bluuebunny/crossref_metadata_2025 huggingface dataset:
Structure, substance and near-surface magmatic chambers of Mutnovsky and Gorely volcanoes (Mutnovsky geothermal region, Kamchatka). III. Gorelovsky volcanic center of Mutnovsky geothermal area
Authors: Selyangin O B
Published: November 2019

The information about the structure, development and composition of the rocks of long-lived Gorelovsky volcanic center, which modern activity stage is represented by multicone intracaldera Gorely volcano with a developed fracture (rift) zone is shown. The features of magma activity in the conditions of low density of hosting crustal rocks are discussed. The conjugation of the directional evolution of magmatic material and magma-conductive structure of the volcanic centre with the formation of modern near-surface magmatic chamber of Gorely volcano is represented.
New data on the stability of flow in steam-water geothermal well
Authors: Shulyupin A N , Chermoshentseva A A
Published: November 2019

New data on the stability of flow in the steam-water geothermal well are presented. There are facts of failures during commissioning of wells, testing which implied a positive result. An explanation of the marked phenomenon is presented in basis of new notions about stability of flow in the steam-water geothermal wells.
Spectral matching and propagation ground motion earthquake from bedrock to surface
Authors: Saputro I T
Published: November 2019

Ground motion earthquake is the acceleration data of ground during the earthquake. The tool used to obtain this data is called the accelerogram. In Indonesia, this data is difficult to obtain due to the limitations of the tool. It needed to analyze high-rise building because analysis structure of high-rise building used the dynamic load from the earthquake. This data is important in analyzing earthquake-resistant buildings. Besides from the accelerograms tool, this data can be obtained through seismic hazard analysis process. This was obtained by taking ground motion from elsewhere and then uniforming the spectrum response results with the location being reviewed. Wave propagation from bedrock to the soil surface will see the amplification process so this needs to be reviewed as well. Based on seismic hazard analysis results obtained ground motion suitable for matching process is San Fernando 1971. Peak ground acceleration on bedrock obtained is about 0.2608 g. After wave propagation to the surface, the peak ground acceleration is about 0.3001 g. Based on that, Amplification factor earthquake waves is about 1.12.
Evaluation of asphalt porous mixture properties due to addition of Arenga pinnata and coconut fibers
Authors: Rachman F , Syammaun T
Published: November 2019

Traffic condition, as well as tropical climate condition in Indonesia, demands high care to produce water resistance based surface layer in the flexible pavement industry. Asphalt porous is one of various technologies that could become promising prospects in this regard. However porous asphalt features might result in lower ability of pavement to endure traffic load. Thus, this study tries to find solution to previously mentioned issue by adding natural fibers to porous asphalt mixture by measuring the permeability, binder drains down, and void in mixture. The natural fiber is known to have in own strength to endure tensile force, and among many natural fibers available, we choose two of the most abundant material in Indonesia, which are Arenga Pinnata fibers and Coconut fibers. The result in this study is the addition of Arenga Pinnata fibers, or Coconut fibers results in decrease of both permeability and binder drain down test value for 8% to 35% and 32% to 73% respectively while it increases the void in mixture.
Comparison of cantabro test using Arenga pinnata fiber and coconut fiber in porous asphalt
Authors: Syammaun T , Rachman F
Published: November 2019

This paper presents the results of a preliminary investigation on using Arenga pinnata fiber (APF) and coconut fiber (CCF) in porous asphalt (PA). The samples were prepared with various percentages of fibers (0%, 1%, 3%, and 5%) by weight of bitumen and evaluated. The laboratory tests included air abrasion loss and water abrasion loss. The results indicate that the addition of fibers provides a positive effect on the properties of PA. A certain amount of fibers as an additive appears to improve resistance to raveling and stripping. However, adding too much fiber would result in higher abrasion loss value and increase the air void.
Physical properties of reclaimed asphalt pavement
Authors: Sunarjono S , Hidayati N
Published: November 2019

Sustainable construction is becoming an important issue in pavement engineering. The use of reclaimed asphalt pavement (RAP) for road reconstruction gives both technical and environmental benefits. Unfortunately, the properties of cold asphalt mixture using RAP is still behind of hot asphalt mixture using fresh aggregate. The objective of research is to explore the physical properties of RAP in order to understand the factors affecting the lack of cold asphalt mixture performance. The laboratory physical tests on RAP and fresh aggregate were performed to investigate particle shape, specific gravity, gradation, and bulk density. It is found that the presence of aged bitumen in the RAP affects the shape formation, specific gravity, absorption, and gradation of RAP. All those factors cause the bulk density of compacted RAP decrease. This finding opens the knowledge of why cold asphalt mixture using RAP is worse than using fresh aggregate.
Design of mobile, portable and ergonomic fish smoke machine on a motorcycle
Authors: Nurmianto E , Anzip A , Sampurno
Published: November 2019

