bluuebunny/crossref_metadata_2025 huggingface dataset:
The Actual Versus Idealized Self: Exploring Responses to Feedback About Implicit Bias in Health Professionals
Authors: Sukhera Javeed , Milne Alexandra , Teunissen Pim W. , Lingard Lorelei , Watling Chris
Published: November 2017

Purpose

Implicit bias can adversely affect health disparities. The implicit association test (IAT) is a prompt to stimulate reflection; however, feedback about bias may trigger emotions that reduce the effectiveness of feedback interventions. Exploring how individuals process feedback about implicit bias may inform bias recognition and management curricula. The authors sought to explore how health professionals perceive the influence of the experience of taking the IAT and receiving their results.

Method

Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 21 pediatric physicians and nurses at the Schulich School of Medicine and Dentistry, Western University, Ontario, Canada, from September 2015 to November 2016 after they completed the mental illness IAT and received their result. Data were analyzed using constant comparative procedures to work toward axial coding and development of an explanatory theory.

Results

When provided feedback about their implicit attitudes, participants described tensions between acceptance and justification, and between how IAT results relate to idealized and actual personal and professional identity. Participants acknowledged desire for change while accepting that change is difficult. Most participants described the experience of taking the IAT and receiving their result as positive, neutral, or interesting.

Conclusions

These findings contribute to emerging understandings of the relationship between emotions and feedback and may offer potential mediators to reconcile feedback that reveals discrepancies between an individual’s actual and idealized identities. These results suggest that reflection informed by tensions between actual and aspirational aspects of professional identity may hold potential for implicit bias recognition and management curricula.
Collaboration and Teamwork in the Health Professions: Rethinking the Role of Conflict
Authors: Eichbaum Quentin
Published: November 2017

Whereas the business professions have long recognized that conflict can be a source of learning and innovation, the health professions still tend to view conflict negatively as being disruptive, inefficient, and unprofessional. As a consequence, the health professions tend to avoid conflict or resolve it quickly. This neglect to appreciate conflict’s positive attributes appears to be driven in part by (1) individuals’ fears about being negatively perceived and the potential negative consequences in an organization of being implicated in conflict, (2) constrained views and approaches to professionalism and to evaluation and assessment, and (3) lingering autocracies and hierarchies of power that view conflict as a disruptive threat.

The author describes changing perspectives on collaboration and teamwork in the health professions, discusses how the health professions have neglected to appreciate the positive attributes of conflict, and presents three alternative approaches to more effectively integrating conflict into collaboration and teamwork in the health professions. These three approaches are (1) cultivating psychological safety on teams to make space for safe interpersonal risk taking, (2) viewing conflict as a source of expansive learning and innovation (via models such as activity theory), and (3) democratizing hierarchies of power through health humanities education ideally by advancing the health humanities to the core of the curriculum.

The author suggests that understanding conflict’s inevitability and its innovative potential, and integrating it into collaboration and teamwork, may have a reassuring and emancipating impact on individuals and teams. This may ultimately improve performance in health care organizations.
Online Ratings of Spine Surgeons
Authors: Zhang Jun , Omar Adan , Mesfin Addisu
Published: November 2017

Study Design.

Observational study.

Objective.

To evaluate the online ratings of spine surgeons and variables that may affect online ratings.

Summary of Background Data.

Physician review Web sites (PRW) are rapidly growing for-profit businesses. Most orthopedic surgeons are rated on at least one PRW as are other surgical specialists. To date the online ratings of spine surgeons have not been evaluated.

Methods.

Cervical Spine Research Society surgeon ratings on five physician rating Web sites were performed in April 2016: “healthgrade.com,” “vitals.com,” “ratemd.com,” “webmd.com,” and “yelp.com.” Numeric ratings from the PRWs were standardized on a scale of 0 to 100 with a higher score indicating positive ratings. Sex, practice sector (academic or private), specialty (orthopedics or neurosurgery), geographic location, and years of practice were also collected.

Results.

A total of 209 spine surgeons were included in our study. Of the 209 spine surgeons, 208 (99.52%) were rated at least once in one of the five PRWs. Average number of ratings per surgeon was 2.96. Average rating was 80 (40–100). There were four female (1.92%) and 204 male surgeons (98.1%). There were 121 (58.2%) in academic practice and 87 (41.8%) in private practice. There were 175 (84.1%) orthopedic surgeons and 33 (15.9%) neurosurgeons. Most of the surgeons were Caucasian 163 (78.4%) and worked in the South and Northeast 135 (64.9%). Those in academic practice had significantly higher ratings (81.6 vs. 77.65; P 
= 0.026). Number of years in practice was significantly associated with ratings (P 
= 0.0003) with those in practice for 21 or more years having significantly lower ratings.

Conclusion.

In this first study evaluating the online ratings of spine surgeons, we found that 99.5% of spine surgeon had at least one rating on a PRW. The average score, 80, indicated mostly positive ratings. Being in practice for 20 years or less and being in academic practice significantly associated with higher ratings.

