bluuebunny/crossref_metadata_2025 huggingface dataset:
Intelligent agents for feature modelling in computer aided design
Authors: Fougères Alain-Jérôme , Ostrosi Egon
Published: December 2017

CAD modelling can be referred to as the process of generating an integrated multiple view model as a representation of multiple views of engineering design. In many situations, a change in the model of one view may conflict with the models of other views. In such situations, the model of some views needs to be adapted in order to make all models consistent. Thus, CAD models should be capable of adapting themselves to new situations. Recently, agent based technologies have been considered in order to increase both knowledge level and intelligence of real and virtual objects. The contribution of this paper consists in introducing the intelligent agents in intelligent CAD modelling. The proposed agents are elementary geometrical and topological objects. They incorporate the functions of observation, decision and action, and possess their own knowledge. Agents have the capacity of communication and inference based on the feature grammars. They are modelled as bio-dynamic objects that enjoy the properties of fusion, division and multiplication. Being aware of the context, the proposed agents interact to form potential regional transitory communities, called regions. Being aware of their belonging in a region, agents interact by generating virtual links (virtual extensions). These virtual links produce: (a) fusion of agents, (b) division of agents and c) multiplication of agents. The emerged agents interact with the other agents in a region to recognize each other and to form specific sub-communities, called intelligent features. From a CAD software development point of view, this paper advocates the idea of a new phase of CAD system development based on the agent-oriented programming (AOP) paradigm.

Highlights This paper proposes the agent paradigm for intelligent CAD modelling. Second section presents the state of art. In the third section, using the linguistic hypothesis of product design, a feature modelling formalism is presented. Fourth section presents a formal model for agent modelling. In the fifth section, agents for feature generation and modelling are formalised and modelled. The sixth section presents the application of the method. Finally, in the last section, the conclusion and future developments are proposed.
Ocean Circulation, Carbon Cycling During the Last Deglaciation
Authors: Azharuddin Syed
Published: December 2017

Past Global Changes (PAGES) OC3 Working Group second workshop on Ocean Circulation and Carbon Cycling during Last Deglaciation: Regional Synthesis of Carbon Isotopes Data; Corvallis, Oregon, 27–29 June 2017
AGU College of Fellows Announces Program Plans
Authors: Williams Billy
Published: December 2017

A new group that represents the American Geophysical Union’s Fellows kicks off its programs through 2018 with a town hall at the 2017 AGU Fall Meeting about scientific publishing.
Single-molecule live-cell imaging of bacterial DNA repair and damage tolerance
Authors: Ghodke Harshad , Ho Han , van Oijen Antoine M.
Published: December 2017

Genomic DNA is constantly under threat from intracellular and environmental factors that damage its chemical structure. Uncorrected DNA damage may impede cellular propagation or even result in cell death, making it critical to restore genomic integrity. Decades of research have revealed a wide range of mechanisms through which repair factors recognize damage and co-ordinate repair processes. In recent years, single-molecule live-cell imaging methods have further enriched our understanding of how repair factors operate in the crowded intracellular environment. The ability to follow individual biochemical events, as they occur in live cells, makes single-molecule techniques tremendously powerful to uncover the spatial organization and temporal regulation of repair factors during DNA–repair reactions. In this review, we will cover practical aspects of single-molecule live-cell imaging and highlight recent advances accomplished by the application of these experimental approaches to the study of DNA–repair processes in prokaryotes.
Eye‐tracking‐aided digital system for strabismus diagnosis
Authors: Chen Zeng Hai , Fu Hong , Lo Wai Lun , Chi Zheru , Xu Bingang
Published: December 2017

Strabismus is one of the most common vision disorders in preschool children. It can cause amblyopia and even permanent vision loss. In addition to a vision problem, strabismus brings to both children and adults serious negative impacts in their daily life, education, employment etc. Timely diagnosis of strabismus is thus crucial. However, traditional diagnosis methods conducted by ophthalmologists rely significantly on their experiences, making the diagnosis results subjective. It is also inconvenient for those methods being used for strabismus examination in large communities such as schools. In light of that, in this Letter, the authors develop an objective, digital and automatic system based on eye‐tracking technique for diagnosing strabismus. The system exploits eye‐tracking technique to acquire a person's eye gaze data while he or she is looking at some targets. A group of features are proposed to characterise the gaze data. The person's strabismus condition can be diagnosed according to the features. A strabismus gaze dataset is built using the system. Experimental results on the dataset demonstrate the effectiveness of the proposed system for strabismus diagnosis.
RETRACTED: Prediction of heart disease using apache spark analysing decision trees and gradient boosting algorithm
Authors: Chugh Saryu , Arivu Selvan K , Nadesh RK
Published: December 2017

Numerous destructive things influence the working arrangement of human body as hypertension, smoking, obesity, inappropriate medication taking which causes many contrasting diseases as diabetes, thyroid, strokes and coronary diseases. The impermanence and horribleness of the environment situation is also the reason for the coronary disease. The structure of Apache start relies on the evolution which requires gathering of the data. To break down the significance of use programming focused on data structure the Apache stop ought to be utilized and it gives various central focuses as it is fast in light as it uses memory worked in preparing. Apache Spark continues running on dispersed environment and chops down the data in bunches giving a high profitability rate. Utilizing mining procedure as a part of the determination of coronary disease has been exhaustively examined indicating worthy levels of precision. Decision trees, Neural Network, Gradient Boosting Algorithm are the various apache spark proficiencies which help in collecting the information.
Interactive or static reports to guide clinical interpretation of cancer genomics
Authors: Gray Stacy W , Gagan Jeffrey , Cerami Ethan , Cronin Angel M , Uno Hajime , Oliver Nelly , Lowenstein Carol , Lederman Ruth , Revette Anna , Suarez Aaron , Lee Charlotte , Bryan Jordan , Sholl Lynette , Van Allen Eliezer M
Published: December 2017

Objective

Misinterpretation of complex genomic data presents a major challenge in the implementation of precision oncology. We sought to determine whether interactive genomic reports with embedded clinician education and optimized data visualization improved genomic data interpretation.