Built and Used On Motorcycle The Mobile, Portable, and Ergonomic Fishmaker are the design of a fish-shaped fog-shaped device transformed into a tool that is on a motorcycle. During this fuming, results are still not optimal because it still interferes with the eyes, nose, and lungs. Smoked fish is only natural without a touch of technology and innovation. The shape of this cupboard is considered appropriate because it has an optimal smoke capacity, a good level of strength so stable when the process of curing, has a practical design because it is easy to carry, dismantled and stored. This fumigation equipment uses motorcycles, with higher production capacity and socialization to the public about the use of proper and correct fish sauce. The innovation of this tool is the reduction of smoke that combines some smoke-reducing functions to be harmless but safe, comfortable and healthy for the users and effective for the products of processed seafood. Its innovative advantages are Practically shaped like cupboard, sturdy and sleek; Ergonomic can be designed and redesigned according to user size; Mobile can be taken anywhere and light; Portable can be off pairs making it easier and lighter to carry and can be used inside the house if the outside is raining; Smoke free because smoke is trapped in the cupboard and after the smoke is complete the valve can be opened then the smoke will be wasted through the chimney after that the fish can be taken; Hygienic and leave a delicious aroma on fumigation results.
Environmental benefit of public fleet fueled by LPG/Vi-Gas in Magelang City, Indonesia: A Simulation Study
Authors: Widodo E M , Setiyo M , Rosyidi M I , Purnomo T A , Waluyo B , Purnomo B C , Murniningsih R
Published: November 2019

This paper presents a simulation study on the utilization of LPG/Vi-Gas for public transport in Magelang City. Estimates of CO2 reduction per year are calculated theoretically and based on data from NEDC experiences. Both of these methods show positive results, reducing CO2 by theoretical calculations and comparing with NEDC experiences are 13.6 and 11 tons per year, respectively. In conclusion, the utilization of LPG/Vi-Gas for public fleets in Magelang city is feasible to be implemented as the Government’s effort to reduce CO2 emission from transportation sector.
Analysis of the security level of modified CBC algorithm cryptography using avalanche effect
Authors: Astuti N R D P , Arfiani I , Aribowo E
Published: November 2019

There have been many modifications of cryptographic algrotima aimed at increasing the security of the algorithm. One cryptographic algorithm that has been modified is CBC (Cipher Block Chaining) cryptography. CBC is a block-based modern cryptographic algorithm. The disadvantages that exist in CBC is the encryption process in each block plainteks using the same key, resulting in if the cryptanalyst finds the key that is used it will be easy to decrypt the ciphertext. Modifications made to CBC aimed at increasing security is by combining the Vigenere algorithm in determining the key and block transposition on the final reading of the encryption process. Parameters for assessing the algorithm are good or not by looking at the value of avalanche effect. A cryptographic algorithm will be categorized as good if the value of avalanche effect ranges between 45%-60% and bernilia is very good if the value of avalanche effect is 50%. The results of this study indicate that the modified CBC cryptographic algorithm resulting from the encryption process of several plaintexts has Avalanche effect values in the range above 50% and below 60%, which means that the modified CBC algorithm is of good value.
The effect of copper flame holder application on butane combustion characteristics in meso-scale combustor
Authors: Sudarman  , Fauzi I , Soegiharto A F H
Published: November 2019

This experimental research aims at determining the characteristics of butane combustion in Mesocombustor made of a quartz glass tube with a diameter of 3.5 mm and an outer diameter of 5 mm. The findings revealed that the flammability limit became wider with sharp curve narrowing. The narrowing of flammability limit did not occur in the other flame holder made of mesh stainless steel. Different from stainless steel conductivity, copper has declining thermal conductivity in each of temperature increase. The wider flame section was due to the increase of temperature in each flow velocity.
Application of catalytic converter copper catalyst with honeycomb surfaces to reduce emissions of flue gas in motorcycles
Authors: Siregar M A , Siregar C A , Muharnif  , Siregar A M , Maulana I
Published: November 2019

The application of a catalytic converter is believed to be able to accelerate the process of chemical reaction in vehicle exhaust gas. This will have an impact on reducing the high rate of air pollution from motorcycles exhaust gases. This study will compare the exhaust emission value of the standard exhaust muffler with the exhaust that has been installed catalytic converter. Catalytic converter which is made from copper with honeycomb surfaces. The motorcycle used with an engine capacity of 125 CC. Testing is done based on three different engine rotation that is 2000 rpm, 3000 rpm, and 4000 rpm. The result, at 4000 rpm engine speed decrease CO emission level of 1.76%, HC of 73 ppm and CO2 of 1.7%.
Early diversification and permeable species boundaries in the Mediterranean firs
Authors: Balao Francisco , Lorenzo María Teresa , Sánchez-Robles José Manuel , Paun Ovidiu , García-Castaño Juan Luis , Terrab Anass
Published: November 2019

Background and Aims

Inferring the evolutionary relationships of species and their boundaries is critical in order to understand patterns of diversification and their historical drivers. Despite Abies (Pinaceae) being the second most diverse group of conifers, the evolutionary history of Circum-Mediterranean firs (CMFs) remains under debate.

Methods

We used restriction site-associated DNA sequencing (RAD-seq) on all proposed CMF taxa to investigate their phylogenetic relationships and taxonomic status.

