bluuebunny/crossref_metadata_2025 huggingface dataset:
Entrepreneurial Strategies to Seek Venture Capital Funding
Authors: Jalalabadi Faryan , Grome Luke , Shahrestani Navid , Izaddoost Shayan , Reece Edward
Published: October 2018

Innovation is vital for progress in any industry. Evolving technology, paired with human ingenuity, brings ideas for prototypes and business models. Many physicians conceptualize platforms to serve their patients; however, many struggle and ultimately fail to bring their product or service to market. Financing is often the limiting factor. Studies have proven venture capital (VC) funding to be a pivotal source for helping a business survive in its early stages. Plastic surgeons can benefit from learning how to seek out VC funding. In this presentation, common terminology and key players will be defined, from seed capital to angel investors. Doing recommended “homework” will help the plastic surgeon identify a financier tailored to their specific needs—ideally one with a focus in the medical space. A clear-cut approach to assembling a “pitch deck” presentation will be outlined to prepare the plastic surgeon for their first meeting. Insider pearls will be presented from the VC perspective. The plastic surgeon should be prepared to answer fundamental questions expected at different stages of the process. Nevertheless, each meeting also serves as an opportunity for the plastic surgeon to probe the VC firm and their intentions. The role of background checks, social media, and electronic profiles will be discussed. Transparency from both parties at all times can help establish a successful relationship, even if it ends in a referral to a better suited VC firm. Between January and September of 2017, $12.1 billion of seed and VC was invested into life science companies in the United States. Growth is exponential. The surgeon is at the frontier of developing ideas and cutting-edge products that help us serve our patients with enhanced care and improved outcomes. In seeking out the proper financier, your product or service can become a reality in the market, contributing to the betterment of medicine and plastic surgery.
Philosophy of religion and the big questions
Authors: Neville Robert
Published: October 2018

Whether philosophy of religion can have a robust future depends on whether it can develop forms that address the Big Questions of religion. I define religion heuristically, for the purposes of philosophy of religion, as the engagement of ultimate realities, and ultimate dimensions of experience, in cognitive, existential, and practical ways. This requires setting philosophy of religion within a larger scale of philosophy that can deal with ultimates, how they are known, and how such philosophy can defend itself against attacks against the possibility of philosophies of ultimate reality. Philosophy of religion is interesting only if it can say, with good arguments, whether we get ultimate realities right when engaging them. The threats to the future of philosophy of religion come from those forms of the discipline that talk only about how to talk about religion or that only describe religious experience without giving a critical normative account of what is experienced as ultimate. The key to advocating philosophy of religion that addresses the Big Questions is showing that it is plausible and possible to have a philosophy of ultimates. The bulk of this article proposes such a philosophy as a plausible hypothesis. Even if this hypothesis about ultimates is rejected in the long run, that will only be by the presentation of a better hypothesis about ultimates. The paideia for philosophy of religion dealing with the Big Questions is discussed, as is the development of an interested audience for such philosophy of religion.
Implications of a regional-scale process (the Lakshadweep low) on the mesozooplankton community structure of the Arabian Sea
Authors: Karati K. K. , Vineetha G. , Raveendran T. V. , Dineshkumar P. K. , Muraleedharan K. R. , Joseph T. , Jayalakshmi K. V.
Published: October 2018

The Arabian Sea, a major tropical ocean basin in the northern Indian Ocean, is one of the most productive regions in the global ocean. Although the classical Arabian Sea ‘paradox’ describes the geographical and seasonal invariability in zooplankton biomass in this region, the effect of the Lakshadweep low (LL), a regional-scale physical process, on the zooplankton community has not yet been evaluated. The LL, characterised by low sea surface height and originating around the vicinity of the Lakshadweep islands during the mid-summer monsoon, is unique to the Arabian Sea. The present study investigated the effect of the LL on the zooplankton community. The LL clearly had a positive effect, with enhanced biomass and abundance in the mixed-layer depth of the LL region. Copepods and chaetognaths formed the dominant taxa, exhibiting strong affinity towards the physical process. Of the 67 copepod species observed, small copepods belonging to the families Paracalanidae, Clausocalanidae, Calanidae, Oncaeidae and Corycaeidae dominated the LL region. Phytoplankton biomass (chlorophyll-a) was the primary determinant influencing the higher preponderance of the copepod community in this region.
Deep neural network improves fracture detection by clinicians
Authors: Lindsey Robert , Daluiski Aaron , Chopra Sumit , Lachapelle Alexander , Mozer Michael , Sicular Serge , Hanel Douglas , Gardner Michael , Gupta Anurag , Hotchkiss Robert , Potter Hollis
Published: October 2018

Significance

Historically, computer-assisted detection (CAD) in radiology has failed to achieve improvements in diagnostic accuracy, decreasing clinician sensitivity and leading to unnecessary further diagnostic tests. With the advent of deep learning approaches to CAD, there is great excitement about its application to medicine, yet there is little evidence demonstrating improved diagnostic accuracy in clinically-relevant applications. We trained a deep learning model to detect fractures on radiographs with a diagnostic accuracy similar to that of senior subspecialized orthopedic surgeons. We demonstrate that when emergency medicine clinicians are provided with the assistance of the trained model, their ability to accurately detect fractures significantly improves.
Remote subsurface ocean temperature as a predictor of Atlantic hurricane activity
Authors: Scoccimarro Enrico , Bellucci Alessio , Storto Andrea , Gualdi Silvio , Masina Simona , Navarra Antonio
Published: October 2018

