bluuebunny/crossref_metadata_2025 huggingface dataset:
The Modified Lateral Intercostal Artery Perforator Flap
Authors: Meybodi Farid , Cocco Annelise M. , Messer David , Brown Alexander , Kanesalingam Kavitha , Elder Elisabeth , Hsu Jeremy , French James
Published: February 2019

Background:

The main surgical options for treatment of breast cancer are breast-conserving surgery and mastectomy. BCS aims to achieve complete excision of the tumor while achieving a pleasing cosmetic result. Excision of tumors in the lateral aspect of the breast has been associated with issues such as contour deformities and asymmetry. Development of volume replacement techniques such as the lateral intercostal artery perforator flap (LICAP) aimed to address these issues. Our modification of the traditional LICAP offers a less visible scar, good access to the axilla, and no need to reposition the patient.

Methods:

All patients undergoing a modified LICAP were identified from our database. The lateral intercostal artery perforators were marked with ultrasound and 2 “lazy S” lines were drawn to mark the flap. The wide local excision (with or without axillary surgery) was performed and the flap mobilized to fill the defect.

Results:

Twenty-two patients underwent modified LICAP in 14 months. The mean specimen weight was 86 g. Four patients (18%) had a re-excision for positive margins. Nineteen patients had axillary surgery performed at the time of their modified LICAP flap. No patients had a scar that extended posterior to the posterior axillary line; no patients required a separate incision for axillary surgery; and no patients needed to be repositioned intraoperatively.

Conclusions:

Our early experience with this innovative procedure has been favorable. The perioperative complication rate is low. Due to the relatively short follow-up, longer term outcomes such as postradiotherapy appearance are yet to be determined.
Skin Necrosis following Rhinoplasty
Authors: Mrad Mohamed A. , Almarghoub Mohammed A.
Published: February 2019

Rhinoplasty is one of the most common cosmetic procedures performed by plastic surgeons worldwide. It is among the top 5 common aesthetic procedures in the United States. The complications rate in rhinoplasty is 8–15%, and a majority of these complications are not life-threatening. One of the rare complications reported is skin necrosis. In our article, we report 2 cases that developed skin necrosis on the nasal dorsum following rhinoplasty.
Fat Chance: The Rejuvenation of Irradiated Skin
Authors: Borrelli Mimi R. , Patel Ronak A. , Sokol Jan , Nguyen Dung , Momeni Arash , Longaker Michael T. , Wan Derrick C.
Published: February 2019

Radiotherapy (RT) helps cure and palliate thousands of patients with a range of malignant diseases. A major drawback, however, is the collateral damage done to tissues surrounding the tumor in the radiation field. The skin and subcutaneous tissue are among the most severely affected regions. Immediately following RT, the skin may be inflamed, hyperemic, and can form ulcers. With time, the dermis becomes progressively indurated. These acute and chronic changes cause substantial patient morbidity, yet there are few effective treatment modalities able to reduce radiodermatitis. Fat grafting is increasingly recognized as a tool able to reverse the fibrotic skin changes and rejuvenate the irradiated skin. This review outlines the current progress toward describing and understanding the cellular and molecular effects of fat grafting in irradiated skin. Identification of the key factors involved in the pathophysiology of fibrosis following RT will inform therapeutic interventions to enhance its beneficial effects.
Lymphovascular Invasion and the Decision for Postmastectomy Radiation Therapy: A Cautionary Case Report
Authors: Jensen J. Arthur , Bakkar Rania , Burnison Michele , Giuliano Armando E.
Published: February 2019

Breast reconstruction is frequently adversely affected by postmastectomy radiation therapy. Some radiation therapists recommend postmastectomy radiation therapy based on the finding of lymphovascular invasion in the context of other findings. However, the diagnosis of lymphovascular invasion varies between pathologists and institutions. Sometimes special endothelial cell stains and outside opinions are necessary for the decision for postmastectomy radiation therapy. This case report illustrates the variation in the diagnosis of lymphovascular invasion. Plastic surgeons must remain current on the standard indications for postmastectomy radiation therapy and on the basic findings of lymphovascular invasion.
Socioeconomic Disparities in Brachial Plexus Surgery: A National Database Analysis
Authors: Bucknor Alexandra , Huang Anne , Wu Winona , Fleishman Aaron , Egeler Sabine , Chattha Anmol , Lin Samuel J. , Iorio Matthew L.
Published: February 2019

Background:

Brachial plexus injuries have devastating effects on upper extremity function, with significant pain, psychosocial stress, and reduced quality of life. The aim of this study is to identify socioeconomic disparities in the receipt of brachial plexus repair in the emergent versus elective setting, and in the use of supported services on discharge.

Methods:

Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database was performed for the years 2009–2014. Adults with brachial plexus injury with or without nerve repair were identified; patient and hospital specific factors were analyzed.

Results:

Overall, 6,618 cases of emergent brachial plexus injury were retrieved. Six hundred sixty cases of brachial plexus repair were identified in the emergency and elective settings over the study period. Of the 6,618 injured, 153 (2.3%) underwent nerve surgery during the admission. Patients undergoing repair in the elective setting were more likely to be white males with private insurance. Patients treated in the emergency setting were more likely to be African American and in the lowest income quartile. Significant differences were also seen in supported discharge: more likely males (P < 0.001), >55 years of age (P < 0.001), white (P < 0.001), with government-based insurance (P < 0.001).