Level of Evidence: 4
Increased Kawasaki Disease Incidence Associated With Higher Precipitation and Lower Temperatures, Japan, 1991–2004
Authors: Abrams Joseph Y. , Blase Jennifer L. , Belay Ermias D. , Uehara Ritei , Maddox Ryan A. , Schonberger Lawrence B. , Nakamura Yosikazu
Published: November 2017

Background:

Kawasaki disease (KD) is an acute febrile vasculitis, which primarily affects children. The etiology of KD is unknown; while certain characteristics of the disease suggest an infectious origin, genetic or environmental factors may also be important. Seasonal patterns of KD incidence are well documented, but it is unclear whether these patterns are caused by changes in climate or by other unknown seasonal effects.

Methods:

The relationship between KD incidence and deviations from expected temperature and precipitation were analyzed using KD incidence data from Japanese nationwide epidemiologic surveys (1991–2004) and climate data from 136 weather stations of the Japan Meteorological Agency. Seven separate Poisson-distributed generalized linear regression models were run to examine the effects of temperature and precipitation on KD incidence in the same month as KD onset and the previous 1, 2, 3, 4, 5 and 6 months, controlling for geography as well as seasonal and long-term trends in KD incidence.

Results:

KD incidence was negatively associated with temperature in the previous 2, 3, 4 and 5 months and positively associated with precipitation in the previous 1 and 2 months. The model that best predicted variations in KD incidence used climate data from the previous 2 months. An increase in total monthly precipitation by 100 mm was associated with increased KD incidence (rate ratio [RR] 1.012, 95% confidence interval [CI]: 1.005–1.019), and an increase of monthly mean temperature by 1°C was associated with decreased KD incidence (RR 0.984, 95% CI: 0.978–0.990).

Conclusions:

KD incidence was significantly affected by temperature and precipitation in previous months independent of other unknown seasonal factors. Climate data from the previous 2 months best predicted the variations in KD incidence. Although fairly minor, the effect of temperature and precipitation independent of season may provide additional clues to the etiology of KD.
Risk Factors for Women Being Under the Influence of Alcohol Compared With Other Illicit Substances at the Time of Committing Violent Crimes
Authors: Brewer-Smyth Kathleen , Pohlig Ryan T.
Published: November 2017

Purpose:

We investigated women under the influence of alcohol compared with other illicit substances at the time of committing a crime to identify predictors of being under the influence of alcohol and female-enacted crime.

Methods:

Analyses of data, obtained from private interviews and examinations of female prison inmates, included regression analyses exploring predictors of being under the influence of alcohol at the time of the crime and predictors of violent crime. In addition, a reanalysis of a previously reported model, predicting conviction of a violent crime, was conducted including a new variable, being under the influence of alcohol at the time of the crime.

Results:

Those under the influence of alcohol at the time of their crime had experienced greater nonfamilial childhood sexual abuse and traumatic brain injuries with loss of consciousness predating their crime. They were more likely to have committed a violent, rather than nonviolent, crime compared with those under the influence of other substances, with the latter being not significantly different for those not under the influence of any substance. Being under the influence of alcohol increased the risk of committing a violent crime, adjusting for other predictors of female violence.

Conclusion:

Women under the influence of alcohol are at a greater risk for committing violent crimes than those under the influence of other substances. Female nonfamilial childhood sexual abuse and traumatic brain injury victims were at a higher risk for being under the influence of alcohol, in comparison with other substances, at the time of committing a violent crime.
Dissipation of energy during the respiratory cycle: conditional importance of ergotrauma to structural lung damage
Authors: Marini John J.
Published: November 2017

Purpose of review

To describe and put into context recent conceptual advances regarding the relationship of energy load and power to ventilator-induced lung injury (VILI).

Recent findings

Investigative emphasis regarding VILI has almost exclusively centered on the static characteristics of the individual tidal cycle – tidal volume, plateau pressure, positive end-expiratory pressure, and driving pressure. Although those static characteristics of the tidal cycle are undeniably important, the ‘dynamic’ characteristics of ventilation must not be ignored. To inflict the nonrupturing damage we identify as VILI, work must be performed and energy expended by high stress cycles applied at rates that exceed the capacity of endogenous repair. Machine power, the pace at which the work performing energy load is applied by the ventilator, has received increasing scrutiny as a candidate for the proximate and integrative cause of VILI.

Although the unmodified values of machine-delivered energy or power (which are based on airway pressures and tidal volumes) cannot serve unconditionally as a rigid and quantitative guide to ventilator adjustment for lung protection, bedside consideration of the dynamics of ventilation and potential for ergotrauma represents a clear conceptual advance that complements the static parameters of the individual tidal cycle that with few exceptions have held our scientific attention.
Inflammatory processes during acute respiratory distress syndrome: a complex system
Authors: Reiss Lucy K. , Schuppert Andreas , Uhlig Stefan
Published: November 2017

Purpose of review

ARDS is a severe pulmonary disease characterized by inflammation. However, inflammation-directed therapies have yet failed to improve the outcome in ARDS patients. One of the reasons may be the underestimated complexity of inflammation. Here, we summarize recent insights into the complex interrelations between inflammatory circuits.

Recent findings

Gene expression analysis from animal models or from patients with ARDS, sepsis or trauma show an enormous number of differentially expressed genes with highly significant overlaps between the various conditions. These similarities, however, should not obscure the complexity of inflammation. We suggest to consider inflammation in ARDS as a system controlled by scale-free networks of genome-wide molecular interaction with hubs (e.g. NFκB, C/EBPβ, ATF3), exhibiting nonlinear emergence and the ability to adapt, meaning for instance that mild and life-threatening inflammation in ARDS are distinct processes. In order to comprehend this complex system, it seems necessary to combine model-driven simulations, data-driven modelling and hypothesis-driven experimental studies. Recent experimental studies have illustrated how several regulatory circuits interact during pulmonary inflammation, including the resolution of inflammation, the inflammasome, autophagy and apoptosis.