Significance

A nonlocal effect associated with eastern Atlantic Ocean temperature provides additional predictive skill of tropical cyclone activity when compared with the well-known local modulation effect associated with sea surface temperature. The most active tropical cyclone seasons occur for lower than normal wind shear conditions and less intense trade winds, which are associated with higher eastern Atlantic sea surface temperature. A significant step toward operationally reliable predictions of tropical cyclone activity is gained after including upper ocean mean temperatures (upper 40-m averages) over the eastern Atlantic domain with remote effects providing potential skill up to 3 months in advance.
Painful Complications After Cosmetic Surgery: Management of Peripheral Nerve Injury
Authors: Chopra Karan , Kokosis Georgios , Slavin Benjamin , Williams Eric , Dellon A Lee
Published: October 2018

Background

Aesthetic procedures are among the most common surgeries performed by plastic surgeons. The prevalence of persistent pain remains unknown and underappreciated in the plastic surgery literature.

Objectives

The purpose of this article was to increase awareness of this problem while describing the diagnostic and management strategies for patients with postoperative pain after aesthetic plastic surgery.

Methods

A literature review was performed utilizing the PubMed database to identify painful complications of brachioplasty, blepharoplasty, rhytidectomy, abdominoplasty, breast augmentation, mastopexy, and breast reduction. A treatment algorithm was described to guide plastic surgeons presented with patients reporting pain after aesthetic surgery.

Results

Title and abstract review followed by application of inclusion and exclusion criteria resulted in 20 clinical studies for this review, including lateral femoral cutaneous nerve, iliohypogastric nerve, and intercostal nerves after abdominoplasty; median antebrachial cutaneous nerve after brachioplasty; supraorbital, supratrochlear, and infratrochlear nerves after blepharoplasty; greater auricular nerve, auriculotemporal nerve, and zygomaticofacial nerve after rhytidectomy; and intercostobrachial nerve after breast surgery.

Conclusions

Neuromas can be the source of pain following aesthetic surgery. The same clinical and diagnostic approach used for upper and lower extremity neuroma pain can be employed in patients with persistent pain after aesthetic surgery.

Level of Evidence: 4
Embracing intensionality: Paradoxicality and semi-truth operators in fixed point models
Authors: Tourville Nicholas , Cook Roy T
Published: October 2018

The Embracing Revenge account of semantic paradox avoids the expressive limitations of previous approaches based on the Kripkean fixed point construction by replacing a single language with an indefinitely extensible sequence of languages, each of which contains the resources to fully characterize the semantics of the previous languages. In this paper we extend the account developed in Cook (2008), Cook (2009), Schlenker (2010), and Tourville and Cook (2016) via the addition of intensional operators such as ``is paradoxical''. In this extended framework we are able to characterize the difference between sentences, such as the Liar and the Truth-teller, that receive the same semantic value in minimal fixed points yet seem to involve distinct semantic phenomena.
Part II Guide to Key Preliminary and Procedural Issues, 5 An Overview of Procedure in an Investment Treaty Arbitration
Authors: Barton Legum
Published: October 2018

The procedure of investment arbitrations vary tremendously. Arbitrations can range from cases that take many years to conclude to cases that are heard within a year or two. The experience in one case may not hold for another. However, there are a number of common elements and fixed variables. An understanding of these elements and variables allows the reader to draw conclusions as to how a specific arbitration will likely play out. This chapter attempts to convey this understanding with a practical focus on the principal strategic decisions in such a case. It divides the activity in an investment-treaty arbitration into five sequential phases: (1) the preparation of the case, (2) the written submissions, (3) the hearing, (4) post-hearing activity, and (5) the decision and its aftermath; each of these activities is discussed in turn.
Part II Guide to Key Preliminary and Procedural Issues, 6 Aspects of Procedure for Institution of Proceedings and Establishment of Tribunals in Investment Treaty Arbitration
Authors: Milanka Kostadinova
Published: October 2018

The institution of treaty-based proceedings in a particular forum or under particular set of arbitration rules depends on the consent provisions of the underlying investment treaty. Some 767 arbitration cases have been initiated so far under the total of 3,324 bilateral investment treaties and other international investment agreements signed to date. This chapter provides an overview of the technical and fairly complex procedures for initiating proceedings and constituting tribunals in investment treaty arbitration. It examines the prevalent practices from the perspective of the International Centre for Settlement of Investment Dispute (ICSID) Convention and Rules, and other leading sets of international arbitration rules such as the United Nations Commission on International Trade Law Arbitration Rules, the Rules of Arbitration of the International Chamber of Commerce, and the Arbitration Rules of the Arbitration Institute of the Stockholm Chamber of Commerce, which are among the non-ICSID Rules more commonly referenced in investment treaties.
Part III Guide to Key Jurisdictional Issues, 11 The Meaning of ‘Investment’ in Investment Treaty Arbitration
Authors: Katia Yannaca-Small , Dimitrios Katsikis
Published: October 2018