Materials and Methods

We conducted a randomized, vignette-based survey study to determine whether exposure to interactive reports for a somatic gene panel, as compared to static reports, improves physicians’ genomic comprehension and report-related satisfaction (overall scores calculated across 3 vignettes, range 0–18 and 1–4, respectively, higher score corresponding with improved endpoints).

Results

One hundred and five physicians at a tertiary cancer center participated (29% participation rate): 67% medical, 20% pediatric, 7% radiation, and 7% surgical oncology; 37% female. Prior to viewing the case-based vignettes, 34% of the physicians reported difficulty making treatment recommendations based on the standard static report. After vignette/report exposure, physicians’ overall comprehension scores did not differ by report type (mean score: interactive 11.6 vs static 10.5, difference = 1.1, 95% CI, −0.3, 2.5, P = .13). However, physicians exposed to the interactive report were more likely to correctly assess sequencing quality (P < .001) and understand when reports needed to be interpreted with caution (eg, low tumor purity; P = .02). Overall satisfaction scores were higher in the interactive group (mean score 2.5 vs 2.1, difference = 0.4, 95% CI, 0.2-0.7, P = .001).

Discussion and Conclusion

Interactive genomic reports may improve physicians’ ability to accurately assess genomic data and increase report-related satisfaction. Additional research in users’ genomic needs and efforts to integrate interactive reports into electronic health records may facilitate the implementation of precision oncology.
A likely planet-induced gap in the disc around T Cha
Authors: Hendler Nathanial P , Pinilla Paola , Pascucci Ilaria , Pohl Adriana , Mulders Gijs , Henning Thomas , Dong Ruobing , Clarke Cathie , Owen James , Hollenbach David
Published: December 2017

We present high-resolution (0.11 × 0.06 arcsec2) 3 mm ALMA observations of the highly inclined transition disc around the star T Cha. Our continuum image reveals multiple dust structures: an inner disc, a spatially resolved dust gap, and an outer ring. When fitting sky-brightness models to the real component of the 3 mm visibilities, we infer that the inner emission is compact (≤1 au in radius), the gap width is between 18 and 28 au, and the emission from the outer ring peaks at ∼36 au. We compare our ALMA image with previously published 1.6 μm VLT/SPHERE imagery. This comparison reveals that the location of the outer ring is wavelength dependent. More specifically, the peak emission of the 3 mm ring is at a larger radial distance than that of the 1.6 μm ring, suggesting that millimeter-sized grains in the outer disc are located farther away from the central star than micron-sized grains. We discuss different scenarios to explain our findings, including dead zones, star-driven photoevaporation, and planet-disc interactions. We find that the most likely origin of the dust gap is from an embedded planet, and estimate – for a single planet scenario – that T Cha's gap is carved by a 1.2MJup planet.
Jet-driven and jet-less fireballs from compact binary mergers
Authors: Salafia O S , Ghisellini G , Ghirlanda G
Published: December 2017

During a compact binary merger involving at least one neutron star (NS), a small fraction of the gravitational energy could be liberated in such a way to accelerate a small fraction (∼10−6) of the NS mass in an isotropic or quasi-isotropic way. In presence of certain conditions, a pair-loaded fireball can form, which undergoes accelerated expansion reaching relativistic velocities. As in the standard fireball scenario, internal energy is partly transformed into kinetic energy. At the photospheric radius, the internal radiation can escape, giving rise to a pulse that lasts for a time equal to the delay time since the merger. The subsequent interaction with the interstellar medium can then convert part of the remaining kinetic energy back into radiation in a weak isotropic afterglow at all wavelengths. This scenario does not require the presence of a jet: the associated isotropic prompt and afterglow emission should be visible for all NS–NS and BH–NS mergers within 90 Mpc, independent of their inclination. The prompt emission is similar to that expected from an off-axis jet, either structured or much slower than usually assumed (Γ ∼ 10), or from the jet cocoon. The predicted afterglow emission properties can discriminate among these scenarios.
The effect of pair cascades on the high-energy spectral cut-off in gamma-ray bursts
Authors: Gill Ramandeep , Granot Jonathan
Published: December 2017

The highly luminous and variable prompt emission in gamma-ray bursts (GRBs) arises in an ultra-relativistic outflow. The exact underlying radiative mechanism shaping its non-thermal spectrum is still uncertain, making it hard to determine the outflow's bulk Lorentz factor Γ. GRBs with spectral cut-off due to pair production (γγ → e+e−) at energies Ec ≳ 10 MeV are extremely useful for inferring Γ. We find that when the emission region has a high enough compactness, then as it becomes optically thick to scattering, Compton downscattering by non-relativistic e±-pairs can shift the spectral cut-off energy well below the self-annihilation threshold, Esa = Γmec2/(1 + z). We treat this effect numerically and show that Γ obtained assuming Ec = Esa can underpredict its true value by as much as an order of magnitude.
Chikungunya Outbreak in Kedougou, Southeastern Senegal in 2009–2010
Authors: Sow Abdourahmane , Faye Oumar , Diallo Mawlouth , Diallo Diawo , Chen Rubing , Faye Ousmane , Diagne Cheikh T , Guerbois Mathilde , Weidmann Manfred , Ndiaye Youssoupha , Senghor Cheikh Sadibou , Faye Abdourahmane , Diop Ousmane M , Sadio Bakary , Ndiaye Oumar , Watts Douglas , Hanley Kathryn A , Dia Anta T , Malvy Denis , Weaver Scott C , Sall Amadou Alpha
Published: December 2017