We suggest that therapeutic interventions in ARDS should be based on a systems approach to inflammation.
New developments in immunotherapy for pediatric leukemia
Authors: Foster Jessica B. , Maude Shannon L.
Published: November 2017

Purpose of review

Immunotherapy for the treatment of cancer has advanced at a tremendous pace over the last decade. In this review, we provide an overview of recent progress in immunotherapy for the treatment of leukemia, focusing on antibody–drug conjugates (ADC), bi-specific T-cell engagers (BiTE), and chimeric antigen receptor (CAR) T cells.

Recent findings

Ongoing clinical trials of CAR T cells directed against CD19 have produced complete remission rates as high as 93%, prompting global multicenter phase 2 trials and the first FDA approval of a CAR T-cell therapy. Insights into cytokine release syndrome, a toxicity of CAR T-cell therapy, and the cause for relapse after CAR T-cell therapy are evolving. The bispecific antibody blinatumomab and the ADCs inotuzumab and gemtuzumab have also recently received FDA approval for ALL and AML, respectively, moving these agents into a more prominent role in the relapse setting.

The use of immunotherapy for leukemia has been successful in creating durable remissions for multiply relapsed and refractory patients who previously had little chance of cure. The ongoing clinical and preclinical work continues to advance our understanding of these immune-based therapies, and will shape the next generation of clinical trials.
Bringing the OhioHealth Nursing Strategic Plan to Life With the AONE Care Innovation and Transformation Program
Authors: Dials Kelly , Gossett Lisa , Osting Lindsey , Rutherford David , Stifter Janet
Published: November 2017

Contemporary CNOs are committed to developing the next generation of nurse leaders. At OhioHealth, the nursing strategic vision includes the belief that every nurse will be a leader in improving health across the care continuum. In 2016, the OhioHealth System partnered with AONE to participate in the Care Innovation and Transformation program resulting in bedside nurses living this strategic vision and creating positive changes in quality, safety, and satisfaction for patients and families.
Incorporating Nurse Input and Evidence Into a Newly Designed Unit to Improve Patient and Nursing Outcomes
Authors: Tafelmeyer Jennifer , Wicks Robin , Brant Jeannine , Smith Laurie
Published: November 2017

OBJECTIVE

The aim of this study was to identify processes, outcomes, and lessons learned from designing a new evidence-based unit. A research study was conducted simultaneously to rigorously measure changes in patient and staff outcomes.

BACKGROUND

Nursing leadership and frontline nursing engagement are critical in evidence-based design to promote positive outcomes and workflow.

METHODS

Quality indicators were tracked premove and postmove. Nursing workflow was tracked, and teamwork was examined.

RESULTS

The incidence of falls and methicillin-resistant Staphylococcus aureus decreased on the new unit. Patient satisfaction improved; the greatest improvement was noise reduction. Teamwork remained stable. Nurses spent significantly more time in the patient rooms on the new unit.

CONCLUSIONS

This hospital found nursing engagement in the unit design process to be imperative to promote positive patient outcomes and stable or improved teamwork. Nursing leaders should be involved at the onset of the design process to facilitate optimal outcomes.
Social Return on Investment
Authors: Laing Catherine M. , Moules Nancy J.
Published: November 2017

OBJECTIVE

To determine whether the methodology of social return on investment (SROI) could be a way in which the value of a healthcare-related program (children's cancer camp) could be captured, evaluated, and communicated.

BACKGROUND

The value of healthcare goes beyond what can be captured in financial terms; however, this is the most common type of value that is measured. The SROI methodology accounts for a broader concept of value by measuring social, environmental, and economic outcomes and uses monetary values to represent them.

METHODS

The steps/stages of an SROI analysis were applied to the context of a children's camp for this article.

RESULTS

Applying the SROI methodology to this healthcare-related program was feasible and provided insight and understanding related to the impacts of this program.

CONCLUSIONS

Because of SROI's flexibility, it is a tool that has great potential in a healthcare environment and for leaders to evaluate programmatic return on investment.
Asymptomatic Microscopic Hematuria in Women
Authors: Nager Charles W. , Sung Vivian W. , Whiteside James L.
Published: November 2017

(Abstracted from Female Pelvic Med Reconstr Surg 2017;23:228–231)

This article presents new guidelines from the American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice and the American Urogynecologic Society on when women with microscopic blood in their urine should be evaluated and tested for urologic cancers.
Plasma Leptin and Premenstrual Syndrome: A Review
Authors: Nicolau Zaira Fernanda Martinho , Bezerra Andréia Gomes , Polesel Daniel Ninello , Andersen Monica Levy , Tufik Sergio , Hachul Helena
Published: November 2017

Importance

Premenstrual syndrome (PMS) is characterized by physical and psychological symptoms in the luteal phase. Leptin can influence PMS as it acts on the hypothalamic-pituitary-gonadal axis.

Objective

The aim of this study was to evaluate data in the literature about the profile of plasma leptin in women with PMS.