Despite the growing number of investor-state arbitrations and resulting jurisprudence, there is still no consensus on the criteria of investment. This chapter first examines the way ‘investment’ is ‘defined’ in bilateral investment treaties and other international investment agreements, as well as the meaning of investment in the International Centre for Settlement of Investment Dispute (ICSID) Convention. It then considers aspects of the arbitral jurisprudence on certain types of assets constituting an investment; the ‘objective’ and ‘subjective’ approach to interpreting definitions of ‘investment’; the characteristics that have been considered to be criteria of an investment; and the requirements that, to be protected, an ‘investment’ must be (i) made in accordance with the host State’s law and (ii) in the territory of the host State.
Part III Guide to Key Jurisdictional Issues, 12 Bifurcation of Investment Disputes
Authors: Baiju S Vasani , Sarah Z Vasani
Published: October 2018

Bifurcation typically involves the division of arbitral proceedings into separate phases addressing jurisdiction/admissibility and the merits and, less frequently, the division of the merits phase into liability and quantum phases. However, tribunals are not restricted to bifurcating proceedings along these lines. For example, some tribunals have bifurcated proceedings in order to hear certain jurisdictional objections as preliminary issues while reserving other jurisdictional objections to be heard with parties’ arguments on the merits. Others still have ‘trifurcated’ proceedings into separate phases dealing with issues of jurisdiction, liability, and quantum. This chapter discusses factors that may provide guidance for parties in making arguments either for or against bifurcation.
Part IV Guide to Key Substantive Issues, 21 The National Treatment Obligation
Authors: Andrea K Bjorklund
Published: October 2018

Most investment agreements contain a national treatment obligation, which requires that a host State treat foreign-owned investments at least as well as similarly situated national investments, or foreign investors as well as domestic investors. This chapter first explores the historical development of the national treatment obligation. It then addresses national treatment in practice, with particular reference to the investment treaty practice of the last decade and a half. As part of that examination, it sets forth the difficult and unresolved issues in the national treatment jurisprudence, including the hurdles that claimants face in establishing a national treatment claim. Finally, it addresses some of the reservations to national treatment that States have included in their investment treaties.
Part VI The Post-Award Phase, 27 Annulment of ICSID Awards: Is it Enough or Is Appeal around the Corner?
Authors: Katia Yannaca-Small
Published: October 2018

The International Centre for Settlement of Investment Dispute (ICSID) Convention prevents domestic courts from reviewing any decisions issued by ICSID panels. ICSID awards are therefore immune from challenges brought before national courts which may have a local bias or be subject to the influence of the host government. This chapter discusses (i) the scope and application of annulment of ICSID awards under the ICSID Convention; (ii) the grounds for annulment; (iii) the stay of enforcement as a requirement that often accompanies an application for annulment; and, (iv) the proposals related to the creation for an appeal mechanism for investment disputes as a response to the mounting criticism of the investor-state dispute settlement system and the quest to improve legitimacy and consistency.
Part VI The Post-Award Phase, 29 Enforcement of Investment Treaty Awards
Authors: August Reinisch
Published: October 2018

Investment arbitration between States and private parties is mostly pursued according to the International Centre for Settlement of Investment Dispute (ICSID) Convention and under various institutional or ad hoc arbitration rules leading to arbitral awards, which are regarded as foreign arbitral awards in the sense of the 1958 Convention on the Recognition and Enforcement of Foreign Arbitral Awards. This chapter distinguishes between enforcement possibilities offered by the New York Convention for non-ICSID awards and the special enforcement regime for ICSID awards laid down in the ICSID Convention. In the majority of that fraction of cases in which host States were found to have incurred liability, the awards seem to have been voluntarily complied with.
The IMO and Global Ocean Governance
Authors: Balkin Rosalie P
Published: October 2018

This chapter shows how the 171 Member States and 3 Associate Members that make up the International Maritime Organization’s (IMO) membership have shown themselves to be focussed on promoting the twin goals of safe, secure, sound, and efficient shipping on clean oceans. This has been achieved in part through the establishment and maintenance of a web of regulations ranging from over 50 fully fledged multinational conventions to a host of other so-called ‘soft law’ instruments. More remarkably, most of the Organization’s main safety and environmental conventions cover over 90 per cent of the tonnage of the world’s commercial fleet. This underscores the significance attributed by the IMO and its membership to the need for global standards and practices. Doubtless, however, much effort still remains to be expended to ensure the global uniform application of these regulations.
The IMO: Maritime Security
Authors: Trelawny Chris
Published: October 2018

This chapter provides a new perspective on the subject of maritime security. It argues that piracy and armed robbery at sea are in reality land-based problems, the root causes of which still remain to be addressed by the international community. However, this chapter also maintains that, instead of focussing on short-term security measures, the stress factors that lead to instability, insecurity, and uncontrolled mass migration should also be addressed. The aim should be to improve economic development, supported by maritime development and underpinned by maritime security. Furthermore, the chapter examines not only the issue of piracy and terrorism at sea but also International Maritime Organization (IMO) measures aimed at improving security of international movements of containers, which has a wider implication than just prevention of terrorism and the protection of customs revenues.
The IMO: Adoption of Counter-piracy Measures to Promote Global Ocean Governance
Authors: Hesse Hartmut Guenther
Published: October 2018