Conclusions:

There are significant disparities in the timing of brachial plexus surgery. These relate to timing rather than receipt of nerve repair; socioeconomically advantaged individuals with private insurance in the higher income quartiles are more likely to undergo surgery in the elective setting and have a supported discharge.
Numerical Simulation Based on Individual Voxel Phantoms for a Sophisticated Evaluation of Internal Doses Mainly From 131I in Highly Exposed Workers Involved in the TEPCO Fukushima Daiichi NPP Accident
Authors: Kunishima Naoaki , Tani Kotaro , Kurihara Osamu , Kim Eunjoo , Nakano Takashi , Kishimoto Riwa , Tsuchiya Hiroki , Omatsu Tokuhiko , Tatsuzaki Hideo , Tominaga Takako , Watanabe Sadahiro , Ishigure Nobuhito , Akashi Makoto
Published: February 2019

As a response to the Tokyo Electric Power Company’s Fukushima Daiichi nuclear power plant accident in 2011, seven TEPCO workers whose exposure doses were expected to be >250 mSv (a tentative dose limit stipulated by the Japanese central authority) attended Japan’s National Institute for Radiological Sciences for additional internal dose measurements. The National Institute for Radiological Sciences examination revealed that these workers’ internal doses came mainly from their intake of the radionuclide 131I during emergency operations. In this study, we performed numerical simulations based on individual volume-pixel (voxel) phantoms of six of the seven workers for a more sophisticated evaluation of their internal doses, taking into account the individual thyroid size and other specific parameters. The voxel phantoms were created from magnetic resonance imaging scan images. As a result, the individual thyroid volumes ranged from 6.5 to 28.2 cm3 and were considerably smaller than the reference value (~20 cm3) adopted in the International Commission on Radiation Protection’s dosimetric model for four of the six subjects. Compared to the original estimates of the thyroid absorbed dose, our preliminary evaluation revealed values that were increased by approximately 3-fold or decreased by 30% at maximum. A wide difference in the individual thyroid size would be one of the significant modifiers in the current dose estimation of subjects of the ongoing epidemiological study project. The present simulations also provided evidence that the direct thyroid measurements by the National Institute for Radiological Sciences to determine the workers’ 131I thyroid contents were sufficiently accurate.
ACES (Accelerated Chest Pain Evaluation With Stress Imaging) Protocols Eliminate Testing Disparities in Patients With Chest Pain
Authors: Miller Chadwick D. , Stopyra Jason P. , Mahler Simon A. , Case L. Doug , Vasu Sujethra , Bell Ronny A. , Hundley W. Gregory
Published: February 2019

Background:

Patients from racial and ethnic minority groups presenting to the Emergency Department (ED) with chest pain experience lower odds of receiving stress testing compared with nonminorities. Studies have demonstrated that care pathways administered within the ED can reduce health disparities, but this has yet to be studied as a strategy to increase stress testing equity.

Methods:

A secondary analysis from 3 randomized clinical trials involving ED patients with acute chest pain was performed to determine whether a care pathway, ACES (Accelerated Chest pain Evaluation with Stress imaging), reduces the racial disparity in index visit cardiac testing between African American (AA) and White patients. Three hundred thirty-four participants with symptoms and findings indicating intermediate to high risk for acute coronary syndrome were enrolled in 3 clinical trials. Major exclusions were ST-segment elevation, initial troponin elevation, and hemodynamic instability. Participants were randomly assigned to receive usual inpatient care, or ACES. The ACES care pathway includes placement in observation for serial cardiac markers, with an expectation for stress imaging. The primary outcome was index visit objective cardiac testing, compared among AA and White participants.

Results:

AA participants represented 111/329 (34%) of the study population, 80/220 (36%) of the ACES group and 31/109 (28%) of the usual care group. In usual care, objective testing occurred less frequently among AA (22/31, 71%) than among White (69/78, 88%, P = 0.027) participants, primarily driven by cardiac catheterization (3% vs. 24%; P = 0.012). In ACES, testing rates did not differ by race [AA 78/80 (98%) vs. White 138/140 (99%); P = 0.623]. At 90 days, death, MI, and revascularization did not differ in either group between AA and White participants.

Conclusions:

A care pathway with the expectation for stress imaging eliminates the racial disparity among AA and White participants with chest pain in the acquisition of index-visit cardiovascular testing.
Symptoms Predictive of Acute Myocardial Infarction in the Troponin Era: Analysis From the TRAPID-AMI Study
Authors: McCord James , Aurora Lindsey , Lindahl Bertil , Giannitsis Evangelos , Calle-Muller Carlos , Nowak Richard , Body Richard , Christ Michael , deFilippi Christopher R. , Christenson Robert H. , Jacobsen Gordon , Alquezar Aitor , Panteghini Mauro , Melki Dina , Plebani Mario , Verschuren Franck , French John , Bendig Garnet , Weiser Silvia , Mueller Christian
Published: February 2019