Evidence Acquisition

We performed a search of databases using both descriptors. Three studies were identified. They included 181 participants. Two of these studies found higher leptin levels in women with PMS.

Results

Conflicting results were found regarding the leptin levels in the luteal phase and the correlation between leptin, estradiol, and progesterone levels.

Conclusions and Relevance

Leptin could have a role in the pathophysiology of PMS and indicate degree of severity of PMS. Future studies on the role of leptin in PMS are needed.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to describe the correlation between women with PMS and leptin concentration, analyze if there is a difference between leptin concentration in the phases of the menstrual cycle, and foresee the future clinical applicability of leptin's concentration in women with PMS.
Sudden Death Due to Cystic Tumor of the Atrioventricular Node and Fibromuscular Dysplasia Involving Branches of the Coronary Arteries
Authors: Farkašová Iannaccone Silvia , Farkaš Daniel , Ginelliová Alžbeta , Švajdler Marián , Laco Ján , Šteiner Ivo , Fröhlichová Lucia
Published: November 2017

In this paper, we report the autopsy findings of a 42-year-old White male who was found deceased at his home by his brother in the early morning hours with a history of excessive alcohol consumption 1 day before his death. A medical record review revealed chronic alcohol use with alcohol dependence syndrome, hypertension, and cardiac arrhythmias by electrocardiogram 2 years prior. External examination revealed only a single bruise on the forehead. Internal examination revealed changes associated with chronic alcohol abuse and mild atherosclerosis. The lack of a cause of death at autopsy resulted in a dissection of the cardiac conduction system and the detection of a small cystic lesion at the atrioventricular node region. Microscopic examination revealed a cystic tumor of the atrioventricular node and fibromuscular dysplasia of the coronary artery branches near the sinoatrial and atrioventricular nodes. Based on the case history and autopsy findings, death was attributed to a fatal cardiac arrhythmia due to cystic tumor of the atrioventricular node with fibromuscular dysplasia of the coronary artery branches near the sinoatrial and atrioventricular nodes a possible contributing factor.
Epithelial-Myoepithelial Carcinoma
Authors: El Hallani Soufiane , Udager Aaron M. , Bell Diana , Fonseca Isabel , Thompson Lester D.R. , Assaad Adel , Agaimy Abbas , Luvison Alyssa M. , Miller Caitlyn , Seethala Raja R. , Chiosea Simion
Published: November 2017

We hypothesized that there is a relationship between the preexisting pleomorphic adenoma [PA]), histologic grade of epithelial-myoepithelial carcinomas (EMCAs), and genetic alterations. EMCAs (n=39) were analyzed for morphologic and molecular evidence of preexisting PA (PLAG1, HMGA2 status by fluorescence in situ hybridization, FISH, and FGFR1-PLAG1 fusion by next-generation sequencing, NGS). Twenty-three EMCAs were further analyzed by NGS for mutations and copy number variation in 50 cancer-related genes. On the basis of combined morphologic and molecular evidence of PA, the following subsets of EMCA emerged: (a) EMCAs with morphologic evidence of preexisting PA, but intact PLAG1 and HMGA2 (12/39, 31%), (b) Carcinomas with PLAG1 alterations (9/39, 23%), or (c) HMGA2 alterations (10/39, 26%), and (d) de novo carcinomas, without morphologic or molecular evidence of PA (8/39, 21%). Twelve high-grade EMCAs (12/39, 31%) occurred across all subsets. The median disease-free survival was 80 months (95% confidence interval, 77-84 mo). Disease-free survival and other clinicopathologic parameters did not differ by the above defined subsets. HRAS mutations were more common in EMCAs with intact PLAG1 and HMGA2 (7/9 vs. 1/14, P<0.001). Other genetic abnormalities (TP53 [n=2], FBXW7 [n=1], SMARCB1 deletion [n=1]) were seen only in high-grade EMCAs with intact PLAG1 and HMGA2. We conclude that most EMCAs arose ex PA (31/39, 80%) and the genetic profile of EMCA varies with the absence or presence of preexisting PA and its cytogenetic signature. Progression to higher grade EMCA with intact PLAG1 and HMGA2 correlates with the presence of TP53, FBXW7 mutations, or SMARCB1 deletion.
Cancer Therapy-associated Lymphoproliferative Disorders
Authors: Pina-Oviedo Sergio , Miranda Roberto N. , Medeiros L. Jeffrey
Published: November 2017