This chapter examines the measures taken by the International Maritime Organization (IMO) to address the issue of piracy and armed robbery, which present a serious threat to the safety of navigation and consequently to the safety of life at sea and to the marine environment. It describes a number of projects which are being implemented in and the guidance material developed by the IMO for the various affected regions. As this chapter shows, piracy and armed robbery are regional phenomena and consequently different approaches are required for different regions. Moreover, where acts of armed robbery take place in the internal waters or territorial seas of a State, this is not an issue for the international community. Rather, it is up to that State to take action or to invite action from the international community if it wishes to do so.
The IMO, the Audit Scheme, and Its Role in Global Ocean Governance
Authors: Barchue Lawrence
Published: October 2018

This chapter explains the origins, aims and structure of the compulsory IMO Audit Scheme recently adopted in the International Maritime Organization (IMO). The Scheme was originally trialled in the IMO on a voluntary basis. The results of the trial, in which several IMO Member States offered themselves for audit, was so positive that any remaining opposition to compulsory audit was soon overcome. The aim of the audits is not to ‘name and shame’ countries which are found to be wanting in terms of compliance with their IMO treaty obligations. Rather, it was conceived as a tool that could assist Member States in identifying any shortcomings in their legal and administrative regimes and in suggesting what further actions need to be taken to overcome these deficiencies.
The IMO: The Role of the Classification Societies in Promoting Global Ocean Governance
Authors: Delgado Ismael Cobos
Published: October 2018

This chapter discusses the role of classification societies in their capacity as recognized organizations (ROs) acting on behalf of maritime administrations to ensure that ships, old and new, meet their obligations under International Maritime Organization (IMO) regulations and standards. Another aspect of the role of classification societies is to ensure that ships are designed, constructed, and maintained in compliance with the standards set by the International Association of Classification Societies (IACS). The chapter helps to that the IMO acting alone cannot provide all the answers to all of the issues regarding ocean governance. After all, the Organization relies heavily on the active participation not only of its Member States but also on those intergovernmental international organizations (IGOs) and non-governmental international organizations (NGOs) that are affiliated to it. In many situations, they have the specialized expertise and experience required to ensure that whatever regulations are adopted by the IMO are practicable.
The IMO: Gender Equality, the Promotion of Women in the Maritime Sector, and Global Ocean Governance
Authors: Tansey Pamela
Published: October 2018

This chapter highlights the steps taken by the International Maritime Organization (IMO) to promote gender equality in the maritime sector, in line with the UN’s Millennium Development Goals (MDGs). This is especially true of MDG 3, which stresses the need for governments to provide women with the skills and tools to bring about their own empowerment. In this way, women are able to provide for their families and generally to make positive, often vital, contributions to the economies of their countries. Employment in the shipping sector has been shown to provide women with access to a regular salary. This has a direct impact on the economic viability of the extended family structure, particularly in developing regions of the world.
The Work of the International Civil Aviation Organization in Respect of Global Ocean Governance
Authors: Rodotheatos Gerasimos
Published: October 2018

This chapter focuses on the work of the International Civil Aviation Organization (ICAO) in respect to global ocean governance. ICAO, which was created to replace the International Commission for Air Navigation (ICAN), has three main goals: encourage international civil aviation and promotion of its benefits; preserve the safety of flights and relevant equipment and installations; and eliminate obstacles and ease tensions related to civil aviation. The chapter first provides a background on ICAO before discussing its role in global ocean governance. It also considers the three pillars of interaction that fall under ICAO’s mandate and are deeply related to ocean affairs and the mandate of marine organizations: aviation, safety/security, and environment. Finally, it assesses future prospects for ICAO with regard to its mandate by highlighting three areas: knowledge building for environmental protection and management, civil–military cooperation in air and sea, and preparedness for emerging/upcoming technological challenges.
INMARSAT and the Modern International Mobile Satellite Organization
Authors: Lyall Francis , Larsen Paul B
Published: October 2018

This chapter focuses on INMARSAT and the modern International Mobile Satellite Organisation (IMSO). INMARSAT is a commercial company that provides maritime communications by satellite as well as telecommunication services to mobile users. It also has international service obligations that fall within the Global Maritime Distress and Safety System (GMDSS) established by the International Maritime Organisation in 1988. Compliance with these is supervised by the IMSO. The chapter first provides a technical background on INMARSAT as well as an overview of its history and its maritime satellite communications services before turning to the IMSO and what it does. In addition to technical responsibilities in relation to GDMSS and the Long-Range Identification and Tracking of Ships (LRIT), IMSO has entered into an Agreement of Cooperation with the International Civil Aviation Organization (ICAO) relating to aeronautical mobile satellite communications.
Global Ocean Governance
Authors: Asariotis Regina , Mott Graham , Premti Anila , Vivas-Eugui David
Published: October 2018