The TRAPID-AMI (High Sensitivity Cardiac Troponin T assay for rapid Rule-out of Acute Myocardial Infarction) study evaluated a rapid “rule-out” acute myocardial infarction (AMI). We evaluated what symptoms were associated with AMI as part of a substudy of TRAPID-AMI. There were 1282 patients evaluated from 12 centers in Europe, the United States of America, and Australia from 2011 to 2013. Multiple symptom variables were prospectively obtained and evaluated for association with the final diagnosis of AMI. Multivariate logistic regression analysis was done, and odds ratios (OR) were calculated. There were 213/1282 (17%) AMIs. Four independent predictors for the diagnosis of AMI were identified: radiation to right arm or shoulder [OR = 3.0; confidence interval (CI): 1.8–5.0], chest pressure (OR = 2.5; CI: 1.3–4.6), worsened by physical activity (OR = 1.7; CI: 1.2–2.5), and radiation to left arm or shoulder (OR = 1.7; CI: 1.1–2.4). In the entire group, 131 (10%) had radiation to right arm or shoulder, 897 (70%) had chest pressure, 385 (30%) worsened with physical activity, and 448 (35%) had radiation to left arm or shoulder. Duration of symptoms was not predictive of AMI. There were no symptoms predictive of non-AMI. Relationship between AMI size and symptoms was also studied. For 213 AMI patients, cardiac troponins I values were divided into 4 quartiles. Symptoms including pulling chest pain, supramammillary right location, and right arm/shoulder radiation were significantly more likely to occur in patients with larger AMIs. In a large multicenter trial, only 4 symptoms were associated with the diagnosis of AMI, and no symptoms that were associated with a non-AMI diagnosis.
Genomic Analysis of an Obesity Paradox: A Microarray Study of the Aortas of Morbidly Obese Decedents With Mild and Severe Atherosclerosis
Authors: Brodsky Sergey V. , Ganju Ramesh , Mishra Sanjay , Ivanov Iouri , Fadda Paolo , Wang Huabao , Barth Rolf F.
Published: February 2019

Background:

Atherosclerosis of the aorta and coronary arteries is still one of the major causes of death. We recently reported obesity paradox between body mass index and atherosclerosis of the aortas (AA) in morbidly obese decedent patients. The cause of this obesity paradox is unknown. The aim of the present study was to carry out genomic microarray analysis to determine gene expression profiles in the aortas of morbidly obese decedents with either mild or severe atherosclerosis of the aorta.

Methods:

Microarray studies using Affymetrix GeneChips Clariom D Human array chips were performed on the aortas obtained from 6 morbidly obese decedents, 3 of whom had minimal AA and 3 who had severe disease.

Results:

Group 1 (severe AA) and group 2 (mild AA) included 3 patients each. The patients were matched by age and body mass index. There were significant (P<0.005) differences in the expressions of 1067 genes between groups 1 and 2, including 602 upregulated and 465 downregulated genes.

Conclusions:

Our data show significantly different gene signatures between morbidly obese decedents who have mild or severe AA, suggesting that genetic factors may be important contributors to the obesity paradox as it relates to aortic atherosclerosis. Further studies are warranted to define differences in protein expression in the aortas of these 2 groups to further elucidate the cause of this obesity paradox.
Improving Door-to-needle Times in the Treatment of Acute Ischemic Stroke Across a Canadian Province: Methodology
Authors: Kamal Noreen , Jeerakathil Thomas , Mrklas Kelly , Smith Eric E. , Mann Balraj , Valaire Shelley , Hill Michael D.
Published: February 2019

Background:

Alteplase is a proven medical treatment for acute ischemic stroke; however, the effectiveness of this treatment is highly time dependent. Therefore, it is imperative that hospitals treat acute ischemic stroke patients as quickly as possible. The measure, door-to-needle time, is the time from hospital arrival to when alteplase administration begins.

Objective:

The goal in the Canadian province of Alberta was to reduce the door-to-needle time to a median of 30 minutes and to increase the percent of patients treated within 60 minutes to 90%.

Overview of Methodology:

A modified version of Institute for Healthcare Improvement Breakthrough Series Collaborative was used. All stroke centers self-enrolled into the collaborative after initial contact, and sites created interdisciplinary teams to participate in the Collaborative. Leadership and faculty were highly experienced in quality improvement and acute stroke. There were 3 daylong face-to-face learning sessions that were attended by enrolled teams, which included presentation about the evidence, site presentations to promote cross-site learning, and time to plan changes with their teams. The sites were also supported by site visits, webinars, and data feedback.
Blunt Scissors Stromal Dissection Technique Compared With Big-Bubble Deep Anterior Lamellar Keratoplasty
Authors: Ucgul Ahmet Yucel , Yesilirmak Nilufer , Yuvarlak Armagan , Aydin Bahri , Ozmen Mehmet Cuneyt , Akata Fikret
Published: February 2019

Objectives:

To evaluate the clinical findings and results of new modified manual deep anterior lamellar keratoplasty (M-DALK) technique compared with a big-bubble DALK (BB-DALK) technique in eyes with corneal scars or lesions.

Methods:

A prospective, nonrandomized, comparative study included 65 eyes of 65 patients treated by M-DALK using the blunt scissors lamellar dissection technique or standard BB-DALK. Visual acuity, endothelial cell density, corneal cylinder (Cyl), central corneal thickness (CCT), residual stromal thickness and aberrometric values were recorded pre-treatment and 1, 3, 6, 12 and 18 months after treatment.

Results:

Thirty-five eyes of 35 patients underwent deep anterior lamellar keratoplasty (DALK) with successful big-bubble technique, whereas 30 eyes of 30 patients underwent DALK with manual technique (in 10 eyes as a primary technique, in 20 eyes as a secondary technique). Successful big-bubble formation was achieved in 35 of 55 (64%) eyes. Microperforations occurred in three eyes in BB-DALK group, in six eyes in M-DALK group, and DALK could be completed successfully in these eyes. Visual acuity and endothelial cell loss results were not significantly different between groups during follow-up period. Mean CCT was significantly different between groups (P=0.035). Mean corneal Cyl, residual stromal thickness, and aberrometric values were similar between groups (P>0.05) at the final visit.