We describe the clinicopathologic features of 17 patients who had a hematologic malignancy of various types, were treated, and subsequently developed a lymphoproliferative disorder (LPD). There were 10 men and 7 women with a median age of 59 years (range, 36 to 83 y). The primary hematologic neoplasms included: 5 chronic lymphocytic leukemia/small lymphocytic lymphoma, 3 plasma cell myeloma, 2 acute monoblastic leukemia, and 1 case each of mixed-phenotype acute leukemia, chronic myeloid leukemia, splenic marginal zone lymphoma, follicular lymphoma, mantle cell lymphoma, T-cell prolymphocytic leukemia, and peripheral T-cell lymphoma. All patients were treated with chemotherapy with or without therapeutic antibodies; 3 also underwent autologous stem cell transplantation. The mean interval from initiation of therapy for initial hematologic malignancy to onset of LPD was 66 months (range, 3 to 299 mo). Ten (59%) LPDs were extranodal and 7 (41%) involved nodal tissues. The histologic diagnoses included: 8 diffuse large B-cell lymphoma, 4 classical Hodgkin lymphoma, 3 polymorphic LPD, 1 lymphomatoid granulomatosis, and 1 Epstein-Barr virus (EBV)+ mucocutaneous ulcer. Fourteen cases were EBV+. Following the onset of LPD, chemotherapy was administered to 10 (59%) patients. With a median follow-up of 100 months (range, 5 to 328 mo), 8 (47%) patients are alive and 9 (53%) died. One (6%) patient with lymphomatoid granulomatosis underwent spontaneous remission. On the basis of the clinicopathologic features and high prevalence of EBV infection in this cohort, we believe that these LPDs show similarities with other types of immunodeficiency-associated LPDs. We suggest that cancer therapy-associated LPD be included in future classification systems for immunodeficiency-associated LPDs.
HPV E6/E7 mRNA In Situ Hybridization in the Diagnosis of Cervical Low-grade Squamous Intraepithelial Lesions (LSIL)
Authors: Mills Anne M. , Coppock Joseph D. , Willis Brian C. , Stoler Mark H.
Published: November 2017

Cervical low-grade squamous intraepithelial lesions (LSIL) (aka cervical intraepithelial neoplasia, grade 1 [CIN1]) can present considerable diagnostic challenges and are associated with poor interobserver reproducibility and overdiagnosis. Furthermore, ancillary studies such as p16 immunohistochemistry have shown little utility in resolving the LSIL versus negative/reactive differential. Human papillomavirus (HPV) RNA in situ hybridization (ISH) has shown promise as a diagnostic aid in this setting, but has not been studied in a large case series. We herein investigate high-risk and low-risk HPV RNA ISH in 126 cervical biopsies originally diagnosed as LSIL/CIN1 and compare HPV RNA ISH results to expert-adjudicated morphologic diagnosis to assess whether this assay can help routine cases attain the existing “gold standard” of morphologic consensus diagnosis. We also assess whether this criterion standard can be further improved by integration of HPV RNA ISH results. A consensus diagnosis of intraepithelial lesion (CIN1+) was confirmed in 61% of cases, whereas 57% were HPV RNA+. HPV-RNA positivity was 84% sensitive and 86% specific for an expert-adjudicated diagnosis of CIN1+. Conversely, consensus diagnosis was 90% sensitive and 78% specific for the presence of HPV RNA. Integrating RNA ISH into morphologic review led to further reclassification of 10% of cases, resulting in 95% sensitivity and 98% specificity of HPV RNA ISH for a CIN1+ diagnosis and 98% sensitivity and 92% specificity of CIN1+ for the presence of HPV RNA. These findings suggest that judicious use of HPV RNA ISH can improve the accuracy of LSIL/CIN1 diagnosis for morphologically ambiguous cases.
Distinguishing Neurofibroma From Desmoplastic Melanoma
Authors: Elsensohn Ashley , Shiu Jessica , Grove Narina , Hosking Anna-Marie , Barr Ronald , de Feraudy Sébastien
Published: November 2017

Distinguishing desmoplastic melanomas (DMs) from neurofibromas (NFs) can be histologically challenging in some cases. To date, a reliable marker to differentiate the 2 entities has remained elusive. S100 subtyping and CD34 fingerprinting have been proposed, but controversy remains as to their reliability. Missense mutations in TP53 are often found in DMs, resulting in a dominant negative effect and paradoxical accumulation of the tumor suppressor protein p53. We hypothesized that p53 may be expressed differentially in DMs, making it a valuable tool in differentiating DMs from NFs. Using immunohistochemistry, we compared p53 protein expression in 20 DMs and 20 NFs retrieved from our tissue archives and stained with p53 antibody (Monoclonal, DO-7). Patients with DM included 18 men and 2 women (age, 36 to 95 y; mean, 70.5 y; median, 70 y). Fifteen (15/20) tumors occurred in head and neck area; 2 (2/20) on the trunk; and 3 (3/20) on the extremities. Patients with NF included 12 men and 8 women (age, 47 to 85 y; mean, 65.2 y; median, 69.5 y). Eleven (11/20) tumors occurred on the trunk, 6 (6/20) on the extremities, and 3 (3/20) on the head and neck area. A total of 19/20 (95%) DMs were positive for p53. DM Histo-scores ranged from 0 to 300 (mean, 203; median, 260). Nuclear accumulation of p53 was seen in all 19 positive DMs. None of the 20 NFs were positive for p53 (2-tailed t test P-value <0.0001). Detection of p53 by immunohistochemistry can help to distinguish DMs from NFs.
Vertical Skin Paddle Orientation for the Latissimus Dorsi Flap in Breast Reconstruction: A Modification to Simultaneously Correct Inferior Pole Constriction and Improve Projection
Authors: Fracol Megan , Grim Michelle , Lanier Steven T. , Fine Neil A.
Published: November 2017