This chapter discusses the work of the United Nations Conference on Trade and Development (UNCTAD) in the area of global ocean governance. UNCTAD is the leading agency of the United Nations in the integrated treatment of trade and development as well as interrelated issues of finance, technology, investment and sustainable development. The chapter first provides a brief historical account of UNCTAD before discussing its role in ocean governance, with a focus on international maritime transport law and policy. It then considers UNCTAD policy research and advice with respect to carriage of goods and international trade law; admiralty law, marine insurance and general average; maritime and supply-chain security; and climate change and maritime transport. The chapter also reviews UNCTAD’s future prospects in terms of ocean governance, role in the governance of trade in fish, and the new UNCTAD XIV mandate.
Our Oceans, Our Livelihoods
Authors: Wong Meagan , Elias Olufemi
Published: October 2018

This chapter focuses on the role of the World Bank in ocean governance. Created in 1944, the World Bank is an international financial institution belonging to the United Nations (UN) system. It comprises two institutions: the International Bank for Reconstruction and Development (IBRD) and the International Development Association (IDA). The chapter first provides an institutional overview and structure of the World Bank before discussing its position in the UN system as well as its mission. It then considers the World Bank’s role in the conservation and management of oceans, and particularly in the areas of food security, marine biodiversity and climate change. It also examines the World Bank’s strategy towards helping to restore ocean health to an optimal through its so-called blue projects.
Ethics of International Maritime Law and Ocean Governance
Authors: Pavliha Marko
Published: October 2018

This chapter examines the role of ethics in international maritime law and ocean governance. It first considers the general ethical flavour of international law, giving a few examples of moral standards in the law of the sea and maritime law, before discussing a range of issues relating to ocean governance. It suggests that the phrase ‘international maritime law’ should be understood broadly as inspired by the International Maritime Organization’s International Maritime Law Institute (IMO IMLI), thus including the law of the sea as part of public international law and the maritime law, also known as shipping, admiralty or marine law. The chapter goes on to outline actions aimed at conserving and sustainably using the oceans, seas and marine resources for sustainable development. Finally, it offers recommendations on how to improve legal education with an obligatory course on legal ethics.
Part I Assessing the UN Institutional Structure for Global Ocean Governance: The UN’s Role in Global Ocean Governance, 2 Role of the International Seabed Authority in Global Ocean Governance
Authors: Yongsheng Cai
Published: October 2018

This chapter examines the role of the International Seabed Authority (ISA) in global ocean governance. In particular, it highlights the assumption of ISA's explicit mandate for environmental protection as an integral aspect of its overall governance of the deep sea-bed ‘Area’ beyond national jurisdiction, especially following the 1994 Implementation Agreement to the 1982 United Nations Convention on the Law of the Sea (UNCLOS). This assumption is particularly significant given the fact that the ISA work programme has now progressed to the point where as of 31 January 2017, a total of twenty-six contracts for exploration had entered into force (sixteen for polymetallic nodules, six for polymetallic sulphides and four for cobalt-rich ferromanganese crusts). The chapter also discusses various activities undertaken in the Area, such as prospecting, exploration and exploitation of resources; marine scientific research; and benefit-sharing for exploitation on the outer continental shelf. Finally, it considers ISA's emphasis on the importance of international cooperation in implementing its mandates.
Part I Assessing the UN Institutional Structure for Global Ocean Governance: The UN’s Role in Global Ocean Governance, 3 Advancing the Deep Seabed ‘Mining Code’: Key Environmental Elements of the Regulatory Framework for the Commercial Exploitation of Mineral Resources
Authors: Henning Jessen
Published: October 2018

This chapter examines the key environmental elements of the International Seabed Authority's (ISA) ‘Mining Code’, a regulatory framework for the commercial exploitation of mineral resources. The term ‘Mining Code’ refers to the whole comprehensive set of rules, regulations and procedures issued by the ISA to regulate prospecting, exploration and exploitation of minerals. The set of rules includes the collaboration of the respective responsibilities of deep seabed explorers and of the ISA in order to ensure environmentally sustainable development of deep seabed mineral resources. The chapter first provides an overview of the general regulatory framework for deep seabed mining, which is a contract-based system, before discussing the continuous legal evolution of the Mining Code. It also considers the generic issues that need to be addressed in relation to the future exploitation of minerals and explains why exploitation-related environmental regulations must be an integral component of advancing the Mining Code.
Part III Marine Biodiversity Conservation and Global Ocean Governance, 8 Marine Biodiversity of Areas Beyond National Jurisdiction: Securing a Sound Law of the Sea Instrument
Authors: Fernanda Millicay
Published: October 2018

This chapter examines the conservation and sustainable use of marine biodiversity of areas beyond national jurisdiction (BBNJ). It first provides an overview of the Preparatory Committee (PrepCom), convened by the UN General Assembly to make recommendations on the elements for a possible future multilateral agreement under the United Nations Convention on the Law of the Sea (UNCLOS). The material scope of the PrepCom is constituted by ‘the package’ agreed upon in 2011 and includes the conservation and sustainable use of marine biological diversity of areas beyond national jurisdiction. The chapter discusses the challenges of the package, focusing on two interlinked dimensions of the package plus the big issue that underlies it. It also considers two main tasks facing PrepCom: the first is to clearly identify all elements of each substantive set of issues composing the package, and the second task is to understand the implications of each element of these three substantive sets of issues and the inter-linkages between them.
Essential articles for the junior resident on an orthopaedic trauma rotation
Authors: Rider Carson M. , Fournier Matthew N. , Weinlein John C.
Published: October 2018

