds to the experience of chronic pain is a primary determinant of pain-related distress and disruptions in functioning. In particular, responses to pain that reflect substantial unwillingness, or a lack of acceptance, in relation to pain are reliably associated with greater difficulties in comparison with responses that reflect willingness and acceptance. To date, several multi-item self-report assessments have been developed to evaluate pain-related willingness and acceptance. The purpose of the present research was to develop and evaluate a single item measure, the Acceptance and Willingness screener (AWS).

Methods:

Participants included 172 individuals with chronic pain. The AWS consisted of 4 statements, reflecting various degrees of acceptance and willingness to experience pain, and participants were asked to endorse the statement that was most reflective of their views.

Results:

Overall, responses were fairly evenly distributed across the statements (range, 20% to 29%). Correlation and regression results indicated significant associations between AWS responses and measures of pain intensity, depression, pain interference, and engagement in activity. Furthermore, when individuals were grouped according to the statement endorsed, significant between-group differences were indicated across these same measures. Differences were particularly pronounced for groups endorsing the lowest levels of acceptance and willingness and those endorsing the highest.

Conclusions:

These results correspond with previous work and provide initial support for the validity of a single item screening measure of acceptance and willingness in chronic pain.
Screw fixation for atlantoaxial dislocation related to Down syndrome in children younger than 5 years
Authors: Ito Kenyu , Imagama Shiro , Ito Zenya , Ando Kei , Kobayashi Kazuyoshi , Hida Tetsuro , Ishikawa Yoshimoto , Ishiguro Naoki
Published: March 2016

The aim of this study was to present cases of upper cervical fixation in Down syndrome patients younger than 5 years. In two cases, C1 lateral mass screws were installed. However, owing to the irreducible atlantoaxial dislocation, the screw backed out and fractured. Therefore, O–C2 fusion was performed. Furthermore, C2 bilateral lamina screws were added to the C2 pedicle screw for reinforcement. C1–C2 fusion is an option for Down syndrome patients younger than 5 years with atlantoaxial dislocation, when the dislocation is reducible. If the dislocation is irreducible, or the implant cannot be firmly secured, the fixation range should be expanded to O–C2 or below.
Successful Anti-PD-1 Antibody Treatment in a Metastatic Melanoma Patient With Known Severe Autoimmune Disease
Authors: Maul Lara V. , Weichenthal Michael , Kähler Katharina C. , Hauschild Axel
Published: March 2016

Pembrolizumab, an anti-programmed death-1 monoclonal antibody, has been approved by the Food and Drug Administration in 2014 on the basis of improved progression-free and overall survival in metastatic melanoma. We report for the first time a successful treatment with a programmed death-1 antibody in a 69-year-old metastastic melanoma patient with a Churg-Strauss lung vasculitis and a prior ipilimumab-induced autoimmune colitis. This case report suggests that pembrolizumab can be given with caution to patients with underlying autoimmune disease. As the use of checkpoint inhibitors expands, knowledge about their safety in patients with underlying autoimmune diseases will become increasingly important, in particular because these patients are typically excluded from clinical trials with immune-checkpoint inhibitors.
Inflammatory/hemostatic biomarkers and coronary artery calcification in midlife women of African-American and White race/ethnicity: the Study of Women's Health Across the Nation (SWAN) heart study
Authors: Wang Norman C. , Matthews Karen A. , Barinas-Mitchell Emma J.M. , Chang Chung-Chou H. , El Khoudary Samar R.
Published: March 2016

Objective:

Inflammatory/hemostatic biomarkers are associated with coronary heart disease events, but relationships in asymptomatic midlife women are uncertain. We evaluated separately whether high-sensitivity C-reactive protein (hsCRP), fibrinogen, plasminogen-activator inhibitor 1, tissue plasminogen activator antigen, and circulating factor VII (factor VIIc) were associated with coronary artery calcification (CAC) in healthy midlife women.

Methods:

A cross-sectional study was performed of participants from the Study of Women's Health Across the Nation. Logistic and Tobit regression was used to assess associations between log-transformed biomarkers, and CAC presence (CAC > 0) and extent. Effect modification by race/ethnicity was evaluated.

Results:

The study included 372 women (mean age 51.3 y; 35.2% African-American). All biomarkers were positively associated with CAC presence and extent (P < 0.001 for all), adjusting for Framingham risk score, site, race/ethnicity, menopause status, income, and education. Additional adjustment for body mass index explained all associations except for factor VIIc, which remained associated with CAC extent only (P = 0.02). Final adjustment for insulin resistance, family history of cardiovascular disease, and cardiovascular medication use produced similar results. Associations between hsCRP, and CAC presence and extent were modified by race/ethnicity (P < 0.05). Log(hsCRP) was positively associated with CAC presence (odds ratio 3.25; 95% CI, 1.53-6.90; P = 0.002; per 1 log unit increase) and CAC extent (β = 19.66; SE = 7.67; P = 0.01; per 1 log unit increase) in African-Americans only.