Key Results

Based on thousands of genome-wide single nucleotide polymorphisms (SNPs), we present here the first formal test of species delimitation, and the first fully resolved, complete species tree for CMFs. We discovered that all previously recognized taxa in the Mediterranean should be treated as independent species, with the exception of Abies tazaotana and Abies marocana. An unexpectedly early pulse of speciation in the Oligocene–Miocene boundary is here documented for the group, pre-dating previous hypotheses by millions of years, revealing a complex evolutionary history encompassing both ancient and recent gene flow between distant lineages.

Conclusions

Our phylogenomic results contribute to shed light on conifers’ diversification. Our efforts to resolve the CMF phylogenetic relationships help refine their taxonomy and our knowledge of their evolution.
The Role of a Resident Aesthetic Clinic in Addressing the Trainee Autonomy Gap
Authors: Shakir Sameer , Kozak Geoffrey M , Nathan Shelby L , Davis Harrison , Whitely Cutler , Broach Robyn B , Fosnot Joshua
Published: November 2019

Background

Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment.

Objectives

The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics.

Methods

A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed.

Results

In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different.

Conclusions

The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.
A Prospective Study on Risk Factors for Olfactory Dysfunction in Aging
Authors: Palmquist Eva , Larsson Maria , Olofsson Jonas K , Seubert Janina , Bäckman Lars , Laukka Erika J
Published: November 2019

Background

Olfactory dysfunction (OD) refers to a reduced or absent ability to smell. OD negatively impacts health and quality of life and its prevalence increases with advancing age. Since OD may be an early marker of dementia and impending death, more knowledge regarding risk factors of OD in aging is warranted. The objective was therefore to explore longitudinally which demographic, genetic, clinical, lifestyle, and cognitive factors predict the development of OD.

Methods

The study included participants aged 60–90 years from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K), who did not have OD at baseline and were reassessed with an odor identification task at a 6-year follow-up (n = 1,004). Risk factors of OD were assessed with multivariable logistic regression analyses.

Results

The percentage of incident OD cases was 14.2% over 6 years in the total sample and this number increased monotonically with age. Increasing age, carrying the ε4 allele of the APOE gene, atrial fibrillation, cerebrovascular disease, and current smoking were found to be risk factors for the development of OD, whereas better olfactory identification and verbal episodic memory proficiency at baseline were identified as protective factors.

Conclusions

In addition to nonmodifiable factors (age and genetic risk), several modifiable risk factors of OD were identified. This suggests that it might be possible to reduce OD incidence through the management of vascular risk factors and maintenance of a healthy lifestyle.
Size structure, sex ratio, and condition factor of the pink shrimp Penaeus (Farfantepenaeus) notialis Pérez Farfante, 1967 (Decapoda: Dendrobranchiata: Penaeidae) in the Colombian Caribbean
Authors: Ramírez Argiro , Paramo Jorge
Published: November 2019

We determined size structure, sex ratio, and condition factor for the pink shrimp, Penaeus notialisPérez Farfante, 1967 in the Caribbean coast of Colombia, information essential for the design of management and conservation strategies to ensure a sustainable fishery. Total length (TL; ± 0.01 mm) ranged from 79.47 to 192.80 mm TL (mean 148.21 ± 17.75) for females and 79.00–181.83 mm TL (mean 122.52 mm ± 12.55) for males. Statistically significant differences (P < 0.01) in size and weight (± 0.1 mg) between sexes were found year-round; males were smaller and weighed less than females. The sex ratio showed significant differences (P < 0.01) between the total number of females and males per total length class when compared with a 50% sex ratio. The monthly sex ratio showed significant differences between the number of females and males. The weight-length relationship showed positive allometric growth (b = 3.118) for females, whereas negative allometric growth (b = 2.663) was observed for males. The condition factor (K) ranged 0.0002–0.0023 (mean 0.0009 ± 0.0007) for females and 0.0005–0.2179 (mean 0.0316 ± 0.0642) for males.
Diagnostic accuracy of a new clinical test (resisted internal rotation) for detection of gluteus medius tears
Authors: Ortiz-Declet Victor , Chen Austin W , Maldonado David R , Yuen Leslie C , Mu Brian , Domb Benjamin G
Published: November 2019

The objective of this study was to evaluate the diagnostic accuracy of a new dynamic clinical examination for detection of gluteus medius (GM) tears. A case group of 50 patients undergoing arthroscopy with GM repair was compared with a control group of 50 patients undergoing arthroscopy who had no peritrochanteric symptoms. Both groups were examined clinically, had magnetic resonance imaging studies performed and underwent arthroscopic surgery. Recorded clinical examinations included abnormal gait (Trendelenburg), tenderness to palpation of the greater trochanter, resisted abduction and the test being studied, resisted internal rotation. For all clinical tests, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rates were calculated and compared with the arthroscopic and MRI data for the case group, and the MRI data for the control group. The resisted internal rotation test had a sensitivity of 92%, specificity of 85% and diagnostic accuracy of 88% in the detection of GM tears, with a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of Trendelenburg gait, showed inferior rates. Trendelenburg gait had a higher specificity, but much lower sensitivity. The resisted internal rotation test aides in the detection of GM pathology. Due to the good results of the resisted internal rotation test in all the diagnostic parameters, we recommend incorporating it on the physical exam of patients with hip pain.
Job Hopping and Adverse Selection in the Labor Market
Authors: Fan Xiaodong , DeVaro Jed
Published: November 2019