The latissimus dorsi myocutaneous flap is a reliable and frequently used option to bring vascularized skin and soft tissue to improve the stability and aesthetic result in breast reconstruction. Standard techniques with skin paddle inset in a horizontal or oblique fashion preferentially improve anterior projection (when inset at the mastectomy scar) or lower pole and inframammary fold constriction (when inset into the inframammary fold). Here, the authors describe a modification for inset of the latissimus dorsi myocutaneous flap that improves both anterior projection and lower pole/inframammary fold constriction, and also allows the latissimus muscle to fan out and provide complete implant coverage. The vertical inset modification brings new skin and soft tissue into both the inferior pole and the central mastectomy scar, allowing simultaneous improvement in both areas and full use of the latissimus muscle to cover the implant or expander.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Deferoxamine Preconditioning of Irradiated Tissue Improves Perfusion and Fat Graft Retention
Authors: Flacco John , Chung Natalie , Blackshear Charles P. , Irizarry Dre , Momeni Arash , Lee Gordon K. , Nguyen Dung , Gurtner Geoffrey C. , Longaker Michael T. , Wan Derrick C.
Published: November 2017

Background:

Radiation therapy is a mainstay in the treatment of many malignancies, but collateral damage to surrounding tissue, with resultant hypovascularity, fibrosis, and atrophy, can be difficult to reconstruct. Fat grafting has been shown to improve the quality of irradiated skin, but volume retention of the graft is significantly decreased. Deferoxamine is a U.S. Food and Drug Administration–approved iron-chelating medication for acute iron intoxication and chronic iron overload that has also been shown to increase angiogenesis. The present study evaluates the effects of deferoxamine treatment on irradiated skin and subsequent fat graft volume retention.

Methods:

Mice underwent irradiation to the scalp followed by treatment with deferoxamine or saline and perfusion and were analyzed using laser Doppler analysis. Human fat grafts were then placed beneath the scalp and retention was also followed up to 8 weeks radiographically. Finally, histologic evaluation of overlying skin was performed to evaluate the effects of deferoxamine preconditioning.

Results:

Treatment with deferoxamine resulted in significantly increased perfusion, as demonstrated by laser Doppler analysis and CD31 immunofluorescent staining (p < 0.05). Increased dermal thickness and collagen content secondary to irradiation, however, were not affected by deferoxamine (p > 0.05). Importantly, fat graft volume retention was significantly increased when the irradiated recipient site was preconditioned with deferoxamine (p < 0.05).

Conclusions:

The authors’ results demonstrated increased perfusion with deferoxamine treatment, which was also associated with improved fat graft volume retention. Preconditioning with deferoxamine may thus enhance fat graft outcomes for soft-tissue reconstruction following radiation therapy.
Comparing Efficacy and Costs of Four Facial Fillers in Human Immunodeficiency Virus–Associated Lipodystrophy: A Clinical Trial
Authors: Vallejo Alfonso , Garcia-Ruano Angela A. , Pinilla Carmen , Castellano Michele , Deleyto Esther , Perez-Cano Rosa
Published: November 2017

Background:

The objective of this study was to evaluate and compare the safety and effectiveness of four different dermal fillers in the treatment of facial lipoatrophy secondary to human immunodeficiency virus.

Methods:

The authors conducted a clinical trial including 147 patients suffering from human immunodeficiency virus–induced lipoatrophy treated with Sculptra (poly-l-lactic acid), Radiesse (calcium hydroxylapatite), Aquamid (polyacrylamide), or autologous fat. Objective and subjective changes were evaluated during a 24-month follow-up. Number of sessions, total volume injected, and overall costs of treatment were also analyzed. A comparative cost-effectiveness analysis of the treatment options was performed.

Results:

Objective improvement in facial lipoatrophy, assessed by the surgeon in terms of changes from baseline using the published classification of Fontdevila, was reported in 53 percent of the cases. Patient self-evaluation showed a general improvement after the use of facial fillers. Patients reported being satisfied with the treatment and with the reduced impact of lipodystrophy on their quality of life. Despite the nonsignificant differences observed in the number of sessions and volume, autologous fat showed significantly lower costs than all synthetic fillers (p < 0.05).

Conclusions:

Surgical treatment of human immunodeficiency virus–associated facial lipoatrophy using dermal fillers is a safe and effective procedure that improves the aesthetic appearance and the quality of life of patients. Permanent fillers and autologous fat achieve the most consistent results over time, with lipofilling being the most cost-effective procedure.
Lower Body Lift in the Massive Weight Loss Patient: A New Classification and Algorithm for Gluteal Augmentation
Authors: Schmitt Taliah , Jabbour Samer , Makhoul Rani , Noel Warren , Reguesse Anne-Sophie , Levan Philippe
Published: November 2017

Background:

An often-neglected part of the lower body lift procedure is the gluteal region. The objective of this study was to classify massive weight loss patients undergoing a body lift procedure and provide a safe, standardized approach for gluteal augmentation.

Methods:

A retrospective review of all body lift procedures performed between January of 2012 and January of 2017 was conducted. Patients undergoing a lower body lift with or without gluteal augmentation were included for analysis. Patients were classified as follows: type I, minimal lower and upper back fat and deflated buttock; type II, substantial lower back fat, minimal upper back fat, and deflated buttock; type III, substantial lower and upper back fat and deflated buttock; and type IV, good buttock projection. Type I patients had gluteal implants, type II patients had autologous flap augmentation, type III patients had gluteal lipofilling, and type IV patients did not have any gluteal augmentation.