Conclusion:

New modified M-DALK technique has similar clinical findings and results with BB-DALK when using as a primary or secondary approach.
Donor-Related Nontuberculous Mycobacterial Interface Infection After Descemet Membrane Endothelial Keratoplasty
Authors: Van Landeghem Ruben , Foets Beatrijs , Desmet Stefanie , Vanhaecke Maarten , Hua Minh-Tri
Published: February 2019

Purpose:

To describe the first reported case of Mycobacterium chelonae–related interface keratitis after Descemet membrane endothelial keratoplasty (DMEK), successfully treated with DMEK exchange.

Methods:

A case of donor-related DMEK interface keratitis, treated with medical therapy and DMEK exchange, was studied retrospectively.

Results:

A patient with Fuchs endothelial dystrophy developed infectious interface keratitis after DMEK. In cultures of the donor cornea transport medium, M. chelonae was isolated. Subsequent clinical investigation showed early signs of infectious keratitis with multiple infiltrates at the donor–graft interface. Cultures at the cornea bank of origin also showed M. chelonae, indicating a donor-related infection. Because of unsuccessful medical therapy, the DMEK graft was exchanged 4.5 months after initial DMEK. After 2 weeks, some interface precipitates appeared. These precipitates regressed over the following months with continued medical therapy. Antibiotic therapy was successfully ended 5 months after DMEK exchange.

Conclusion:

This case highlights the importance of early diagnosis and intensive treatment of nontuberculous mycobacterial interface keratitis. If intensive medical therapy is able to contain infection but fails to eradicate interface keratitis, DMEK exchange is a possible treatment option.
Micropulse Transscleral Cyclophotocoagulation in Keratoplasty Eyes
Authors: Subramaniam Kavitha , Price Marianne O. , Feng Matthew T. , Price Francis W.
Published: February 2019

Purpose:

To assess the outcomes of micropulse transscleral cyclophotocoagulation for intraocular pressure (IOP) control in keratoplasty eyes.

Methods:

Outcomes of micropulse laser treatments of postkeratoplasty eyes were retrospectively reviewed. IOP was assessed with applanation tonometry. Keratoplasty survival was calculated with Kaplan–Meier survival analysis.

Results:

Sixty-one eyes in 57 patients received laser treatment; 31 eyes received 1, 21 received 2, 8 received 3, and 1 received 4 treatments. The median follow-up was 21 months (range, 2–35 months). At baseline, the mean IOP was 28 ± 11 mm Hg. At 1, 3, 6, and 12 months after the last treatment, respectively, the numbers of eyes with IOP data were 58, 50, 46, and 38; the mean IOP was 17 ± 7, 17 ± 8, 18 ± 9, and 15 ± 5 mm Hg; the proportions of eyes with IOP ≤ 15 mm Hg were 40%, 51%, 48%, and 55%; and the proportions with IOP ≤ 12 mm Hg were 21%, 29%, 20% and 29%. Six eyes (10%) received subsequent glaucoma filtration surgery. The mean number of antiglaucoma medications used before the initial treatment was 2.7 (range, 0–4) versus 2.2 (range, 0–4) at last follow-up. At baseline, 7 grafts were decompensated and 5 of 54 clear grafts (9%) had endothelial cell density < 700 cells/mm2. Graft survival was 94% at 1 year and 81% at 2 years after the initial laser treatment.

Conclusions:

Micropulse transscleral cyclophotocoagulation is a noninvasive alternative to glaucoma filtration surgery for IOP reduction in keratoplasty eyes.
Rotavirus Vaccination Does Not Increase Type 1 Diabetes and May Decrease Celiac Disease in Children and Adolescents
Authors: Hemming-Harlo Maria , Lähdeaho Marja-Leena , Mäki Markku , Vesikari Timo
Published: February 2019

Background:

Rotavirus (RV) infection has been proposed to trigger type 1 diabetes mellitus (DM1) and celiac disease (CD) by molecular mimicry in genetically susceptible children. If so, a live attenuated oral RV vaccine could also trigger these autoimmune diseases, or else, prevent the effect of wild-type RV infection.

Methods:

In Rotavirus Efficacy and Safety Trial, conducted between 2001 and 2003, the participant children received RotaTeq (Kenilworth, NJ) vaccine or placebo in 1:1 ratio. The surveillance was extended as Finnish Extension Study. A questionnaire was sent in 2015 to the parents of 19,133 Finnish Extension Study participants and 5764 (30%) returned the questionnaire. Diagnosis of DM1, biopsy-proven CD and other autoimmune disease over the 11–14 year period were inquired.

Results:

At the time of questionnaire, the prevalence of DM1 was similar in both groups, 0.97% (25 of 2580 children) in the placebo group and 1.04% (33 of 3184 children) in the vaccine group (P = 0.810). The prevalence of CD was significantly higher in placebo recipients (1.11%; confidence interval: 0.78%–1.6%) than in vaccine recipients (0.60%; confidence interval: 0.38%–0.93%) (P = 0.027).