A model of employer learning (both symmetric and asymmetric) about worker ability from job histories is constructed, and testable implications are derived to detect asymmetric learning empirically. The model predicts that early-career bad job matches are particularly damaging when learning is asymmetric. Analysis of NLSY79 data reveals that job hopping is associated with lower wages for college graduates, controlling for measured ability, labor market experience, and current job tenure. Suggestive of asymmetric learning, the effect is strongest for job tenures less than one year and for early-career workers, and mitigated when job hopping severs matches that were formed during economic downturns. (JEL D82, J31, J63)
The polarized signal from broad emission lines in AGNs
Authors: Lira P , Goosmann R W , Kishimoto M , Cartier R
Published: November 2019

Using the stokes Monte Carlo radiative transfer code, we revisit the predictions of the spectropolarimetric signal from a disc-like broad emission line region (BLR) in type I active galactic nuclei due to equatorial scattering. We reproduce the findings of previous works, but only for a scatterer that is much more optically and geometrically thick than previously proposed. We also find that when taking into account the polarized emission from all regions of the scatterer, the swing of the polarization position angle (PA) is in the opposite direction to that originally proposed. Furthermore, we find that the presence of outflows in the scattering media can significantly change the observed line profiles, with the PA of the scattering signal being enhanced in the presence of radially outflowing winds. Finally, a characteristically different PA profile, shaped like an ‘M’, is seen when the scatterer is co-spatial with the BLR and radially outflowing.
On the road to per cent accuracy – III. Non-linear reaction of the matter power spectrum to massive neutrinos
Authors: Cataneo M , Emberson J D , Inman D , Harnois-Déraps J , Heymans C
Published: November 2019

We analytically model the non-linear effects induced by massive neutrinos on the total matter power spectrum using the halo model reaction framework of Cataneo et al. In this approach, the halo model is used to determine the relative change to the matter power spectrum caused by new physics beyond the concordance cosmology. Using standard fitting functions for the halo abundance and the halo mass–concentration relation, the total matter power spectrum in the presence of massive neutrinos is predicted to per cent-level accuracy, out to $k=10 \,{ h}\,{\rm Mpc}^{-1}$. We find that refining the prescriptions for the halo properties using N-body simulations improves the recovered accuracy to better than 1 per cent. This paper serves as another demonstration for how the halo model reaction framework, in combination with a single suite of standard Λ cold dark matter (ΛCDM) simulations, can recover per cent-level accurate predictions for beyond ΛCDM matter power spectra, well into the non-linear regime.
Stereotactic Radiation as Salvage Therapy for Recurrent Rathke Cleft Cysts
Authors: Agarwalla Pankaj K , Koch Matthew J , Royce Trevor J , Redjal Navid , Bussière Marc R , Loeffler Jay S , Swearingen Brooke
Published: November 2019

BACKGROUND

Rathke cleft cysts (RCCs) are sellar-based cystic lesions that are often found incidentally but occasionally become symptomatic with significant visual and/or endocrine deficits. The standard of treatment is surgery, but rare cases of multiply recurrent RCCs can be refractory to surgical drainage, leading to significant morbidity.

OBJECTIVE

To demonstrate the safety and feasibility of fractionated stereotactic radiotherapy (SRT) as salvage therapy in multiply recurrent RCCs refractory to surgical drainage.

METHODS

An IRB-approved retrospective review at a single institution was conducted to identify and describe patients with multiply recurrent RCCs refractory to surgical drainage who underwent SRT.

RESULTS

From 1994 to 2015, 6 patients (5 female) who underwent SRT for recurrent RCCs were identified. A total of 4 presented with visual deficits, and 2 presented with endocrine dysfunction and severe headaches prior to their initial drainage. All patients had initial postoperative improvement but then developed multiple, symptomatic recurrences. Median number of surgical drainage procedures prior to radiotherapy was 3. A total of 3 patients underwent LINAC-based SRT, and 3 had proton-based SRT. Treatment doses were 45 Gy over 25 fractions (n = 5) and 50.4 Gy over 28 fractions (n = 1). Median follow-up after radiation therapy was 69 mo (range 24-154 mo). In the follow-up period, stabilization of the RCC was achieved, although 2 patients required additional drainage procedures. Only 1 patient developed new hypothyroidism and hypoadrenalism after SRT.