Background

In Senegal, Chikungunya virus (CHIKV), which is an emerging mosquito-borne alphavirus, circulates in a sylvatic and urban/domestic cycle and has caused sporadic human cases and epidemics since 1960s. However, the real impact of the CHIKV sylvatic cycle in humans and mechanisms underlying its emergence still remains unknown.

Methodology

One thousand four hundred nine suspect cases of CHIKV infection, recruited from 5 health facilities located in Kedougou region, south-eastern Senegal, between May 2009 to March 2010, together with 866 serum samples collected from schoolchildren from 4 elementary schools in May and November 2009 from Kedougou were screened for anti-CHIKV immunoglobulin (Ig)M antibodies and, when appropriate, for viral nucleic acid by real-time polymerase chain reaction (rPCR) and virus isolation. In addition, mosquitoes collected in the same area from May 2009 to January 2010 were tested for CHIKV by rPCR and by virus isolation, and 116 monkeys sera collected from March 2010 to May 2010 were tested for anti-CHIKV IgM and neutralizing antibodies.

Results

The main clinical manifestations of the CHIKV suspect cases were headache, myalgia, and arthralgia. Evidence for CHIKV infection was observed in 1.4% (20 of 1409) of patients among suspect cases. No significant difference was observed among age or sex groups. In addition, 25 (2.9%) students had evidence of CHIKV infection in November 2009. Chikungunya virus was detected in 42 pools of mosquitoes, mainly from Aedes furcifer, and 83% of monkeys sampled were seropositive.

Conclusions

Our findings further documented that CHIKV is maintained in a sylvatic transmission cycle among monkeys and Aedes mosquitoes in Kedougou, and humans become infected by exposure to the virus in the forest.
Risk Factors for Viridans Group Streptococcal Bacteremia in Neutropenic and Non-neutropenic Patients: A Single Center Case-Case-Control Study
Authors: Dulanto Chiang Augusto , Sinaii Ninet , Palmore Tara N
Published: December 2017

Background

Viridans group streptococcal (VGS) bacteremia is common among neutropenic patients. Although VGS bacteremia occurs in non-neutropenic patients, risk factors are not well established. We conducted a case-case-control study to identify risk factors for VGS among neutropenic and non-neutropenic patients.

Methods

Patients with VGS bacteremia between January 2009 and December 2014 in our 200-bed clinical research hospital were identified using microbiology records. Neutropenic and non-neutropenic patients at the time of positive culture were matched 1:1 to controls on the basis of neutrophil count (ANC), ward, and length of stay. We extracted demographic, laboratory, medication, and other clinical data from chart reviews. Data were analyzed using McNemar’s test, Wilcoxon signed-rank test, and conditional logistic regression modeling.

Results

Among 101 patients, 63 were neutropenic and 38 non-neutropenic at the time of VGS bacteremia. In multivariable analysis of neutropenic patients, only lower ANC predicted VGS bacteremia (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05–0.59; P = 0.006). Recent use of vancomycin was protective (OR, 0.23; 95% CI, 0.07–0.73; P = 0.013). No clinical factors were associated with VGS in the non-neutropenic cases.

Conclusions

Only lower ANC nadir increased the risk for VGS bacteremia in the neutropenic group, and vancomycin was protective. Other previously described factors (chemotherapy, radiation, oral conditions) related to neutropenia were not independently associated with VGS bacteremia. No tested clinical factors predicted infection in the non-neutropenic group. Our results suggest that VGS bacteremia should be anticipated when making antimicrobial choices in profoundly neutropenic patients, and merit further exploration in non-neutropenic patients.
Misplacement of Stent Into Epidural Venous Plexus With Resultant Cauda Equina Syndrome and Open Surgical Treatment: A Case Report
Authors: Whiting Benjamin B , Mulholland Celene B , Daniels Lorin , Kakarla U Kumar , Theodore Nicholas , Snyder Laura A
Published: December 2017

BACKGROUND AND IMPORTANCE

Endovascular therapy has proven to be a safe, minimally invasive treatment for multiple etiologies, but proper precautions must be taken to avoid complications. When complications occur, they should be promptly identified and corrected when possible. This case report describes endovascular stents misplaced into the epidural spinous venous plexus rather than the iliofemoral arteries, causing cauda equina syndrome, as well as the spinal procedure performed to treat the resulting spinal canal compression.

CLINICAL PRESENTATION

A 67-yr-old man had undergone what he thought was iliofemoral arterial stenting at an outside hospital for peripheral vascular disease. He presented 8 d later to our hospital with cauda equina syndrome comprising back pain, right L5 radiculopathy, perianal numbness, urinary retention, and constipation. Scans demonstrated stents deployed into the venous system, traversing the spinal canal and the right L5-S1 neural foramen, resulting in severe spinal canal stenosis, right L5-S1 foraminal stenosis, and moderate left S1-S2 foraminal stenosis. The patient underwent an L5-S1 laminectomy with full right L5-S1 facetectomy and left S1-S2 medial facetectomy, with associated L5-S1 posterolateral fusion with fixation to remove the stent and decompress the neural elements.