Results:

Two hundred eighty patients were included for analysis. Two hundred thirty-eight underwent concomitant gluteal augmentation (85 percent): 213 had autologous flaps (76 percent), 13 had gluteal implants (5 percent), and 12 had large-volume lipofilling (4 percent). Forty-two patients underwent a body lift with no gluteal augmentation (15 percent). Gluteal augmentation did not increase the rate of complications. In both groups, no skin necrosis, venous thrombosis, or pulmonary embolism was reported. Patients who had a sleeve gastrectomy had significantly lower odds of complications compared with gastric bypass (OR, 0.45; p = 0.017).

Conclusion:

A standardized algorithmic approach for gluteal augmentation may optimize the result without increasing the complication rate.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Exploring the Impact of Primary Care Physician Burnout and Well-Being on Patient Care: A Focus Group Study
Authors: Hall Louise H. , Johnson Judith , Heyhoe Jane , Watt Ian , Anderson Kevin , O’Connor Daryl B.
Published: November 2017

Objectives

The aims of the study were (1) to explore whether primary care physicians (general practitioners [GPs]) perceive burnout and well-being to impact on the quality and safety of patient care and (2) to determine potential mechanisms behind these associations.

Method

Five focus groups with 25 practicing GPs were conducted in England, either in the participants’ practice or in a private meeting room outside of their workplace.

An interview schedule with prompts was followed with questions asking how participants perceive GP burnout and poor well-being could impact on patient care delivery. Audio recordings were transcribed verbatim and analyzed using thematic analysis.

Results

General practitioners believed that poor well-being and burnout affect the quality of care patients receive through reducing doctors’ abilities to empathize, to display positive attitudes and listening skills, and by increasing the number of inappropriate referrals made. Participants also voiced that burnout and poor well-being can have negative consequences for patient safety, through a variety of mechanisms including reduced cognitive functioning and decision-making abilities, a lack of headspace, and fatigue. Furthermore, it was suggested that the relationship between well-being/burnout and mistakes is likely to be circular.

Conclusions

Further research is needed to ascertain the validity of these perceptions. If found, physicians, healthcare organizations, and policy makers should examine how they can improve physician well-being and prevent burnout, because this may be a route to ensure high-quality and safe patient care.
Inconsistencies Between Two Cross-Cultural Adaptations of the Hospital Survey on Patient Safety Culture Into French
Authors: Boussat Bastien , François Patrice , Gandon Gérald , Giai Joris , Seigneurin Arnaud , Perneger Thomas , Labarère José
Published: November 2017

Objectives

Two cross-cultural adaptations of the 12-dimension Hospital Survey on Patient Safety Culture (HSOPSC) into French coexist: the Occelli and Vlayen versions. The objective of this study was to assess the psychometric properties of the Occelli version in comparison with those reported for the Vlayen and the original US versions of this instrument.

Methods

Using the original data from a cross-sectional study of 5,064 employees at a single university hospital in France, we examined the acceptability, internal consistency, factorial structure, and construct validity of the Occelli version of the HSOPSC.

Results

The response rate was 76.8% (n = 3888). Our study yielded lower missing value rates (median, 0.4% [range, 0.0%–2.4%] versus 0.8% [range, 0.2%–11.4%]) and lower dimension scores (median, 3.19 [range, 2.67–3.54] versus 3.42 [range, 2.92–3.96]) than those reported for the Vlayen version. Cronbach alphas (median, 0.64; range, 0.56–0.84) compared unfavorably with those reported for the Vlayen (median, 0.73; range, 0.57–0.86) and original US (median, 0.78; range, 0.63–0.84) versions. The results of the confirmatory factor analysis were consistent between the Vlayen and Occelli versions, making it possible to conduct surveys from the 12-dimensional structure with both versions.

Conclusions

The inconsistencies observed between the Occelli and Vlayen versions of the HSOPSC may reflect either differences between the translations or heterogeneity in the study population and context. Current evidence does not clearly support the use of one version over the other. The two cross-cultural adaptations of the HSOPSC can be used interchangeably in French-speaking countries.
Antiplatelet Therapy for Critically Ill Patients: A Pairwise and Bayesian Network Meta-Analysis
Authors: Du Fangbing , Jiang Pan , He Shengteng , Song Dongming , Xu Feng
Published: November 2017

Antiplatelet therapy is an attractive treatment option for critically ill patients. However, more evidence on the benefit of this therapy is required. We searched the PubMed and Embase databases from their inception to June 2017 for randomized controlled trials and observational studies that assess the effect of antiplatelet therapy in critically ill patients. Antiplatelet therapy resulted in significant decreases in hospital mortality (risk ratio [RR] 0.81, 95% confidence interval [CI], 0.68–0.97; P = 0. 025), intensive care unit (ICU) mortality (RR 0.78, 95% CI, 0.63–0.97; P = 0. 027), incidence of respiratory distress syndrome or acute lung injury (RR 0.73, 95% CI, 0.58–0.91; P = 0.006), and incidence of sepsis (RR 0.81, 95% CI, 0.68–0.97; P = 0.021). A predefined subgroup analysis according to patient type suggested that hospital mortality and ICU mortality benefits were seen only in septic patients (RR 0.71, 95% CI, 0.58–0.86; P < 0.0001) and (RR 0.65, 95% CI, 0.49–0.86; P = 0.002). By network meta-analysis, the predictive interval plot showed that patients treated with aspirin and clopidogrel had lower risk of hospital mortality as compared with control group. The assessment of rank probabilities using SUCRA plots indicated that aspirin presented the greatest likelihood of having lowest hospital mortality rate. The results of this meta-analysis suggest that antiplatelet therapy is useful for the treatment in critically ill patients, and this is primarily due to an effect on septic patients. Network meta-analysis shows that the probability of being the best antiplatelet therapy for critically ill patients was aspirin.
Toll-Like Receptor 4 and NLRP3 Caspase 1- Interleukin-1β-Axis are Not Involved in Colon Ascendens Stent Peritonitis-Associated Heart Disease
Authors: Alarcón Maria Micaela Lopez , Ruocco Julieta Fernández , Ferreira Fabiano , Paula-Neto Heitor A. , Sepúlveda Marisa , Vila Petroff Martín , Carvalho Adriana Bastos , Ramos Isalira Peroba , Branda Hugo Justino , Paiva Claudia N. , Medei Emiliano
Published: November 2017