CONCLUSION

In rare cases of multiply recurrent RCCs refractory to repeat surgical drainage, stereotactic fractionated radiation therapy is a safe and effective salvage therapy.
Identification of measures predictive of age of puberty onset in gilts
Authors: Graves Kody L , Mordhorst Bethany R , Wright Elane C , Hale Benjamin J , Stalder Kenneth J , Keating Aileen F , Ross Jason W
Published: November 2019

A potential indicator of female lifetime productivity in swine is age of puberty, when a gilt achieves her first behavioral estrus. Follicular activity, as determined by tertiary follicle development, in prepubertal gilts begins during postnatal day (PND) 75 to 115. The central hypothesis of this study is that gilts demonstrating tertiary follicle development earlier in life, assessed using vulva size as a proxy, achieve puberty earlier in life compared with counterparts of a similar age and weight that lack tertiary follicle development. The objectives of this project were to identify a developmental time point when variation in ovarian development exists and to determine whether a relationship between the age prepubertal ovarian development and the age at onset of puberty exists. To accomplish this, 155 gilts of similar age (± 2 d) were weighed and vulva size measured on PND 75, 85, 95, 105, and 115. Vulva measures, including vulva width (VW), vulva length (VL), and vulva area (VA), were utilized as developmental proxies for follicular activity. At each time point, gilts (n = 10) were sacrificed and ovarian follicular activity recorded. In a subset of gilts (n = 105), estrus detection was conducted daily on PND days 126 to 200. Mean VA on PND 75, 85, 95, 105, and 115 was 596 ± 206, 683 ± 190, 864 ± 212, 1014 ± 228, and 1265 ± 252 mm2, respectively. Of the gilts demonstrating behavioral estrus, 28 were within PND 140 to 160, 36 between PND 161 to 180, 15 between PND 181 to 200, and 26 did not demonstrate estrus behavior within 200 d of age. All gilts euthanized at PND 75 lacked follicular activity as defined by having a minimum of 2 antral follicles per ovary, whereas 60%, 80%, 90%, and 100% demonstrated follicular activity on PND 85, 95, 105, and 115, respectively. Body weight at PND 75 and VW at PND 115 were correlated to age at first estrus (P < 0.05). Of the gilts whose VA was less than 1 SD from the mean on PND 95 (i.e., <652 mm2), 31% and 50% demonstrated their first behavioral estrus by PND 180 and 200, respectively. However, of gilts whose VA was within or greater than 1 SD of the mean (i.e., ≥652 mm2), 66% and 79% exhibited estrus prior to PND 180 and 200, respectively. These data support utilization of VA changes between 95 and 115 d of age as a useful tool to identify replacement gilts prior to puberty for inclusion into the sow herd.
SNAP reverses temozolomide resistance in human glioblastoma multiforme cells through down‐regulation of MGMT
Authors: Tsai Chia‐Kuang , Huang Li‐Chun , Wu Yi‐Ping , Kan I‐Ying , Hueng Dueng‐Yuan
Published: November 2019

Glioblastoma multiforme (GBM) is the most frequently occurring and gravest primary tumor of the CNS in adults. The development of chemoresistance to temozolomide (TMZ), the first‐line chemotherapy for GBM, is an important factor contributing to poor treatment outcomes. Down‐regulation of O‐6‐methylguanine‐DNA methyltransferase (MGMT) expression in GBM cells is an attractive strategy for overcoming TMZ resistance and improving outcomes. This study revealed that the nitric oxide (NO) donor S‐nitroso‐N‐acetylpenicillamine (SNAP) exerts antitumorigenic effects on TMZ‐sensitive and TMZ‐resistant (TMZ‐R) glioma cells. Pretreatment with SNAP not only induced apoptosis, mitochondrial dysfunction, and hypoxia‐inducing factor 1, but also resensitized TMZ‐R GBM cells to TMZ through down‐regulation of MGMT expression. SNAP acted principally through post‐translational modification of p53, phosphorylated N‐myc downstream regulated gene 1, and MGMT protein stability in TMZ‐R GBM cells. Additionally, when applied together, SNAP and TMZ enhanced the inhibition of tumor growth in vitro and in vivo. This study sheds new light on a potential strategy to overcome TMZ resistance in GBM and thus possesses the potential for prolonging survival of patients with GBM.—Tsai, C.‐K., Huang, L.‐C., Wu, Y.‐P., Kan, I.‐Y., Hueng, D.‐Y. SNAP reverses temozolomide resistance in human glioblastoma multiforme cells through down‐regulation of MGMT. FASEB J. 33, 14171‐14184 (2019). www.fasebj.org
On Time and Tea Bags: Chronos, Kairos, and Teaching for Humanistic Practice
Authors: Kumagai Arno K. , Naidu Thirusha
Published: November 2019