The orthopaedic resident has a staggering number of journal articles, textbooks, and other learning platforms available to help establish a foundation of knowledge during the early stages of training. Each orthopaedic subspecialty has its own set of topics and classic articles that are important, and orthopaedic trauma is no exception. Choosing resources that are concise, up-to-date, and accurate can be an overwhelming task for junior residents as they prepare for a new rotation. In this review, we highlight and summarize 10 articles that are essential for junior residents as they prepare for an orthopaedic trauma rotation.
Hepatitis C is an Independent Risk Factor for Perioperative Complications and Nonroutine Discharge in Patients Treated Surgically for Hip Fractures
Authors: Grau Luis , Zachwieja Erik , Summers Spencer H. , Massel Dustin H. , Ong Alvin , Hernandez Victor H. , Merose Omri
Published: October 2018

Objective:

To evaluate the relationship between noncirrhotic hepatitis C virus (HCV) infection, perioperative complications, and discharge status in patients undergoing surgical procedures for hip fractures.

Methods:

A retrospective epidemiological study was performed, querying the National Hospital Discharge Survey. Patients were selected using the International Classification of Diseases-9 diagnostic codes for hip fracture and primary procedural codes for open reduction internal fixation, hemiarthroplasty, total hip arthroplasty, or internal fixation. Patients with concurrent cirrhosis, HIV, hepatitis A, B, D, or E were excluded. Pearson χ2 tests, independent-samples t test, and multivariable binary logistic regression were used for data analysis.

Results:

Two cohorts surgically treated for a hip fracture were identified and compared. The first cohort included 5377 patients with a concurrent diagnosis of noncirrhotic HCV infection (HCV+) and the second included 4,712,159 patients without a diagnosis of HCV (HCV−). The HCV+ cohort was younger and had fewer medical comorbidities, yet was found to have a longer length of hospital stay, higher rates of nonroutine discharge, and higher rates of complications than the HCV− cohort. Multivariate regression analysis demonstrated that HCV+ is an independent risk factor for perioperative complications and nonroutine discharge.

Conclusions:

In conclusion, our study demonstrates a negative association between noncirrhotic HCV infection and hip fracture surgery outcomes. Caution and appropriate preparation should be taken when surgically treating hip fractures in HCV+ patients because of higher risk of perioperative complications and nonroutine discharge.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Expectant Management of High-Grade Anal Dysplasia in People with HIV: Long-term Data
Authors: Cajas-Monson Luis C. , Ramamoorthy Sonia L. , Cosman Bard C.
Published: October 2018

BACKGROUND:

Both ablation and expectant management of high-grade squamous intraepithelial lesions have been proposed. Expectant management would be reasonable if 1) the rate of high-grade squamous epithelial lesion progression to anal squamous cell carcinoma were low, and 2) anal squamous cell carcinoma arising under surveillance had a better prognosis than anal squamous cell carcinoma presenting without an identified precursor.

OBJECTIVE:

This study aims to quantify aspects of high-grade squamous epithelial lesion/anal squamous cell carcinoma clinical evolution in a surgical practice.

DESIGN:

This is a retrospective cohort study.

SETTINGS:

This study was performed in 1 colorectal surgeon’s practice over a 20-year period.

PATIENTS:

Consecutive patients with high-grade squamous intraepithelial lesion and anal squamous cell carcinoma were included.

MAIN OUTCOME MEASURES:

We looked at the rate and timing of progression to anal squamous cell carcinoma, and the stage, treatment, and outcome of anal squamous cell carcinoma. We reviewed a comparison group of HIV-positive patients presenting de novo with anal squamous cell carcinoma (no prior history of high-grade squamous intraepithelial lesion).

RESULTS:

With consideration of only HIV-positive patients, 341 patients had a mean 5.6 years follow-up from high-grade squamous intraepithelial lesion diagnosis to the most recent documented anal examination. Twenty-four of these surveillance patients developed anal squamous cell carcinoma, yielding a progression rate of 1.3% per patient-year. Mean follow-up was 7.3 years from the initial cancer diagnosis to the most recent contact. Forty-seven patients who presented de novo with anal squamous cell carcinoma developed 74 lesions, with a mean follow-up of 5.7 years after initial diagnosis. This de novo group had higher anal squamous cell carcinoma-specific mortality (3% per patient-year vs 0.05%). Our study did not show a significantly higher rate of high stage (stage III or IV) at anal squamous cell carcinoma diagnosis in the de novo group in comparison with the surveillance group (25.5% vs 8.3% (p = 0.09)).

LIMITATIONS:

This study was retrospective in nature and had a predominately male population.