Conclusions:

Inflammatory/hemostatic biomarkers were associated with CAC through obesity, except for factor VIIc. Among African-American women only, hsCRP was independently associated with CAC, suggesting that hsCRP may have a role in coronary heart disease prevention in African-American midlife women.
Neuroimaging in Blast-Related Mild Traumatic Brain Injury
Authors: Mu Weiya , Catenaccio Eva , Lipton Michael L.
Published: March 2016

Objective:

To summarize imaging findings in blast-related mild traumatic brain injury.

Design:

Our structured review of the literature yielded 5 structural magnetic resonance imaging (sMRI), 18 diffusion tensor imaging, 9 functional magnetic resonance imaging (fMRI), 3 positron emission tomography, 4 magnetoencephalography, 2 electroencephalography, and 1 single-positron emission computerized tomography studies.

Results:

Four of the 5 sMRI studies reported decreased cortical thickness and decreased thalamus and amygdala volume. Diffusion tensor imaging studies showed abnormal diffusion within white matter tracts commonly associated with traumatic brain injury, including the corpus callosum (8 of the 18) and superior longitudinal fasciculus (8 of the 18). Resting-state fMRI studies reported a variety of functional network differences. Other functional imaging studies showed diffuse changes in activity, especially in the frontal, parietal, temporal, and cingulate regions.

Conclusion:

Vast variation in the sample, design, and measurement features across studies precludes salient conclusions regarding the effectiveness of neuroimaging to assess outcomes and elucidate pathomechanisms. The inherent spatial heterogeneity of mild traumatic brain injury pathology presents a major challenge to meaningful convergence across and generalizable inferences. Approaches to standardize methodology and facilitate access to data and integration across studies hold promise for enhancing our understanding of this complex brain disorder, but can only bear fruit if they are actually consistently implemented.
Characteristics and Concerns of Caregivers of Adults With Traumatic Brain Injury
Authors: Powell Janet M. , Wise Elizabeth K. , Brockway Jo Ann , Fraser Robert , Temkin Nancy , Bell Kathleen R.
Published: March 2016

Objective:

To describe the characteristics of caregivers of adults with traumatic brain injury (TBI) and their concerns in the first months after community discharge of the TBI survivor.

Design:

Secondary analysis of data collected during a parallel-group randomized controlled trial.

Setting:

Community.

Participants:

A total of 153 consecutively enrolled caregivers of adults with moderate to severe TBI discharged to the community following acute and/or rehabilitation care at a Level I trauma center with 71 caregivers in the treatment group identifying concerns as part of the intervention procedures.

Main Measures:

Caregiver demographics, caregiver-survivor relationship characteristics, caregiver activity changes, and concerns targeted by caregivers for education and problem-solving via biweekly phone calls.

Results:

Thirty-nine percent of caregivers were spouses and 35% parents. Sixty-five percent lived in the same house as the survivor preinjury with 86% in touch daily to several times per week. Concerns targeted by more than one-third of caregivers related to managing their emotional adjustment, strategies for getting things done, managing survivor emotions and behaviors, and engaging in healthful habits.

Conclusions:

Caregivers of TBI survivors targeted personal concerns relating to their own emotional adjustment and participation as well as concerns relating to symptoms and recovery of the TBI survivor to address through education and problem-solving.
Compensatory Cognitive Training for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans With Mild Traumatic Brain Injury
Authors: Storzbach Daniel , Twamley Elizabeth W. , Roost Mai S. , Golshan Shahrokh , Williams Rhonda M. , O'Neil Maya , Jak Amy J. , Turner Aaron P. , Kowalski Halina M. , Pagulayan Kathleen F. , Huckans Marilyn
Published: March 2016

Objective:

The purpose of the study was to evaluate the efficacy of group-based compensatory cognitive training (CCT) for Operation Enduring Freedom (OEF)/Operation Iraqi Freedom(OIF)/Operation New Dawn (OND) Veterans with a history of mild traumatic brain injury.