In these days of overwhelming clinical work, decreased resources, and increased educational demands, time has become a priceless commodity. Competency-based medical education attempts to address this challenge by increasing educational efficiency and decreasing the “steeping” of learners in clinical activities for set durations of time. However, in this environment, how does one teach for compassionate, humanistic practice? The answer arguably lies in clinician–teachers’ recognition and engagement in a different type of time, that of kairos. Ancient Greek thought held that there were 2 interrelated types of time: chronological, linear, quantitative time—chronos—and qualitative, opportune time—kairos. Unlike chronos, kairos involves a sense of the “right time,” the “critical moment,” the proportionate amount. Developing a sense of kairos involves learning to apply general principles to unique situations lacking certainty and acting proportionally to need and context. Educationally, it implies intervening at the critical moment—the moment in which a thoughtful question, comment, or personal expression of perplexity, awe, or wonder can trigger reflection, dialogue, and an opening up of perspectives on the human dimensions of illness and medical care. A sensibility to kairos involves an awareness of what makes a moment “teachable,” an understanding of chance, opportunity, and potential for transformation. Above all, inviting kairos means grasping an opportunity to immerse oneself and one’s learners—even momentarily—into an exploration of patients and their stories, perspectives, challenges, and lives.
Postoperative Pain and Analgesic Requirements in the First Year after Intraoperative Methadone for Complex Spine and Cardiac Surgery
Authors: Murphy Glenn S. , Avram Michael J. , Greenberg Steven B. , Shear Torin D. , Deshur Mark A. , Dickerson David , Bilimoria Sara , Benson Jessica , Maher Colleen E. , Trenk Gregory J. , Teister Kevin J. , Szokol Joseph W.
Published: November 2019

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Methadone is a long-acting opioid that has been reported to reduce postoperative pain scores and analgesic requirements and may attenuate development of chronic postsurgical pain. The aim of this secondary analysis of two previous trials was to follow up with patients who had received a single intraoperative dose of either methadone or traditional opioids for complex spine or cardiac surgical procedures.

Methods

Preplanned analyses of long-term outcomes were conducted for spinal surgery patients randomized to receive 0.2 mg/kg methadone at the start of surgery or 2 mg hydromorphone at surgical closure, and for cardiac surgery patients randomized to receive 0.3 mg/kg methadone or 12 μg/kg fentanyl intraoperatively. A pain questionnaire assessing the weekly frequency (the primary outcome) and intensity of pain was mailed to subjects 1, 3, 6, and 12 months after surgery. Ordinal data were compared with the Mann–Whitney U test, and nominal data were compared using the chi-square test or Fisher exact probability test. The criterion for rejection of the null hypothesis was P < 0.01.

Results

Three months after surgery, patients randomized to receive methadone for spine procedures reported the weekly frequency of chronic pain was less (median score 0 on a 0 to 4 scale [less than once a week] vs. 3 [daily] in the hydromorphone group, P = 0.004). Patients randomized to receive methadone for cardiac surgery reported the frequency of postsurgical pain was less at 1 month (median score 0) than it was in patients randomized to receive fentanyl (median score 2 [twice per week], P = 0.004).

Conclusions

Analgesic benefits of a single dose of intraoperative methadone were observed during the first 3 months after spinal surgery (but not at 6 and 12 months), and during the first month after cardiac surgery, when the intensity and frequency of pain were the greatest.
Parents want to attend pediatric fracture reductions
Authors: Kearney Sean P.
Published: November 2019

Pediatric fracture reductions can create anxiety for the child and parent. While cross-cultural evidence supports parental presence during some pediatric procedures, no study addresses parental presence during fracture reductions. This study investigates parent experiences during their child’s reduction and provides guidance regarding parental attendance during fracture reductions. Sixty consecutive parents were retrospectively surveyed about their experience during their child’s fracture reduction. Parents were grouped according to presence or absence during the reduction and were compared. Forty parents attended the reduction and 20 parents were absent. All parents attending the reduction were satisfied with their experience. Thirty-nine parents (98%) believed their presence was helpful for their child and 36 (90%) believed it was personally helpful. Of the 20 absent parents, four (20%) were dissatisfied with their experience, five (25%) believed it was personally harmful, and two (10%) thought it was harmful to their child. All parents reporting negative experiences were prohibited from attending the reduction. When deciding about parental presence during reductions, 55 (92%) parents wanted to be included in this process. Overall, 47 parents (78%) wanted to attend the reduction and 52 (87%) would prefer to attend a future reduction. Most parents prefer to attend their child’s fracture reduction and believe their presence is helpful personally and for their child. Parents in attendance report a positive experience, while parents prohibited from attending report dissatisfaction with the experience and believe their absence is harmful to themselves and their children. It is recommended that healthcare workers consider parental attendance during pediatric reductions.
Mid-term clinical result of femoral varus osteotomy combined with Pemberton osteotomy in treating spastic hip subluxation
Authors: Wen Jie , Liu Hong , Xiao Sheng , Li Xin , Fang Ke , Tang Zhongwen , Cao Shu , Li Fanling
Published: November 2019