CONCLUSION

Although stent misplacement is an uncommon complication of endovascular therapy, this case demonstrates the importance of ensuring access to the proper vessel before stent placement. Once this complication was recognized, safe removal of the stents was possible and the patient demonstrated meaningful postoperative improvement in symptoms and strength.
Intravenous Acetaminophen Reduces Length of Stay Via Mediation of Postoperative Opioid Consumption After Posterior Spinal Fusion in a Pediatric Cohort
Authors: Olbrecht Vanessa A. , Ding Lili , Spruance Kristie , Hossain Monir , Sadhasivam Senthilkumar , Chidambaran Vidya
Published: December 2017

Objectives:

Since approval of intravenous acetaminophen (IV APAP), its use has become quite common without strong positive evidence. Our goal was to determine the effect of IV APAP on length of hospital stay (LOS) via mediation of opioid-related side effects in pediatric patients.

Materials and Methods:

After Institutional Review Board approval, 114 adolescents undergoing posterior spinal fusion were prospectively recruited and managed postoperatively with patient-controlled analgesia and adjuvant therapy. Patients were divided into 2 groups based on the use of IV APAP: control (n=70) and treatment (n=44). Association of IV APAP use with opioid outcomes was analyzed using inverse probability of treatment weighting (IPTW)-adjusted propensity scores to balance the 2 groups for all significant covariates except postoperative opioid consumption. Mediation analysis was carried out for LOS with IV APAP as the independent variable and morphine consumption as the mediator.

Results:

Oral intake was delayed by ∼1 day (P<0.001) and LOS was 0.6 days longer in the control group (P=0.044). After IPTW, time to oral intake remained significantly longer in the control group (P=0.014). The mediation model with IPTW revealed a significant negative association between IV APAP and morphine consumption (P<0.001), which significantly increased LOS (P<0.003). IV APAP had a significant opioid-sparing effect associated with shorter LOS.

Discussion:

IV APAP hastens oral intake and is associated with decreased LOS in an adolescent surgery population likely through decreased opioid consumption. Through addition of IV APAP in this population, LOS may be decreased, an important implication in the setting of escalating health care costs.
Four Types of Pulse Oximeters Accurately Detect Hypoxia during Low Perfusion and Motion
Authors: Louie Aaron , Feiner John R. , Bickler Philip E. , Rhodes Laura , Bernstein Michael , Lucero Jennifer
Published: December 2017

Background

Pulse oximeter performance is degraded by motion artifacts and low perfusion. Manufacturers developed algorithms to improve instrument performance during these challenges. There have been no independent comparisons of these devices.

Methods

We evaluated the performance of four pulse oximeters (Masimo Radical-7, USA; Nihon Kohden OxyPal Neo, Japan; Nellcor N-600, USA; and Philips Intellivue MP5, USA) in 10 healthy adult volunteers. Three motions were evaluated: tapping, pseudorandom, and volunteer-generated rubbing, adjusted to produce photoplethsmogram disturbance similar to arterial pulsation amplitude. During motion, inspired gases were adjusted to achieve stable target plateaus of arterial oxygen saturation (SaO
2) at 75%, 88%, and 100%. Pulse oximeter readings were compared with simultaneous arterial blood samples to calculate bias (oxygen saturation measured by pulse oximetry [SpO
2] − SaO
2), mean, SD, 95% limits of agreement, and root mean square error. Receiver operating characteristic curves were determined to detect mild (SaO
2 < 90%) and severe (SaO
2 < 80%) hypoxemia.

Results

Pulse oximeter readings corresponding to 190 blood samples were analyzed. All oximeters detected hypoxia but motion and low perfusion degraded performance. Three of four oximeters (Masimo, Nellcor, and Philips) had root mean square error greater than 3% for SaO
2 70 to 100% during any motion, compared to a root mean square error of 1.8% for the stationary control. A low perfusion index increased error.

Conclusions

All oximeters detected hypoxemia during motion and low-perfusion conditions, but motion impaired performance at all ranges, with less accuracy at lower SaO
2. Lower perfusion degraded performance in all but the Nihon Kohden instrument. We conclude that different types of pulse oximeters can be similarly effective in preserving sensitivity to clinically relevant hypoxia.
The Superiorly Based Partial Rectus Abdominis and External Oblique Flap: A New Technique for Breast Asymmetry Reconstruction
Authors: Nowicki Jake L. , Lam Quoc Tai Khoa , Dean Nicola R.
Published: December 2017

Breast asymmetry has a wide spectrum of presentations with several employable strategies for surgical correction. Historically, the external oblique muscle has proven to be a versatile flap option for the reconstruction of both local and distant defects. It has also been described for use in breast reconstruction for coverage of the lower pole of implant prostheses. The external oblique muscle flap can be harvested in several ways to capture overlying fat and skin. In this study, we describe the use of a superiorly based partial rectus and external oblique flap for surgical correction of lower pole breast hypoplasia. This flap provides vascularized autologous volume to the lower pole of the breast with minimal donor morbidity. Other advantages of this flap are that it can increase the nipple to inframammary fold distance and lower the inframammary fold. This technique represents an evolution of an under-utilized flap and is the first study describing the use of the external oblique flap in the management of breast asymmetry.
Totally Thoracoscopic Pulmonary Vein Isolation
Authors: Al-Jazairi Meelad I.H. , Klinkenberg Theo J. , Van Putte Bart P. , Mariani Massimo A. , Benussi Stefano
Published: December 2017