Conclusions:

RV vaccination using RotaTeq did not alter the occurrence of DM1 but decreased the prevalence of CD in childhood and adolescence. We propose that wild-type RV may trigger CD and the triggering effect can be prevented or reduced by RV vaccination.
Implementation of a Highly Accurate Rapid Point-of-Care Test for Group a Streptococcus Detection at a Large Pediatric Emergency Department in South London
Authors: Demirjian Alicia , Bustinduy Amaya L. , Ladhani Shamez , Iqbal Yasser , Sharland Mike
Published: February 2019

Rapid group A Streptococcus point-of-care testing is not currently used in the United Kingdom in the management of acute tonsillitis. This prospective, observational study describes a strong association between a molecular-based point-of-care testing result and outpatient antibiotic prescribing (odds ratio = 48; P < 0.001) in 339 children seen at our center. It highlights challenges in implementing new rapid diagnostics.
Effects of Cumulative Adversity on Preschool Self-Regulation and Student–Teacher Relationships in a Highly Dense Hispanic Community
Authors: Loomis Alysse M. , Mogro-Wilson Cristina
Published: February 2019

Young Hispanic children make up an increasing percentage of children enrolled in preschools; however, little is known about the effects of adversity on their preschool outcomes. This pilot study uses descriptive, correlational, and hierarchical multiple regression analyses to explore the relationship between cumulative adversity, teacher-rated and observed measures of self-regulation, and student–teacher conflict in a predominately Hispanic preschool sample. More than 50% of preschoolers in the study had experienced at least one type of adversity. Results suggest that preschooler's exposure to cumulative adversities may negatively predict both teacher-rated child self-regulation and the student–teacher relationship, indicating that early adversity negatively impacts children's socioemotional skills as well as their relationships with their teachers. This pilot study supports the need for future research expanding on the role of adversity in the preschool context, particularly for Hispanic children.
Strengths and Challenges of Service Coordination in Eight States
Authors: Childress Dana C. , Nichols Sarah , Schnurr Melissa
Published: February 2019

A survey was distributed in 8 states to learn about perceived strengths and challenges of service coordination from those working in early intervention (EI) programs under Part C of the Individuals with Disabilities Education Act. Survey responses from 769 service coordinators and other EI personnel in 8 states provide an overview of state systems and the implementation of service coordination activities within these state EI systems. Respondents suggested that service coordinators experience the following needs: (1) balancing the workload by reducing the number of families served per service coordinator and decreasing the amount of paperwork; (2) improved compensation and funding; and (3) better and more frequent training opportunities. Findings from this survey were analyzed and used by representatives from participating states to determine state and national action plans for improving the professional development and identity of service coordinators, with the goal of prioritizing support for this important part of the early childhood intervention workforce.
SUMMIT-07: a randomized trial of NKTR-181, a new molecular entity, full mu-opioid receptor agonist for chronic low-back pain
Authors: Markman John , Gudin Jeffrey , Rauck Richard , Argoff Charles , Rowbotham Michael , Agaiby Eva , Gimbel Joseph , Katz Nathaniel , Doberstein Stephen K. , Tagliaferri Mary , Lu Lin , Siddhanti Suresh , Hale Martin
Published: February 2019

NKTR-181, a new molecular entity, mu-opioid receptor agonist with an inherently slow rate of central nervous system (CNS) entry, was designed to provide analgesia while reducing abuse potential. This phase 3, enriched-enrollment, randomized-withdrawal trial evaluated the analgesic efficacy, safety, and tolerability of NKTR-181 in patients with chronic low-back pain (CLBP). Adults with moderate-to-severe CLBP refractory to nonopioid analgesics achieving an analgesic NKTR-181 dosage (100-400 mg twice daily) during the open-label titration period were randomized to continued NKTR-181 treatment, double-blind, or switched to placebo. The study was conducted at 55 sites in the United States. Of 1189 patients exposed to NKTR-181 during the titration period, 610 were randomized to NKTR-181 100 to 400 mg every 12 hours or placebo for 12 weeks. The primary outcome measure was change in weekly pain score (scale, 0-10) at 12 weeks from randomization baseline. Secondary outcome measures included responder rates defined by ≥30% and ≥50% improvement in pain score from screening to 12 weeks. Among 610 randomized patients, the mean pain score decreased from 6.73 to 2.32 during open-label titration. After randomization, the least-squares mean change in pain score was +0.92 for NKTR-181 vs +1.46 for placebo (P = 0.002). The ≥30%-improvement responder rate of NKTR-181 vs placebo was 71.2% vs 57.1% (P < 0.001), and the ≥50%-improvement responder rate was 51.1% vs 37.9% (P = 0.001). NKTR-181 was well tolerated with a low incidence (<3%) of CNS-related adverse events during the randomized treatment phase. In patients with moderate-to-severe CLBP, NKTR-181 demonstrated significant analgesic efficacy and a favorable safety/tolerability profile, with a low incidence of CNS adverse events.
Frail Phenotype and Disability Prediction in Community-Dwelling Older People: A Systematic Review and Meta-Analysis of Prospective Cohort Studies
Authors: CHANG Shu-Fang , CHENG Chih-Ling , LIN Hsiang-Chun
Published: February 2019

Background:

The World Health Organization has identified frailty as a crucial factor affecting successful aging. Systematic literature reviews have yet to focus on the relationship between stages of frailty and disability in community-dwelling older adults.

Purpose:

The purpose of this study was to investigate the relationships between various frailty types and disability in community-dwelling older adults and to explore how various frailty criteria have been used to assess disability in this population.

Methods:

A systematic literature review and meta-analysis were conducted on articles from the following databases: Cochrane Library, CINAHL, PubMed, and Ovid. Database search criteria included articles that were published between January 2001 and July 2017 and study samples that included community-dwelling adults aged 60 years and older. We excluded studies that were conducted in institutions or hospitals and experimental studies on frailty. Two reviewers independently assessed eligibility and extracted data. A random-effects model was used to analyze the literature and to calculate the pooled disability of frailty.

Results:

In total, nine studies with a total sample of 32,998 participants that recorded 8,666 disabilities and a mean follow-up time of 30.4 months (SD = 29.26) were pooled for the meta-analysis. Using various indicators to predict the risk of disability compared with robust older adults, those with frailty faced a higher risk of disability, followed by older adults at risk of frailty.