Hip subluxation in ambulant children with cerebral palsy may lead to limited walking and pain. This study aimed to introduce the indications and methods of femoral varus osteotomy combined with Pemberton osteotomy in treating spastic hip subluxation to evaluate the interim clinical result and outcome and to discuss its corrective mechanism and orthopedic effect. A total of 23 children with spastic hip subluxation, who underwent femoral varus osteotomy combined with Pemberton osteotomy were selected. The clinical effects were evaluated according to the migration percentage, acetabular index, proximal femur neck shaft angle (NSA), and Melbourne Cerebral Palsy Hip Classification System (MCPHCS). The median migration percentage was 55 (50, 75) before operation, 20 (0, 30) at postoperative 1 year, and 22 (5, 32) at last follow-up. The median acetabular index was 30° (25°, 40°) before operation, 20°(15°, 26°) at postoperative 1 year, and 20° (15°, 25°) at last follow-up. The median NSA was 145 (138, 153) before operation, 117 (107, 126) at postoperative 1 year, and 118 (110, 125) at last follow-up. The MCPHCS grade 4 counts 23 (100%) before operation, grade 3 counts 20 (87.0%), grade 2 counts 2 (8.7%) and grade 1 counts 1 (4.3%) at postoperative 1 year, and grade 4 counts 1 (4.3%), grade 3 counts 21 (91.3%) and grade 1 counts 1 (4.3%) at last follow-up. Femoral varus osteotomy combined with Pemberton osteotomy is a good surgical treatment for children with Gross Motor Function Classification System levels I and II and migration percentage greater than 50%.
Two-Level Osteotomy for the Corrective Surgery of Severe Kyphosis From Ankylosing Spondylitis
Authors: Zhong Woquan , Chen Zhongqiang , Zeng Yan , Sun Chuiguo , Li Weishi , Qi Qiang , Guo Zhaoqing
Published: November 2019

Study Design.

Retrospective study.

Objective.

To describe the treatment results of patients with severe ankylosing spondylitis (AS) kyphosis who underwent two-level osteotomy and correction surgery.

Summary of Background Data.

The best solution for the fixed kyphotic deformity of AS is corrective osteotomy. Many osteotomy options are available: pedicle subtraction osteotomy (PSO), Smith-Peterson osteotomy (SPO), and vertical column resection (VCR). These procedures all provide multiplanar deformity correction. Nevertheless, when the AS deformity is severe, an additional osteotomy site to get more correction, achieve more ideal, and smooth curvature of the spine than single osteotomy.

Methods.

From May, 2008 to August, 2016, 19 patients of severe AS kyphosis underwent two-level spinal osteotomy and correction surgery. The patients had an average kyphosis angle greater than 90°. The radiological features and clinical evaluation, including Oswestry Disability Index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22 components were assessed before surgery and at follow-up. The patients underwent either one-level PSO combined with one-level SPO (n = 9) or two-level PSO (n = 10).

Results.

The height was increased after surgery in all patients (P < 0.05). The median follow-up was 24 months. The kyphosis angle improved from 92.0 ± 16.6° to 30.0 ± 17.2°. The chin-brow vertical angle improved from 37.6 ± 19.2° to –0.6 ± 2.5°. The sacral slope improved from 3.9 ± 11.8° to 21.7 ± 7.4°. Sagittal imbalance improved from 241.4 ± 115.3 mm to 74.6 ± 48.5 mm (P < 0.05). Lumbar lordosis improved from –3.9 ± 20.8° to 29.4 ± 14.1° (all P < 0.05). There were significant improvements in the ODI, VAS, and all components of SRS-22 (all P < 0.05). All patients with pseudarthrosis (n = 5) underwent PSO + SPO and achieved satisfactory results. Six complications were observed perioperatively, but without permanent sequelae.

Conclusion.

Two-level osteotomy and correction procedure can achieve satisfactory results in severe AS kyphosis. PSO + SPO could be a good option for patients with pseudarthrosis because of relatively easier and faster operation.

Level of Evidence: 4
Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Renal Replacement Therapy: A Multinational Survey of Critical Care Practitioners
Authors: Murugan Raghavan , Ostermann Marlies , Peng Zhiyong , Kitamura Koichi , Fujitani Shigeki , Romagnoli Stefano , Di Lullo Luca , Srisawat Nattachai , Todi Subhash , Ramakrishnan Nagarajan , Hoste Eric , Puttarajappa Chethan M. , Bagshaw Sean M. , Weisbord Steven , Palevsky Paul M. , Kellum John A. , Bellomo Rinaldo , Ronco Claudio
Published: November 2019

Objectives:

To assess the attitudes of practitioners with respect to net ultrafiltration prescription and practice among critically ill patients with acute kidney injury treated with renal replacement therapy.

Design:

Multinational internet-assisted survey.

Setting:

Critical care practitioners involved with 14 societies in 80 countries.

Subjects:

Intensivists, nephrologists, advanced practice providers, ICU and dialysis nurses.

Intervention:

A cross-sectional survey.

Measurement and Main Results:

Of 2,567 practitioners who initiated the survey, 1,569 (61.1%) completed the survey. Most practitioners were intensivists (72.7%) with a median duration of 13.2 years of practice (interquartile range, 7.2–22.0 yr). Two third of practitioners (71.0%; regional range, 55.0–95.5%) reported using continuous renal replacement therapy with a net ultrafiltration rate prescription of median 80.0 mL/hr (interquartile range, 49.0–111.0 mL/hr) for hemodynamically unstable and a maximal rate of 299.0 mL/hr (interquartile range, 200.0–365.0 mL/hr) for hemodynamically stable patients, with regional variation. Only a third of practitioners (31.5%; range, 13.7–47.8%) assessed hourly net fluid balance during continuous renal replacement therapy. Hemodynamic instability was reported in 20% (range, 20–38%) of patients and practitioners decreased the rate of fluid removal (70.3%); started or increased the dose of a vasopressor (51.5%); completely stopped fluid removal (35.8%); and administered a fluid bolus (31.6%), with significant regional variation. Compared with physicians, nurses were most likely to report patient intolerance to net ultrafiltration (73.4% vs 81.3%; p = 0.002), frequent interruptions (40.4% vs 54.5%; p < 0.001), and unavailability of trained staff (11.9% vs 15.6%; p = 0.04), whereas physicians reported unavailability of dialysis machines (14.3% vs 6.1%; p < 0.001) and costs associated with treatment as barriers (12.1% vs 3.0%; p < 0.001) with significant regional variation.