Since the introduction of thoracoscopic ablation for atrial fibrillation (AF), the field of minimally invasive AF treatment has evolved toward an established treatment option for AF, with an overall 2-year antiarrhythmic drug free success rate of 77%. Complications are usually minor, and the incidence of bleeding needing conversion to sternotomy or (mini-)thoracotomy varies between 0% and 1.6%. Bleeding is often related to encircling the pulmonary veins, which is a blind maneuver that has to be done without direct camera vision. We propose here a modified surgical technique to simplify the procedure, shorten the operating time, and lower the risk of complications.
The Addition of Dexmedetomidine as an Adjunctive Therapy to Benzodiazepine Use in Alcohol Withdrawal Syndrome
Authors: Ferenchak Tarenne A.
Published: December 2017

Alcohol withdrawal syndrome (AWS) is commonly encountered in the intensive care unit population. Currently, the mainstay treatment for AWS is the use of benzodiazepines. However, some patients are refractory to benzodiazepine treatment due to heavy alcohol abuse. In addition, escalating doses of benzodiazepines can lead to respiratory depression, requiring intubation and mechanical ventilation. Intubation and mechanical ventilation increase both intensive care unit and hospital length of stay. The addition of pharmacological agents to reduce the amount of benzodiazepine use in AWS has recently been studied. Most recently, the addition of dexmedetomidine, a selective α2 adrenoceptor agonist, has been explored. Dexmedetomidine provides sedation without depressing the respiratory system, making it an ideal pharmacological agent to use. The addition of dexmedetomidine in adjunct to benzodiazepine use has been proven to reduce the amount of benzodiazepine administered, decrease the number of patients requiring intubation and mechanical ventilation, and decrease length of intensive care unit stay and overall length of hospital stay. However, the use of dexmedetomidine has also produced harmful side effects such as hypotension and bradycardia. The use of dexmedetomidine in conjunction with benzodiazepines in the setting of AWS is promising; however, more research needs to be conducted in regard to the safety and efficacy of its use.
Compliance With Best Practice Guidelines for Neurodevelopmental Supportive Care in South Africa
Authors: Rheeder Aletta , Lubbe Welma , van der Walt Christa S. J. , Pretorius Ronel
Published: December 2017

Neurodevelopmental supportive care provides preterm infants with evidence-based care to ensure the best possible neurological outcomes. The study aimed to determine the compliance of current nursing care practices with best practice guidelines by means of a situational analysis. The situational analysis was done in 2 cycles in the neonatal intensive care units (n = 25) of a private healthcare provider in South Africa. Structured observations were done in cycle 1 using the Implementation of Neurodevelopmental Supportive Care checklist. Cycle 2 comprised focus group discussions to verify findings from cycle 1. Seventeen conclusion statements were formulated, which were thematically combined to be presented as 9 categories: neonatal intensive care unit design, individualized care, family-centered care, infant positioning, handling techniques, environmental manipulation, pain management, knowledge of infant behavior, and feeding. The conclusion statements identified improvement opportunities in current practice and offer suggestions, which can be used to guide an implementation strategy for best practice guidelines of neurodevelopmental supportive care in the neonatal intensive care units of the private healthcare group in future. Addressing improvement opportunities in all the categories will ensure that all aspects of the guideline requirements are met, resulting in a comprehensive strategy improving practice and patient outcomes.
Stress From the Neonatal Intensive Care Unit to Home
Authors: Garfield Craig F. , Simon Clarissa D. , Rutsohn Joshua , Lee Young S.
Published: December 2017

To examine cortisol diurnal rhythms over the transition from the critical care setting to home for fathers and mothers of very low-birth-weight infants, including how cortisol is associated with psychosocial stress and parenting sense of competence. This cohort study in a level III neonatal intensive care unit and the general community had 86 parents complete salivary collection and self-reported psychosocial measures. Salivary samples were collected 3 times a day on the day before discharge, and on 3 subsequent days at home. Self-report measures included the Perceived Stress Scale and the Parenting Sense of Competence Scale, which measure parenting satisfaction. Fathers showed increased physiologic stress over the transition home, reflected by flattening of slopes, lower wakeup, and higher bedtime cortisol. Mothers reporting increases in perceived stress over the transition home had higher bedtime cortisol, suggesting a link between higher perceived stress and higher physiologic stress. Results were significant after controlling for breastfeeding, insurance status, and gestational age. This study examined a physiologic marker of stress in parents with very low-birth-weight infants, finding sex disparities in diurnal cortisol patterns during the transition from neonatal intensive care unit to the community. Fathers may be especially susceptible to stressors during this transition.
Validation of an Algorithm to Identify Infective Endocarditis in People Who Inject Drugs
Authors: Ball Laura J. , Sherazi Adeel , Laczko Dora , Gupta Kaveri , Koivu Sharon , Weir Matthew A. , Mele Tina , Tirona Rommel , McCormick John K. , Silverman Michael
Published: December 2017

Introduction:

Infective endocarditis is associated with high morbidity and mortality. Currently, there is concern that the incidence of infective endocarditis associated with people who inject drugs (PWID) is increasing. However, it is difficult to monitor population-wide trends in PWID-associated infective endocarditis, as there is no International Statistical Classification of Diseases, 10th Revision (ICD-10) code for injection drug use. To address this barrier, we sought to develop a validated algorithm using ICD-10 discharge diagnosis codes.