Method:

One hundred nineteen OEF/OIF/OND Veterans with history of mild traumatic brain injury participated at 3 sites, and 50 of the Veterans were randomized to CCT group, while 69 Veterans were randomized to the usual care control group. The CCT group participated in 10 weeks of CCT. Both CCT and usual care groups were assessed at baseline, 5 weeks (midway through CCT), 10 weeks (immediately following CCT), and 15 weeks (5-week follow-up) on measures of subjective cognitive complaints, use of cognitive strategies, psychological functioning, and objective cognitive performance.

Results:

Veterans who participated in CCT reported significantly fewer cognitive and memory difficulties and greater use of cognitive strategies. They also demonstrated significant improvements on neurocognitive tests of attention, learning, and executive functioning, which were 3 of the cognitive domains targeted in CCT.

Conclusions:

Findings indicate that training in compensatory cognitive strategies facilitates behavioral change (ie, use of cognitive strategies) as well as both subjective and objective improvements in targeted cognitive domains.
Surgical Management of Obstructive Sleep Apnea
Authors: Tanna Neil , Smith Benjamin D. , Zapanta Philip E. , Karanetz Irena , Andrews Brian T. , Urata Mark M. , Bradley James P.
Published: March 2016

Surgical management of snoring and obstructive sleep apnea is indicated when a surgically correctable abnormality is believed to be the source of the problem. Many patients opt for surgical treatment after noninvasive forms of treatment have been proven ineffective or difficult to tolerate. With increasing frequency, functional rhinoplasty, septoplasty, turbinoplasty, palatal surgery, and orthognathic surgery are being used in the management of snoring and obstructive sleep apnea. Plastic surgeons’ experience with aesthetic nasal surgery, nasal reconstruction, palatal surgery, and craniofacial surgery puts them at the forefront of performing surgery for snoring and sleep apnea. The role of functional septorhinoplasty, turbinoplasty, palatal surgery, genioglossal advancement, and orthognathic surgery is indispensable in the surgical management of obstructive sleep apnea. Multidisciplinary management of these patients is critical, and plastic surgeons are encouraged to work collaboratively with sleep medicine clinicians and centers.
Body Image Disorders and Surgical Timing in Patients Affected by Poland Syndrome: Data Analysis of 58 Case Studies
Authors: Baldelli Ilaria , Santi Pierluigi , Dova Laura , Cardoni Gaia , Ciliberti Rosagemma , Franchelli Simonetta , Merlo Domenico F. , Romanini Maria V.
Published: March 2016

Background:

Poland syndrome is a congenital anomaly of pectoralis muscles, breast, chest, and upper arm. Several studies have reported that patients affected by chest wall deformities often experience body image disorders and decreased quality of life. Cosmetic corrective surgery is generally postponed until physical development is achieved, and latissimus dorsi flap surgery is usually suggested. This study aims to propose a new surgical timing for these patients.

Methods:

Patients affected by Poland syndrome (n = 58) and control patients (n = 50) were included in the study, and their body-related psychopathology was evaluated through the Body Uneasiness Test, a valuable multidimensional tool for the clinical assessment of body uneasiness. The Global Severity Index and several subscales were considered. Age and surgical status were taken into account.

Results:

Significant differences were detected between Poland syndrome patients and controls with respect to all Body Uneasiness Test subscales. Among subjects aged younger than 20 years, the group of patients not operated on was the most affected, whereas the group of peers after surgery showed scores similar to those detected in the control group.

Conclusions:

Surgical planning for patients with Poland syndrome should start in the period of growth to allow proper body image stabilization. Current surgical options allow for reduction of the use of invasive interventions such as the latissimus dorsi flap, in favor of less invasive surgical techniques such as expanders, implants, and autologous fat grafting. This new surgical timing will help to ameliorate problems with physical and mental development.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Carbon Ion Implantation: A Good Method to Enhance the Biocompatibility of Silicone Rubber
Authors: Zhou Xin , Chen Xing , Mao Tong-cun , Li Xiang , Shi Xiao-hua , Fan Dong-li , Zhang Yi-ming
Published: March 2016

Background:

Silicone rubber and silicone rubber–based materials have been used as medical tissue implants in the field of plastic surgery for many years, but there are still some reports of adverse reactions to long-term implants. Earlier studies have shown that ion implantation could enhance the biocompatibility of biomaterials. However, whether ion implantation has a good effect on silicone rubber is unknown.

Methods:

Three types of carbon ion silicone rubber were obtained by implanting three doses of carbon ions. Then, the antibacterial adhesion properties and the in vivo host responses were evaluated. The antibacterial adhesion properties were examined by plate colony counting, fluorescence staining, and scanning electron microscopic observation. The host responses were evaluated by surveying inflammation and fiber capsule formation that developed after subcutaneous implantation in Sprague-Dawley rats for 7, 30, 90, and 180 days. In addition, the possible mechanism by which ion implantation enhanced the biocompatibility of the biomaterial was investigated and discussed.