Conclusions/Implications for Practice:

Frailty is a crucial health consideration among older adults. Those who are frail have the highest relative risk of disability, followed by those at risk of frailty. Early assessment of frailty may effectively prevent the occurrence of frailty-induced disability in older adults.
Psychometric Testing of the Turkish Version of the Stroke Self-Efficacy Questionnaire
Authors: ARKAN Gulcihan , BESER Ayse , OZTURK HANEY Meryem , OZTURK Vesile
Published: February 2019

Background

When stroke survivors return to their lives in society, they often face issues such as physical or cognitive impairment, dependence on others, social isolation, and reduced self-esteem, which may lead to disastrous consequences in patients' self-perceived self-efficacy and self-confidence in everyday life. Self-efficacy plays an important role in the well-being of stroke patients. Accurate assessment of the stroke patients' self-efficacy by health professionals is critical to obtaining data regarding their functioning levels.

Purpose

The aim of this study was to evaluate the psychometric properties of the Turkish version of the Stroke Self-Efficacy Questionnaire (T-SSEQ).

Methods

A sample of 185 stroke patients (mean age = 64.78 ± 10.7) was recruited from a university hospital in Izmir, Turkey. Data were collected between April and October 2016. Translation and back-translation processes were used to translate the T-SSEQ into Turkish. Data were analyzed using the Rasch partial credit model with the Winsteps program to investigate the response scale analysis, tests of fit to the model, unidimensionality, local dependency, item and person separation reliability, separation index, and differential item functioning.

Results

The Rasch analysis showed goodness of fit for both the activity and self-management subscales. Moreover, both scales were identified as being unidimensional in structure. Furthermore, the participants were able to distinguish between the categories of the response options, and scale reliability was supported for both subscales using Rasch analyses.

Conclusions/Implications for Practice

These results indicate that the T-SSEQ is acceptable for use with Turkish stroke patients in both practice and research settings. Furthermore, the questionnaire is suitable for nurses to use in designing interventions and evaluating stroke patients' self-efficacy in clinics, home care, and rehabilitation centers.
The Influence of Social Media on Intrapartum Decision Making
Authors: Wright Erin M. , Matthai Maude Theo , Meyer Erin
Published: February 2019

Social media has been influential in decision making regarding a number of health concerns. However, comparatively little has been examined with regard to its effects on pregnant women. The goal of this scoping review was to examine the literature and identify the role of social media in intrapartum decision making. A scoping review of the literature published between January 1990 and June 2018 was performed using PubMed, CINAHL, EMBASE, PsychINFO, Web of Science, and Cochrane databases. Of the initial 1951 records reviewed, 5 met inclusion criteria. Two of the 5 were quantitative in design, 1 was qualitative, and 2 used mixed methods. Internationally widespread, studies largely took place in developed nations including the United States, the United Kingdom, Canada, Australia, New Zealand, and Finland. Women are using the Internet, including social media, consistently as a source of pregnancy information, for example, 97% of 2400 participates in 1 exploratory study. This knowledge seeking was found to increase women's confidence and self-assurance in making decision during labor and birth. Studies identified issues surrounding women's ability to appraise available information. While it is clear that social media has an influence on women's intrapartum decision making, it is not clear exactly how. Further studies are needed to determine the content of the social media being appraised, the accuracy of the information, and the resulting decision as it affects the intrapartum experience. In addition, efforts should be made to open lines of communication between patients and care providers. This may foster a greater clinical understanding of social media consumption and its influences.
An Evidence-Based Approach to Casting and Orthosis Management of the Pediatric, Adolescent, and Young Adult Population for Injuries of the Upper Extremity: A Review Article
Authors: McVeigh Kimberly H. , Berger Thomas G. , Cudahy Ryan , Dekker Timothy M. , Brigham Tara J. , Braxton James C.
Published: February 2019

Objective:

Review the use of upper-extremity orthoses and casts after injuries to the wrist and hand in the pediatric, adolescent, and young adult population. The common injuries reviewed include pediatric distal radius fractures, scaphoid fractures, metacarpal fractures, mallet fingers, volar plate injuries of the proximal interphalangeal (PIP) joint, and ulnar collateral ligament (UCL) tears of the thumb metacarpophalangeal (MCP) joint.

Data Sources:

We conducted a literature review from 1985 to 2016 of upper-extremity orthotic interventions. Non–English language citations and animal studies were excluded. Citations from retrieved studies were used to identify other relevant publications. This review included cases of common injuries to the upper extremity, which required orthotic intervention.

Main Results:

Immobilization recommendations for nonsurgical pediatric distal radius fractures, nonsurgical metacarpal fractures, mallet fingers, and UCL tears of the thumb MCP include a removable orthosis. Nondisplaced scaphoid fracture orthosis recommendations include initial immobilization in a nonremovable short-arm thumb spica cast. Volar plate injuries of the PIP joint require buddy straps for healing.

Conclusions:

The literature demonstrates the effectiveness of removable orthoses in healing, patient satisfaction, and time to return to activity after many common upper-extremity injuries. Removable orthoses should be considered an equal or superior treatment method to cast immobilization, immobilization of additional joints, or longer periods of immobilization.
Interprofessional “on-call” e-learning for family nurse practitioner students: Preparing for primary care across the life span
Authors: Conelius Jaclyn , Grossman Sheila , Becht Lisa Grossman
Published: February 2019

Background and Purpose:

Nurse practitioners (NPs) are expected to fill gaps in providing primary care in the United States and need vital skills to meet the growing need for primary care providers. One necessary skill is managing “on-call” clinical questions/concerns by patients across the life span. To date, there are no published studies that address “on-call” simulations for family NP (FNP) students across the life span.