CONCLUSIONS:

The progression of untreated high-grade squamous intraepithelial lesion to anal squamous cell carcinoma approximates 1% per patient-year. Anal squamous cell carcinoma developing under surveillance tends to be of an earlier stage and to require fewer major interventions than anal squamous cell carcinoma presenting de novo. Cancer-specific mortality was lower for malignancies that developed under surveillance. We suggest that expectant management of patients with high-grade squamous intraepithelial lesion is a rational strategy for preventing anal cancer morbidity. See Video Abstract at http://links.lww.com/DCR/A699.
Aspects of the Natural History of Sessile Serrated Adenomas/Polyps: Risk Indicators for Carcinogenesis in the Colorectal Mucosa?
Authors: Neary Peter M. , Schwartzberg David M. , Bora Cengiz Turgot , Kalady Matthew F. , Church James M.
Published: October 2018

BACKGROUND:

Sessile serrated adenomas/polyps are potentially premalignant colorectal lesions that are precursors to colorectal cancer arising via CpG island methylator phenotype. They are caused by the combination of a BRAF mutation and promoter hypermethylation. DNA methylation is an age-dependent phenomenon in the right colon, and we would expect the occurrence and severity of serrated neoplasia to reflect this.

OBJECTIVE:

The purpose of this study was to document the natural history of sessile serrated adenomas/polyps, including the ages at which they appear and the ranges of their number, size, and associated lesions.

DESIGN:

This was a retrospective cohort study.

SETTINGS:

The study was conducted at a tertiary referral center.

PATIENTS:

Consecutive patients with sessile serrated adenomas/polyps removed between 2006 and 2015 were included. Patients with IBD, familial adenomatous polyposis, Lynch syndrome, serrated polyposis, and hereditary nonpolyposis colorectal cancer were excluded.

MAIN OUTCOME MEASURES:

Age at which polyps were first diagnosed, location and size of polyps, demographics, and family history were measured.

RESULTS:

A total of 440 patients had 668 sessile serrated adenomas/polyps, 257 (58%) also had ≥1 adenoma, and 28 (6%) had a history of colorectal cancer. Mean age at diagnosis was 68 ± 11 years, and 45% were men. Two hundred had had ≥1 colonoscopy before the diagnosis of the first sessile serrated adenomas/polyps. A total of 136 patients (31%) had multiple sessile serrated adenomas/polyps, including 24% synchronous and 10% metachronous. The range of total cumulative sessile serrated adenomas/polyps was from 1 to 7. A total of 554 (83%) of 668 sessile serrated adenomas/polyps were right sided; 48% were ≥1 cm diameter and 22% were >2 cm. The size of the first sessile serrated adenomas/polyps in those diagnosed under age 50 years averaged 10 mm, those between 50 and 60 years averaged 12 mm, and those between 60 and 70 years averaged 12 mm.

LIMITATIONS:

No measurement of methylation or BRAF mutations in polyps or normal mucosa and a lack of subclassification of hyperplastic polyps limited this study.

CONCLUSIONS:

The age of onset of sessile serrated adenomas/polyps varies, but the pattern is consistent with increasing methylation in the mucosa. Early negative colonoscopies predict a low risk of methylator cancers. See Video Abstract at http://links.lww.com/DCR/A736.
Influence of Intraoperative Air Tamponade Time on Graft Adherence in Descemet Membrane Endothelial Keratoplasty
Authors: Santander-García Diana , Peraza-Nieves Jorge , Müller Thomas M. , Gerber-Hollbach Nadine , Baydoun Lamis , Liarakos Vasilios S. , Dapena Isabel , Oellerich Silke , Van Dijk Korine , Melles Gerrit R. J.
Published: October 2018

Purpose:

To study the influence of different intraoperative air tamponade times on graft adherence after Descemet membrane endothelial keratoplasty (DMEK).

Methods:

In this interventional case series, we evaluated 117 eyes with Fuchs endothelial corneal dystrophy (FECD) that underwent DMEK using intraoperative air tamponade times of 60 minutes (group I; n = 39), 45 minutes (group II; n = 39), or 30 minutes (group III; n = 39). At 1 and 6 months postoperatively, graft adherence status, endothelial cell density, central pachymetry, and postoperative complications were recorded.

Results:

At 1 month, 19 of the 117 eyes (16.2%) showed a clinically significant detachment (>1/3 of the graft surface area and affecting visual axis): 6 eyes in group I (15.4%), 5 eyes in group II (12.8%), and 8 eyes in group III (20.5%) (P = 0.82). A minor detachment (<1/3 of the graft surface area and not affecting visual axis) was observed in 6 eyes in group I (15.4%), in 7 eyes in group II (17.9%), and in 4 eyes in group III (10.3%) (P = 0.82). The overall rebubbling rate was 11%, with no difference among the groups (P = 0.07). Mean endothelial cell density decrease at 6 months was 41% (±17%) (P = 0.56), whereas mean central pachymetry decreased by 23 (±10) % (P = 0.77), with no differences between the groups.

Conclusions:

The incidence of graft detachment after DMEK for FECD did not differ between the eyes that had a 60-, 45-, or 30-minute intraoperative air tamponade. Reducing the intraoperative air tamponade time to 30 minutes may be considered for DMEK in eyes with uncomplicated FECD.
The Relationship Between Pregnancy Exposure to Antidepressant and Atypical Antipsychotic Medications and Placental Weight and Birth Weight Ratio
Authors: Frayne Jacqueline , Nguyen Thinh , Hauck Yvonne , Liira Helena , Keelan Jeffrey A.
Published: October 2018

Background

Psychotropic medication use in pregnancy has been associated with altered fetal growth. The aim of this study was to investigate the relationship between placental weight and placental weight–to–birth weight (PBW) ratio, as a potential marker of placental efficiency, and medication use in a cohort of women with severe mental illness in pregnancy.