Hemodynamic collapse and myocardial dysfunction are among the major causes of death in severe sepsis. The purpose of this study was to assess the role played by toll-like receptor 4 and by the NLRP3 inflammasome in the cardiac dysfunction that occurs after high-grade polymicrobial sepsis. We performed the colon ascendens stent peritonitis (CASP) surgery in Tlr4

−/−
, Nlrp3

−/−
, and caspase-1

−/−
mice. We also assessed for the first time the electrical heart function in the colon ascendens stent peritonitis (CASP) model. The QJ interval was increased in wild-type C57BL/6J mice after CASP when compared with sham controls, a result paralleled by an increase in the cardiac action potential (AP) duration (APD). The decreases in ejection fraction (EF), left ventricle end diastolic volume, stroke volume, and cardiac output found after CASP were similar among all groups of mice. Similar heart response was found when Nlrp3

−/−
mice were submitted to high-grade cecal ligation and puncture. Despite developing cardiac dysfunction similar to wild types after CASP, Nlrp3

−/−
mice had reduced circulating levels of interleukin (IL)-1β, IL-6 and tumor necrosis factor-α. Our results demonstrate that the genetic ablation of Tlr4, Nlrp3, and caspase-1 does not prevent the cardiac dysfunction, despite preventing the increase in pro-inflammatory cytokines, indicating that these are not feasible targets to therapy in high-grade sepsis.
Dodecafluoropentane Emulsion (DDFPE) as a Resuscitation Fluid for Treatment of Hemorrhagic Shock and Traumatic Brain Injury: A Review
Authors: Graham Kaitlin , Moon-Massat Paula F. , Unger Evan C.
Published: November 2017

Dodecafluoropentane emulsion (DDFPe) is a novel nanotechnology for oxygen delivery with therapeutic potential for hemorrhagic shock and/or traumatic brain injury (TBI). DDFPe demonstrates efficacy at smaller doses than previously tested perfluorocarbon oxygen therapeutics. This smaller dose potentially eliminates toxicities exhibited by previous oxygen therapeutics, whereas anti-inflammatory properties of DDFPe may alleviate damage from ischemia reperfusion injury. This minireview summarizes our progress in developing a battlefield-ready product to prevent combat death due to hemorrhagic shock and/or TBI. Preclinical studies, for both indications, show promising effects of DDFPe as a resuscitation fluid. DDFPe may become a part of the toolkit for tactical healthcare professionals in battlefield and domestic emergency medicine.
Percutaneous Image-guided Surgery Training: Model IHU-DAICIM
Authors: Gimenez Mariano Eduardo , Davrieux Carlos Federico , Serra Edgardo , Palermo Mariano , Houghton Eduardo Javier , Acquafresca Pablo Agustin , Dallemagne Bernard , Kwak Jung-Myun , Gonzalez Cristians Alejandro , Marescaux Jacques
Published: November 2017

The evolution of guided imaging surgery is well known in recent years. As the field of action becomes more specific, learning and teaching are also more specific. State-of-the-art medical training should be mandatory in the field of general medicine and surgery in particular. In this work, we report on how to create a model for the formation of guided surgery by images in a simple and fast way, and its implementation by young surgeons. Pig models have been used in which collections made by bovine small intestine and simulated tumor lesions have been placed. Several types of image-guided procedures have been performed. No major complications were found during the development of the model or during its use. It is possible to develop a quick, simple, and safe living training model that can be used immediately after preparation.
Percutaneous Transhepatic Y-shaped Stent Placement in Portal-superior Mesenteric Vein Tumor Thrombosis Before Right Colectomy
Authors: Pesce Antonio , Boncoraglio Andrea , Basile Antonio , Puleo Stefano
Published: November 2017

Portal-mesenteric tumor thrombosis represents a rare finding in patients with colorectal cancers. To our knowledge this is the first report of a patient diagnosed as having a wide stenosing right colon cancer with portal-superior mesenteric vein tumor thrombosis at the time of diagnosis, who was treated before surgery by positioning a percutaneous transhepatic Y-shaped stent through the main portal vein and the superior mesenteric vein. Percutaneous interventional procedures have gained worldwide acceptance for improving the symptoms of portal hypertension, because of their minimal invasiveness and high success rates with low number of complications. A multidisciplinary approach is mandatory in order to choose the best therapeutic option for the patients and the importance of a strong collaboration between interventional radiologist and surgeon has to be considered.