Methods:

This quasi-experimental, mixed-methods design used a confidence scale and Krippendorff's method for content analysis of discussion pages to determine the effectiveness and confidence of simulated “on-call” scenarios for FNP students during each of their clinical courses.

Conclusions:

There was a significant increase in the confidence level of students as measured by the confidence questionnaire (t = 3.07 [33]; p < .001), at the end of the FNP didactic and clinical courses. Krippendorff content analysis revealed three themes: self-reliance; thinking on your feet; and uncertainty of management.

Implications for Practice:

“On-call” processing is a skill that is needed in graduate FNP programs so that these providers are fully prepared to meet any challenge they may encounter.
Preparing for the transition from clinical practice to academia
Authors: Smith Susan , Karosas Laima , Beauchesne Michelle A.
Published: February 2019

Although education is an essential component of good nursing practice, clinical practice proficiency does not equate to competence in academia. Expert clinicians are not automatically expert educators. However, more and more academic institutions are relying on full-time clinicians to assume academic teaching positions. The decision to transition from clinical practice to academia requires careful consideration of numerous personal and professional issues. The purpose of this brief overview is to offer insight and guidance for nursing professionals embarking on this journey.
Role of Diagnostic Endoscopic Ultrasound in Idiopathic Acute Pancreatitis and Acute Recurrent Pancreatitis in Children
Authors: Kadyada Srikanth Puttaiah , Thapa Babu Ram , Dhaka Narendra , Bhatia Anmol , Menon Jagadeesh
Published: February 2019

Objectives

Endoscopic ultrasound (EUS) is a minimally invasive pancreatic imaging modality. We evaluated children with idiopathic acute pancreatitis (IAP) and acute recurrent pancreatitis (ARP) for changes of chronicity (Rosemont criteria) and biliary risk factors. Diagnostic yield of simultaneously performed transabdominal ultrasonography (TUS) was compared with EUS.

Methods

This was a prospective observational study. Patients underwent EUS and TUS after 2 months of pancreatitis attack.

Results

Forty-five (18 IAP, 27 ARP) patients underwent EUS and TUS. Mean (standard deviation) age and weight were 9.1 (2.6) years and 32.66 (12.43) kg in IAP, whereas these were 12.2 (3.1) years and 44.84 (15.12) kg in ARP, respectively. Endoscopic ultrasound demonstrated morphological abnormality in 33.3% and 40.7% of IAP and ARP, respectively (P = 0.61), whereas 16.6% and 25.9% were abnormal in TUS. Endoscopic ultrasound showed unequivocal changes of chronicity (11.1% vs 0%) and risk factors only among ARP (25.9% vs 0%; P = 0.03) and demonstrated slightly higher odds ratio (95% confidence interval) as compared with TUS to detect abnormalities in both IAP (2.43 [0.49–14.17], P = 0.28) and ARP (1.94 [0.60–6.47], P = 0.26).

Conclusions

Applying EUS, changes of chronicity and risk factors were noted only in ARP. Endoscopic ultrasound performed better than TUS in detecting chronicity.
Expression and Clinical Significance of Protein Kinase RNA–Like Endoplasmic Reticulum Kinase and Phosphorylated Eukaryotic Initiation Factor 2α in Pancreatic Ductal Adenocarcinoma
Authors: Wang Eric M. , Akasaka Hironari , Zhao Jun , Varadhachary Gauri R. , Lee Jeffrey E. , Maitra Anirban , Fleming Jason B. , Hung Mien-Chie , Wang Huamin , Katz Matthew H. G.
Published: February 2019

Objectives

Endoplasmic reticulum stress and subsequent phosphorylation of eukaryotic initiation factor 2α (eIF2α) by protein kinase R–like endoplasmic reticulum kinase (PERK) plays an important role in the development and chemoresistance of pancreatic ductal adenocarcinoma (PDAC). However, the expression and significance of phosphorylated eIF2α (p-eIF2α) and PERK in PDAC have not been examined.

Methods

We examined p-eIF2α and PERK expression in 84 PDAC and paired normal pancreas samples by immunohistochemistry and Western blotting and correlated the results with clinicopathologic parameters and survival.

Results

Mean PERK H score was 140.8 in PDAC compared with 82.1 in normal pancreas (P< 0.001). High p-eIF2α expression was present in 56% of PDACs versus 7.6% of normal pancreases (P< 0.001). High PERK and p-eIF2α expression correlated with shorter overall survival (P= 0.048 andP= 0.03, respectively). By multivariate analysis, high p-eIF2α (P= 0.01), positive margin (P= 0.002), and lymph node metastasis (P= 0.01) were independent prognosticators for survival.

Conclusions

The expression levels of PERK and p-eIF2α are higher in PDAC than those in normal pancreas. High levels of PERK and p-eIF2α are predictors of shorter survival in PDAC patients, suggesting that PERK and eIF2α could be promising targets in PDAC.
HLA‐DQ Genotyping, Duodenal Histology, and Response to Exclusion Diet in Autistic Children With Gastrointestinal Symptoms
Authors: Alessandria Carlo , Caviglia Gian P. , Campion Daniela , Nalbone Federica , Sanna Claudia , Musso Alessandro , Abate Maria L. , Rizzetto Mario , Saracco Giorgio M. , Balzola Federico
Published: February 2019

Objectives:

A correlation between autism spectrum disorders (ASDs) and gastrointestinal (GI) problems, and a possible link between gluten consumption and ASD have been increasingly reported. Gluten/casein‐free diet (GCFD) is often undertaken, with conflicting results. This study aimed at evaluating the distribution of human leukocyte antigen (HLA)‐DQ2/DQ8 typing among patients with ASD with GI symptoms, together with its correlation with duodenal histology and response to GCFD.