Materials and Methods:

We constructed a cohort of patients whose hospital discharge diagnosis included infective endocarditis. We reviewed 100 patients with incident infective endocarditis from 2014 to 2016 for their infective endocarditis and injection drug use status. We calculated the operating characteristics for algorithms constructed using permutations of ICD-10 codes associated with injection drug use. We repeated this analysis in a cohort of 100 patients with incident infective endocarditis from 2009 to 2011 to examine the temporal stability of the operating characteristics of each algorithm.

Results:

We found that a combination of hepatitis C virus, drug use, and mental/behavioral disorder codes yielded the highest sensitivity (93%) and positive predictive value (83%) of the algorithms analyzed.

Discussion:

We have described the first algorithm, validated against chart review data, for identifying PWID-associated infective endocarditis cases using ICD-10 codes. The high sensitivity and positive predictive value indicate that this algorithm can be used for surveillance and research with confidence.

Conclusions:

This algorithm will enable researchers to examine epidemiological trends in PWID-associated infective endocarditis.
A Rare Vehicle-Assisted Ligature Hanging
Authors: Barranco Rosario , Caputo Fiorella , Bonsignore Alessandro , Fraternali Orcioni Giulio , Ventura Francesco
Published: December 2017

Suicide by hanging inside a motor vehicle is a rare occurrence. A 48-year-old woman suffering from major depression was found having agonal breathing inside her automobile. A 20-mm diameter blue nylon rope was wrapped tightly around her neck, with its other end tied to a nearby wooden fence post. Despite resuscitation attempts, she was declared deceased after several minutes. The vehicle was located in an area with a slight downward slope. The motor was off. It was in neutral gear, with the parking brake disengaged. Consequently, the gravitational forces, attributable to the mass of the vehicle and the declivity of the terrain, caused the rope to tighten.

The dynamics fulfill the criteria for a partial hanging, given the difference in height between the point at which the rope was secured to the post and woman's neck, which in turn presented the typical oblique upward groove.

This case, thus, represents a unique mode of partial hanging inside a passenger vehicle, rarely reported in the literature. The relative lack of internal injury is also noteworthy, along with the fact that the victim was discovered while still alive. The latter feature can be explained by the absence of the sudden or violent acceleration forces that can be generated with the engine on.
BCOR Internal Tandem Duplication in High-grade Uterine Sarcomas
Authors: Mariño-Enriquez Adrián , Lauria Alexandra , Przybyl Joanna , Ng Tony L. , Kowalewska Magdalena , Debiec-Rychter Maria , Ganesan Raji , Sumathi Vaiyapuri , George Suzanne , McCluggage W. Glenn , Nucci Marisa R. , Lee Cheng-Han , Fletcher Jonathan A.
Published: December 2017

Endometrial stromal sarcomas (ESSs) are mesenchymal uterine tumors characterized by recurrent genetic events, most commonly chromosomal rearrangements, that create oncogenic gene fusions. High-grade endometrial stromal sarcomas (HG-ESSs), as defined in the 2014 World Health Organization Classification, typically contain oncogenic YWHAE-NUTM2 fusions; however, although not well characterized, there are tumors morphologically overlapping with HG-ESS that do not contain the YWHAE-NUTM2 fusions. These fusions are also found in certain pediatric primitive sarcomas, including clear cell sarcoma of the kidney and soft tissue undifferentiated round cell sarcoma of infancy. A subset of these same pediatric sarcomas lack YWHAE-NUTM2 fusions and instead have internal tandem duplications (ITDs) involving exon 15 of BCOR (BCOR ITD). We investigated the presence of BCOR ITD by targeted sequencing in a series of 31 uterine sarcomas, comprising 5 low-grade ESS, 13 uterine sarcomas diagnosed as HG-ESS, and 13 undifferentiated uterine sarcomas. BCOR ITD were present in 1 uterine sarcoma diagnosed as HG-ESS and 2 undifferentiated sarcomas with uniform nuclear features, all of which lacked any of the recurrent chromosome translocations known to occur in ESS. These 3 high-grade sarcomas with BCOR ITD affected young patients (average age, 24) and morphologically were composed of nonpleomorphic spindle cells admixed with epithelioid and round cell areas. Focal myxoid stroma was present in 2 cases. Mitotic activity was brisk, necrosis was present, and there was lymphovascular involvement in all cases. The 3 uterine sarcomas with BCOR ITD exhibited diffuse cyclin D1 immunohistochemical expression and there was diffuse BCOR expression in the 2 cases tested. Long-term follow-up in 2 patients revealed 1 to be tumor-free after 22 years and the other to die of disease after 8 years. In conclusion, BCOR ITD is an oncogenic alternative to YWHAE-NUTM2 fusion in high-grade uterine sarcomas with uniform nuclear features. We propose that neoplasms with the morphology described and BCOR ITD be regarded as a unique subtype of high-grade uterine sarcoma, possibly within the family of endometrial stromal neoplasia.
Adult Primary Immune Thrombocytopenia
Authors: Furudoï Adeline , Rivière Étienne , Lazaro Estibaliz , Furudoï Enio , Viallard Jean-François , Parrens Marie
Published: December 2017