Results:

Carbon ion silicone rubber exhibits less bacterial adhesion, less collagen deposition, and thinner and weaker tissue capsules. Immunohistochemical staining results for CD4, tumor necrosis factor-α, α-smooth muscle actin, and elastin showed the possible mechanism enhancing the biocompatibility of silicone rubber. These data indicate that carbon ion silicone rubber exhibits good antibacterial adhesion properties and triggers thinner and weaker tissue capsules. In addition, high surface roughness and high zeta potential may be the main factors that induce the unique biocompatibility of carbon ion silicone rubber.

Conclusion:

Ion implantation should be considered for further investigation and application, and carbon ion silicone rubber could be a better biomaterial to decrease silicone rubber–initiated complications.
Evaluation of Cutaneous Spatial Resolution and Pressure Threshold Secondary to Digital Nerve Repair
Authors: Klein Holger J. , Fakin Richard M. , Ducommun Pascal , Giesen Thomas , Giovanoli Pietro , Calcagni Maurizio
Published: March 2016

Background:

As the sophistication of functional reconstruction procedures continues to increase, so does the need for valid, precise, and reliable instruments to assess their clinical results. The authors compare two tests for spatial resolution and two for cutaneous pressure threshold in an adult patient cohort having undergone microsurgical digital nerve repair after traumatic transection.

Methods:

Patients who underwent epineural coaptation after digital nerve transection at the authors’ institution between June of 2006 and December of 2011 were asked to participate in a follow-up examination assessing spatial resolution (two-point discrimination and grating orientation test) and cutaneous pressure threshold (Semmes-Weinstein monofilament test and pressure-specifying sensory device). Interinstrument correlations were conducted and critically elucidated.

Results:

Eighty-one patients (26 female and 55 male patients; median age, 42 years; interquartile range, 23 years) were examined with a mean follow-up period of 3.5 ± 1.4 years. Although all tests could differentiate between the healthy and operated fingers, poor to moderate correlations were found between two-point discrimination and grating orientation test (ρoperated = 0.483, p < 0.0001; ρhealthy = 0.350, p < 0.0001), and between Semmes-Weinstein monofilament test and Pressure-Specified Sensory Device testing (ρoperated = 0.287, p = 0.01; ρhealthy = 0.382, p < 0.001), indicating that they measure different properties. Altogether, the grating orientation test proved superior to two-point discrimination, whereas Pressure-Specified Sensory Device testing was superior to Semmes-Weinstein monofilament testing.

Conclusions:

Thoughtful use of test instruments is advisable when assessing sensibility of the hand. This study suggests including Pressure-Specified Sensory Device testing to assess cutaneous pressure threshold and the grating orientation test to assess spatial resolution in clinical, routine test batteries.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Diagnostic, III.
A Comparison of Robotically Assisted Microsurgery versus Manual Microsurgery in Challenging Situations
Authors: Willems Joost I. P. , Shin Alexandra M. , Shin Delaney M. , Bishop Allen T. , Shin Alexander Y.
Published: March 2016

Background:

Microsurgery can be challenging secondary to orientation of the vessels, accessibility, or depth of the wound. Robotically assisted microsurgery reduces tremors and improves visualization and may improve the quality of anastomosis compared with traditional microsurgery. The purpose of this study was to compare robotically assisted microsurgery to traditional microsurgery in technically challenging situations with respect to time of anastomosis, quality of anastomosis, and Objective Structured Assessment of Technical Skills.

Methods:

Two investigators with no prior surgery or microsurgery experience performed 160 anastomoses on artificial microvessels after undergoing standardized traditional and robotically assisted microsurgery courses. Five different exposure groups were created with depths of 0, 10, and 20 cm and sidewall angles of 20 and 30 degrees. A comparison of 80 manual with 80 robotically assisted microsurgery anastomoses in different exposure groups was undertaken. The modified Objective Structured Assessment of Technical Skills scoring system, duration per anastomosis, and a subjective comfort scale were evaluated.

Results:

In the most difficult exposure, Objective Structured Assessment of Technical Skills scores were similar in both groups (p = 0.98), the duration was higher in the manual group (p = 0.004), and the subjective comfort rating was higher in the robotically assisted microsurgery group (p < 0.001). In the easiest (0-cm depth, flat) exposure, Objective Structured Assessment of Technical Skills scores were higher in the manual group (p = 0.018) and the duration was longer in the robotically assisted microsurgery group (p = 0.008).