Methods

A retrospective database analysis was carried out on a cohort of pregnant women with severe mental illness (242 singleton pregnancies) and grouped according to their psychotropic medication use. Demographic, obstetric, neonatal, and psychiatric variables were analyzed using t tests, χ2, analysis of variance, univariate, binary, and multiple regression adjusting for potential confounders.

Results

Multiple regression analysis demonstrated a mean adjusted increase in placental weight of 114 g (95% confidence interval [CI], 60.2–165.6 g) in women taking antidepressant medication and 113 g (CI, 65.1–162.8 g) in women taking combined antidepressant and atypical antipsychotic medication in pregnancy. There was also a significantly elevated PBW ratio in these 2 medication groups (B 0.02: CI, 0.006–0.034; and B 0.025: CI, 0.012–0.038). Binary regression, adjusted for sex and gestational age, showed a significant odds ratio of 4.57 (95% CI, 2.17–9.62) for PBW ratio of greater than 90% in those taking antidepressant medication, either alone or in combination, compared with unmedicated women.

Conclusions

The use of antidepressant medication, alone or in combination, has a significant effect on placental weight and PBW ratio after adjusting for confounding variables. Given that this may reflect adverse effects on intrauterine growth and have possible long-term implications for the fetus, further research is warranted to confirm these findings.
A Hermeneutic Interpretation of Nurses’ Experiences of Truth Telling and Harms in Cancer Care in Qatar
Authors: Alsaadi Wafa A. , Rankin Janet M. , Bylund Carma L.
Published: October 2018

Background

Telling the truth to cancer patients remains under debate in the Middle East, where concealment about diagnosis and prognosis occurs in some cases. Concealment results in challenges for nurses providing care.

Objective

The aim of this study was to understand nurses’ lived experiences of caring for cancer patients whose cancer diagnosis or prognosis has been withheld from them.

Methods

Eight nurses from the national cancer center in Qatar were interviewed. The transcripts of the interview texts were interpreted using Gadamer’s hermeneutic approach.

Results

The interpretations are shaped by understandings of harm. Nurses assessed harm using empathy. Nurses’ empathy was permeated with fears that accompany a cancer diagnosis; the language of cancer is interpreted as a language of fear. It is ideas about harms and evoking patients’ fear that generates nurses’ experiences of complexity, ambiguity, and conflicting feelings regarding truth telling and concealment. The meanings nurses drew from their experiences rested on understandings about love, vulnerability, and opportunities to atone. We interpret nurses’ descriptions of being enmeshed in a web of lies through which multidimensional harms are experienced. The complexities of nurses’ experiences go well beyond the universal concepts of informed consent and patients’ rights.

Conclusions

Nurses’ experiences reveal insights that likely resonate across other jurisdictions in the Arabic Gulf and other Eastern cultures, where nurses deal with these sensitive issues case by case.

Implications for Practice

Leaders and health professionals in cancer care in such cultures must establish more nuanced and transparent interdisciplinary approaches to respond to the complexities of truth telling in cancer care.
Utilization of a Clinical Decision Support Tool to Reduce Child Tobacco Smoke Exposure in the Urgent Care Setting
Authors: Mahabee-Gittens Esther Melinda , Merianos Ashley L. , Dexheimer Judith W. , Meyers Gabe T. , Stone Lara , Tabangin Meredith , Khoury Jane C. , Gordon Judith S.
Published: October 2018

Background

Clinical decision support systems (CDSS) may facilitate caregiver tobacco screening and counseling by pediatric urgent care (UC) nurses.

Objective

This study aimed to assess the feasibility of a CDSS to address caregivers' tobacco use and child tobacco smoke exposure (TSE).

Methods

We conducted a 3-month prospective study on caregivers screened using a CDSS. Nurses used the CDSS to advise, assess, and assist caregivers to quit. We assessed caregiver sociodemographics, smoking habits, and child TSE.

Results

We screened 185 caregivers whose children were exposed to TSE for study inclusion; 155 (84%) met the eligibility criteria, and 149 (80.5%) were included in the study. Study nurses advised 35.2% of the caregivers to quit, assessed 35.9% for readiness to quit, and assisted 32.4%. Of the 149 participants, 83.1% were female; 47.0% were white and 45.6% African American; 84.6% had public insurance or were self-pay; 71.1% were highly nicotine dependent; 50.0% and 50.7% allowed smoking in the home and car, respectively; and 81.3% of children were biochemically confirmed to be exposed to tobacco smoke. At follow-up (86.6% retention), 58.9% reported quit attempts at 3 months. There was a significant decrease in nicotine dependence and a significant increase in motivation to quit. Self-reported quit rate was 7.8% at 3 months.

Conclusions

An electronic health record–embedded CDSS was feasible to incorporate into busy UC nurses' workloads and was associated with encouraging changes in the smoking behavior of caregivers. More research on the use of CDSS to screen and counsel caregivers who smoke in the UC and other acute care settings is warranted.