Immune thrombocytopenia (ITP) is an acquired antibody-mediated disease, for which splenectomy remains a curative treatment. We analyzed histology and phenotypes of ITP-splenectomy specimens from 41 adult patients, with different previous ITP-specific treatments, including B-cell–depleting rituximab (RTX) or not, in an attempt to predict splenectomy success or failure on the basis of day 56 postoperative platelet counts. RTX-naive ITP-spleen samples, compared with those from a 20-patient control trauma cohort, contained the following nonspecific, ITP-evocative, white-pulp lesions: follicular helper T-cell (programmed death-1+ and inducible T-cell COStimulator+) expansion in reactive follicles (P=0.01 and 0.03, respectively) and regulatory T-cell (FOXP3+) expansion in the T-cell zone (P=0.049). On comparing ITP-splenectomy samples that would be successful with those that would be failures, only marginal zone hyperplasia differed (P=0.017). Indeed, 13/21 (61.9%) successful splenectomy samples exhibited marginal zone hyperplasia, as opposed to 1/9 (11.1%) failed splenectomy specimens. RTX impact on ITP-splenectomy samples was characterized by white-pulp (P=0.03) and marginal zone atrophies (P=0.01), and periarteriolar T-cell–zone hyperplasia (P<0.0001). The results of this novel comparative study of the histologic patterns of 41 ITP patients’ evocative splenic lesions enabled clear description of different ITP morphologies and phenotypes, as a function of prior treatment and splenectomy success or failure.
Dispatcher-Assisted Cardiopulmonary Resuscitation Program and Outcomes After Pediatric Out-of-Hospital Cardiac Arrest
Authors: Lee Yu Jin , Song Kyoung Jun , Shin Sang Do , Lee Seung Chul , Lee Eui Jung , Ro Young Sun , Ahn Ki Ok
Published: December 2017

Objectives

A dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) is expected to influence the outcomes of pediatric out-of-hospital cardiac arrest (OHCA). Our objective was to measure the effect size of a DA-BCPR on survival outcomes according to location of the event.

Methods

All emergency medical service treated OHCA patients younger than 19 years in Korea from January 2012 through December 2013 were analyzed. Patients with OHCA witnessed by emergency medical service providers and those with missing outcome information were excluded. Patients were categorized into the following categories: No-BCPR, BCPR without dispatcher assistance (BCPR-NDA), and BCPR-DA. The primary outcome was survival to hospital discharge. Multivariable logistic regression analysis was performed to calculate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for outcomes by exposure group (reference, No-BCPR group) with and without an interaction term between exposure and location of arrest.

Results

A total of 1013 eligible patients were analyzed. Among these patients, 16.6% received BCPR-NDA, 23.2% received BCPR-DA, and 60.2% received no BCPR. After adjusting for potential confounders, compared with N0-BCPR group, AORs for survival were 1.79 (95% CI, 1.03–3.12) in BCPR group, 1.71 (95% CI, 0.85–3.46) in BCPR-NDA group, and 1.39 (95% CI, 0.72–2.69) in BCPR-DA group. The AORs for survival of BCPR-NDA and BCPR-DA in public location were 3.30 (95% CI, 1.12–9.72) and 2.95 (95% CI, 1.00–8.67), whereas BCPR-NDA and BCPR-DA in private locations were 1.62 (95% CI, 0.68–3.88) and 1.15 (95% CI, 0.53–2.51).

Conclusion

The DA-CPR was associated with better outcomes in pediatric OHCA patients whose arrest occurred in public locations, but no improvement in outcomes was identified in patients whose arrest occurred at private locations.
Effects of the Introduction of Intranasal Fentanyl on Reduction of Pain Severity Score in Children
Authors: Lord Bill , Jennings Paul A. , Smith Karen
Published: December 2017

Objectives

Children are at risk of inadequate analgesia due to paramedics' inexperience in assessing children and challenges in administering analgesics when the patient is distressed and uncooperative. This study reports on the outcome of a change to practice guidelines that added intranasal fentanyl and intramuscular morphine within a large statewide ambulance service.

Methods

This retrospective study included patients younger than 15 years treated by paramedics between January 2008 and December 2011. The primary outcome of interest was the proportion of patients having a 2/10 or greater reduction in pain severity score using an 11-point Verbal Numeric Rating Scale before and after the intervention. Segmented regression analysis was used to estimate the effect of the intervention over time. A multiple regression model calculated odds ratios with 95% confidence intervals.

Results

A total of 92,378 children were transported by paramedics during the study period, with 9833 cases included in the analysis. The median age was 11 years; 61.6% were male. Before the intervention, 88.1% (n = 3114) of children receiving analgesia had a reduction of pain severity of 2 or more points, with 94.2% (n = 5933) achieving this benchmark after intervention (P < 0.0001). The odds of a reduction in pain of 2 or more points increased by 1.01 per month immediately before the intervention and 2.33 after intervention (<0.0001).

Conclusions

This large study of a system-wide clinical practice guideline change has demonstrated a significant improvement in the outcome of interest. However, a proportion of children with moderate to severe pain did not receive analgesia.
The Impact of Intra-articular Depot Betamethasone Injection on Insulin Resistance Among Diabetic Patients With Osteoarthritis of the Knee
Authors: Habib George , Chernin Mark , Sakas Fahed , Artul Suheil , Jabbour Adel , Jabaly-Habib Haneen
Published: December 2017

Objective

The aim of this study was to evaluate the impact of intra-articular corticosteroid injection (IACI) of depot betamethasone at the knee joint on insulin resistance (IR).

Methods

Patients with type 2 diabetes, non–insulin treated, with painful osteoarthritis of the knee were requested to participate in our study. After consent, demographic, clinical, and laboratory parameters were documented in addition to fasting blood glucose (FBG) and fasting blood insulin levels just prior to IACI of 1 mL of depot betamethasone. Fasting blood glucose and fasting blood insulin levels were repeated the next day following the IACI and 8 days later. Age- and sex-matched group of patients with type 2 diabetes from the same clinic were recruited as a control group (case-control study). Insulin resistance was calculated using Homeostasis Model Assessment–Insulin Resistance. Mann-Whitney U test, χ2 test, and Wilcoxon signed rank tests were used for statistical analysis.