Conclusions:

Manual surgery was superior to robotically assisted microsurgery in technically easy exposures. In difficult exposures (greater depth and lower sidewall angles), however, robotically assisted microsurgery had a shorter surgery time and a higher comfort rating, with Objective Structured Assessment of Technical Skills scores similar to those assessing traditional microsurgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
A Practical Approach to Rhinoplasty
Authors: Rohrich Rod J. , Ahmad Jamil
Published: March 2016

Learning Objectives:

After studying this article, the participant should be able to: 1. Understand both preoperative aesthetic and functional assessment of the rhinoplasty patient. 2. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function.

Rhinoplasty continues to be one of the most commonly performed aesthetic surgical procedures. Over the past 25 years, the open approach has increased in popularity and is the focus of this article. The principles for successful rhinoplasty include comprehensive clinical analysis and defining rhinoplasty goals, preoperative consultation and planning, precise operative execution, postoperative management, and critical analysis of one’s results. Systematic nasal analysis is critical to establish the goals of surgery. Techniques to address the nasal dorsum, nasal airway, tip complex, alar rims, and bony vault that provide consistent results are discussed.
Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process
Authors: Sollid Stephen J.M. , Dieckman Peter , Aase Karina , Søreide Eldar , Ringsted Charlotte , Østergaard Doris
Published: March 2016

Objectives

There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety.

Methods

An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems.

Results

The expert group agreed on the following topics: technical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology.

Conclusions

The expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.
The Relationship Between Optic Nerve Sheath Decompression Failure and Intracranial Pressure in Idiopathic Intracranial Hypertension
Authors: Robinson Mark E. , Moreau Annie , O'Meilia Ryan , Pagteilan John , Ding Kai , Siatkowski Raymond Michael , Farris Bradley K.
Published: March 2016

Background:

To our knowledge, there are no studies of patients with idiopathic intracranial hypertension (IIH) that address the relationship between level of intracranial pressure (ICP) and likelihood of progressive visual loss despite uncomplicated optic nerve sheath decompression (ONSD). This study investigated whether patients with IIH undergoing ONSD had a higher risk of surgical failure if opening pressure (OP) on lumbar puncture was ≥50 cm H2O compared to those with OP <50 cm H2O.

Methods:

We conducted a retrospective chart review of consecutive patients with IIH who failed maximal medical therapy and underwent ONSD between January, 1992 and November, 2014, and were followed at least 3 months postoperatively. The main outcome measure was the relationship between OP on lumbar puncture and ONSD failure. We also investigated the relationship of OP with visual acuity, visual fields, age, and gender.

Results:

During this period, 174 patients met inclusion criteria. Of the 40 patients who had an OP ≥50 cm H2O, 6 (15%) had progressive visual loss after uncomplicated ONSD, vs 6 (4.5%) of 134 patients with an OP <50 cm H2O (P = 0.032, Fisher exact test). Patients with worse visual acuity at presentation also had a higher risk of progressive visual loss after ONSD (P < 0.001, Cochran–Armitage trend test), as did men (P = 0.048, Fisher exact test).

Conclusions:

Patients with IIH and an OP ≥50 cm H2O had a 3-fold increased risk of failure of ONSD to prevent progressive visual loss, requiring a shunting procedure when compared to those with OP <50 cm H2O. Visual acuity at presentation and male sex also were associated with progressive visual decline after ONSD. These risk factors merit closer follow-up in the postoperative period when signs of further visual deterioration would indicate an urgent need for neurosurgical shunting.
Developmental influences on fertility decisions by women: an evolutionary perspective
Authors: Coall D. A. , Tickner M. , McAllister L. S. , Sheppard P.
Published: March 2016

Developmental environments are crucial for shaping our life course. Elements of the early social and biological environments have been consistently associated with reproduction in humans. To date, a strong focus has been on the relationship between early stress, earlier menarche and first child birth in women. These associations, found predominately in high-income countries, have been usefully interpreted within life-history theory frameworks. Fertility, on the other hand—a missing link between an individual's early environment, reproductive strategy and fitness—has received little attention. Here, we synthesize this literature by examining the associations between early adversity, age at menarche and fertility and fecundity in women. We examine the evidence that potential mechanisms such as birth weight, childhood body composition, risky health behaviours and developmental influences on attractiveness link the early environment and fecundity and fertility. The evidence that menarche is associated with fertility and fecundity is good. Currently, owing to the small number of correlational studies and mixed methodologies, the evidence that early adversity predicts fecundity and fertility is not conclusive. This area of research is in its infancy; studies examining early adversity and adult fertility decisions that can also examine likely biological, social and psychological pathways present opportunities for future fertility research.