Methods:

Between 2002 and 2015 all patients with ASD with GI symptoms referred to our outpatient clinic, displaying clinical, laboratory, or ultrasound findings suggestive of organic disease, underwent endoscopy, celiac disease (CD) serum antibodies testing and HLA‐DQ2/DQ8 genotyping. Patients were prescribed a 6‐month GCFD, and then clinically reassessed.

Results:

Among 151 enrolled patients, 134 (89%) were negative for CD‐specific antibodies; 72 (48%) were positive for HLA‐DQ2/DQ8; and 56 (37%) showed duodenal microscopic inflammation. Clinical improvement was observed in non‐CD patients irrespective of the rigorous or partial adherence to the diet, being the difference nonstatistically significant. Response to diet was related to the presence of histological duodenal alterations at baseline (odds ratio 11.323, 95% confidence interval 1.386–92.549 for Marsh 2 pattern), but not to HLA‐DQ2/DQ8 positivity (odds ratio 1.120, 95% confidence interval 0.462–2.716).

Conclusions:

Our data suggest that children with ASD with GI symptoms have a high prevalence of duodenal intraepithelial lymphocytic infiltration, which seems to be linked to a mechanism other than autoimmune response to gluten consumption. Alteration of duodenal histology, but not the HLA‐DQ2/DQ8 status, was associated with clinical response to the diet.
Risk‐factors Associated With Poor Outcomes in VEO‐IBD Secondary to XIAP Deficiency
Authors: Lekbua Asama , Ouahed Jodie , O'Connell Amy E. , Kahn Stacy A. , Goldsmith Jeffrey D. , Imamura Toshihiko , Duncan Christine N. , Kelsen Judith R. , Worthey Elizabeth , Snapper Scott B. , Softic Samir
Published: February 2019

Very early onset inflammatory bowel disease (VEO‐IBD) represents a diagnostic and treatment challenge. Here we present a case of VEO‐IBD secondary to a mutation in BIRC4 gene, which encodes X‐linked inhibitor of apoptosis protein (XIAP), in a 17‐month‐old boy with severe failure to thrive, intractable diarrhea, and hepatosplenomegaly. Endoscopy and histology identified only mild duodenitis and ileitis, but severe pancolitis with crypt abscesses and epithelium apoptosis. Minimal improvement in symptoms was achieved with total parenteral nutrition (TPN), intravenous (IV) corticosteroids, and tacrolimus, whereas induction and maintenance therapy with adalimumab led to complete remission. After 6 months, the patient developed hemophagocytic lymphohistiocytosis and eventually died due to multisystem organ failure. A review of the literature revealed that some patients with VEO‐IBD secondary to XIAP deficiency develop symptoms that are refractory to medical and surgical management, while initial reports suggest that allogeneic hematopoietic stem cell transplantation (HSCT), with reduced intensity conditioning, can successfully induce long‐lasting remission and may even be curative. We propose that in patients with XIAP deficiency a constellation of symptoms including colitis at an early age, severe failure to thrive, and splenomegaly/hepatosplenomegaly can identify a subgroup of patients at high risk of experiencing medically refractory IBD phenotype and increased mortality. Hematopoietic stem cell transplant should be considered early in these high‐risk patients, as it may resolve both their intestinal inflammation and a risk of developing life threatening hemophagocytic lymphohistiocytosis .
The Association of Glasgow Coma Scale Score With Clinically Important Traumatic Brain Injuries in Children
Authors: Johnson M. Austin , Nishijima Daniel K. , Kuppermann Nathan
Published: February 2019

Objective

An accurate understanding of the incidence of clinically important traumatic brain injuries (ciTBIs) based on presenting Glasgow Coma Scale (GCS) scores in pediatric patients is required to formulate a pretest probability of disease to guide testing and treatment. Our objective was to determine the prevalence of ciTBI and neurosurgical intervention for each GCS score (range 3–15) in children presenting after blunt head trauma.

Methods

This was a secondary analysis of prospectively collected observational data from 25 pediatric emergency departments in the Pediatric Emergency Care Applied Research Network. Patients younger than 18 years with nontrivial blunt head injury were included.

Results

A total of 43,379 children with complete GCS scores were included in the analysis. Seven hundred sixty-three children had ciTBIs (1.8%) and 200 underwent neurosurgery (0.5%). Children with GCS scores of 4 had the highest incidence of ciTBI (21/22, 95.5%) and neurosurgical intervention (16/22, 72.2%). A nearly linear decrease in the prevalence of ciTBI from a GCS score of 4 to a score of 15 was observed (R = 0.92). Of 1341 children, 107 (8.0%) presenting with GCS scores of 14 were found to have ciTBIs and 17 (1.3%) underwent neurosurgical intervention.

Conclusions

A nearly linear relationship exists between the initial GCS score and ciTBI in children with blunt head trauma. The highest prevalence of ciTBI and neurosurgical intervention occurred in children with GCS scores of 4. Children presenting with GCS scores of 14 had a nonnegligible prevalence of ciTBI. These findings are critical to providers caring for children with blunt head trauma to accurately formulate pretest probabilities of ciTBI.