Results

Eleven patients were recruited in the patients' group and 10 patients in the control group. Median FBG in the patients' group at baseline was 148 ± 51 mg/dL, and median IR was 5.12 ± 2.46. One day following the IACI, median FBG level was 247 ± 104 mg/dL (P = 0.004, compared with baseline), with median IR of 20.8 ± 7.01 (P = 0.0039). The median ratios of blood glucose and IR 1 day following the IACI compared with baseline were 1.7 and 4.1, respectively. Eight days following the IACI, mean FBG and IR levels were not significantly different from baseline.

Conclusions

Intra-articular corticosteroid injection of betamethasone at the knee joint among patients with diabetes was associated with a significant increase in IR levels compared with baseline levels, 1 day following the injection. The mean percentage of increase in IR was higher than that for FBG levels.
Relationship Between Ventricular Arrhythmias, Conduction Disorders, and Myocardial Fibrosis in Patients With Systemic Sclerosis
Authors: Muresan Lucian , Oancea Irinel , Mada Razvan Ovidiu , Petcu Ana , Pamfil Cristina , Muresan Crina , Rinzis Mirela , Pop Dana , Zdrenghea Dumitru , Rednic Simona
Published: December 2017

Background

Delayed-enhancement magnetic resonance imaging (DE-MRI) is a noninvasive diagnostic tool able to identify myocardial fibrosis. In patients with scleroderma, its relationship with arrhythmias and conduction disorders has not been fully explored.

Objectives

The aim of this study was to evaluate the possible correlations between ventricular arrhythmias, conduction disorders, and myocardial fibrosis in patients with systemic sclerosis.

Methods

Thirty-six patients with diffuse or limited cutaneous scleroderma underwent 12-lead electrocardiogram (ECG), 24-hour Holter ECG monitoring, transthoracic echocardiography, and cardiac DE-MRI, with gadolinium administration in 33 patients.

Results

High-quality DE-MRI scans were obtained in 30 patients. Myocardial fibrosis was detected in 25 patients (83.3%). Eighteen patients (60%) had ventricular arrhythmias or conduction disorders. There was no significant difference in ventricular arrhythmia burden (the total number of premature ventricular contractions [PVCs]/24 hours) (48 ± 304 vs. 69 ± 236, P = 0.97), ventricular arrhythmia severity (couplets, triplets, runs) on Holter ECG, or in the presence of conduction disorders (36% vs. 40%, P = 0.86) between patients with and without myocardial fibrosis. In univariate analysis, diffuse fibrosis was weakly associated with the number of PVCs/24 hours (R
2 = 0.157, P = 0.03). A number of at least 597 PVCs/24 hours had a sensitivity of 60% and a specificity of 92% in predicting the presence of diffuse fibrosis on DE-MRI (area under the curve = 0.640).

Conclusions

Delayed-enhancement magnetic resonance imaging can identify myocardial fibrosis in a high percentage of scleroderma patients. Its presence does not seem to influence the ventricular arrhythmia burden and severity or the presence of conduction disorders, with the exception of diffuse myocardial fibrosis, which modestly influences the total number of PVCs/24 hours.
No intravenous access, no problem: Intraosseous administration of tranexamic acid is as effective as intravenous in a porcine hemorrhage model
Authors: Lallemand Michael S. , Moe Donald M. , McClellan John M. , Loughren Michael , Marko Shannon , Eckert Matthew J. , Martin Matthew J.
Published: December 2017

BACKGROUND

The acute coagulopathy of trauma is often accompanied by hyperfibrinolysis. Tranexamic acid (TXA) can reverse this phenomenon, and, when given early, decreases mortality from bleeding. Establishing intravenous (IV) access can be difficult in trauma and intraosseous (IO) access is often preferred for drug administration. Currently, there are no data on the efficacy of IO administered TXA. Our objectives were to compare serum concentrations of TXA when given IV and IO and to compare the efficacy of IO administered TXA to IV at reversing hyperfibrinolysis.

METHODS

Using a porcine hemorrhage and ischemia-reperfusion model, 18 swine underwent hemorrhagic shock followed by a tissue plasminogen activator infusion to induce hyperfibrinolysis. Animals then received an IV or tibial IO infusion of TXA over 10 minutes. Blood was then analyzed using rotational thromboelastometry to monitor reversal of hyperfibrinolysis. Serum was analyzed for drug concentrations.

RESULTS

After hemorrhage and ischemia-reperfusion, there were no significant differences in mean arterial pressure (48 vs. 49.5), lactate (11.1 vs. 10.8), and pH (7.20 vs. 7.22) between groups. Intraosseous TXA corrected the lysis index at 30 minutes in EX-TEM and IN-TEM, like IV infusion. Peak serum levels of TXA after IV and IO administration show concentrations of 160.9 μg/mL and 132.57 μg/mL respectively (p = 0.053). Peak levels occurred at the completion of infusion. Drug levels were tracked for four hours. At the end of monitoring, plasma concentrations of TXA were equivalent.

CONCLUSION

Intraosseous administration of TXA is as effective as IV in reversing hyperfibrinolysis in a porcine model of hemorrhagic shock. Intraosseous administration was associated with a similar peak levels, pharmacokinetics, and clearance. Intraosseous administration of TXA can be considered in hemorrhagic shock when IV access cannot be established.