Conclusions:

Our study provides new knowledge about the presence and extent of international practice variation in net ultrafiltration. We also identified barriers and specific targets for quality improvement initiatives. Our data reflect the need for evidence-based practice guidelines for net ultrafiltration.
Self-Care
Authors: Spurlock Rachel
Published: November 2019

What does it mean to practice self-care? How do we care effectively and compassionately for our patients while maintaining our own physical and emotional health? Nursing associations have incorporated the importance of self-care into models for good nursing practice. The perspective on self-care can change from one of self-focus to one of stewardship. Self-care from a stewardship view reflects what God is already doing to take care of us.
Transthyretin Cardiac Amyloidosis as Diagnosed by 99mTc-PYP Scanning in Patients with Acute Heart Failure and Preserved Ejection Fraction
Authors: Lo Presti Saberio , Horvath Sofia A. , Mihos Christos G. , Rajadhyaksha Chetan , McCloskey Veronica , Santana Orlando
Published: November 2019

Transthyretin amyloid deposition is present in 17% of autopsies of patients with heart failure and a preserved ejection fraction (HFpEF). 99mTechnetium-pyrophosphate scintigraphy (99mTc-PYP) is sensitive and specific to diagnose cardiac transthyretin amyloid deposition (ATTR). The prevalence of ATTR by 99mTc-PYP was evaluated along with echocardiographic parameters in patients with HFpEF. One-hundred consecutive patients with HFpEF, who had 99mTc-PYP, were retrospectively evaluated. Echocardiographic variables were analyzed to compare patients with positive versus negative ATTR infiltration. Myocardial ATTR was present in 19% of patients. Individuals with ATTR were older with a mean age of 82 ± 7 versus 75 ± 13 years (P = 0.03), had increased left ventricular hypertrophy with the interventricular septum measuring 1.6 (IQR, 1.4–2.0) versus 1.4 (IQR, 1.3–1.6) cm (P = 0.002), had a greater mean left ventricular mass index of 160 ± 50 g/m2 versus 131 ± 44 g/m2 (P = 0.01), and a reduced global longitudinal strain measuring −11% (IQR, −9 to −12) versus −12% (IQR, −10 to −16), P = 0.04. The prevalence of ATTR myocardial deposition demonstrated by 99mTc-PYP in patients with HFpEF is comparable to that of autopsy studies. It is more common in older patients, with increased left ventricular hypertrophy and reduced global longitudinal strain.
PSEUDOMONAL CHOROIDAL ABSCESS AFTER ROUTINE PARS PLANA VITRECTOMY IN AN IMMUNOSUPPRESSED PATIENT
Authors: Wang Kendrick M. , Liu Tin Yan Alvin , Sein Julia , Arevalo J. Fernando
Published: November 2019

Purpose:

To describe an unusual case of pseudomonal choroidal abscess which developed after a routine pars plana vitrectomy in an immunosuppressed patient.

Methods:

Case report. A 61-year-old woman with a history of rheumatoid arthritis and ulcerative colitis on abatacept underwent pars plana vitrectomy. A few days after the patient's operation, a partially serous choroidal detachment was identified. Her choroidal detachment increased in size despite prednisone therapy, and she was taken to the operating room for repeat vitrectomy and choroidal drainage. Intraoperatively, there was no significant intraocular inflammation, but purulent whitish material was expressed during external choroidal drainage which grew Pseudomonas aeruginosa.

Results:

The patient was given intravenous antibiotics. Systemic infectious workup was negative for blood and urine cultures. The patient was transitioned to oral antibiotics, but had persistent eye pain after discharge and vision remained at count fingers. A computed tomography orbit scan with contrast showed persistent choroidal abscess, and intravitreal ceftazidime injections were administered. The patient's subjective pain resolved within several days of the first intravitreal injection; repeat ultrasound also showed interval resolution of the choroidal elevation. One year after the resolution of her choroidal abscess, her visual acuity was Snellen 20/250 in the affected eye.

Conclusion:

Isolated choroidal bacterial abscess is a possible, but rare, complication of pars plana vitrectomy. Although visual prognosis is poor, especially for pseudomonal choroidal abscesses, aggressive treatment with timely choroidal drainage, systemic antibiotics, and intravitreal antibiotics may allow recovery of some ambulatory vision.
Evaluation of 99mTC-ECD SPECT/CT brain Imaging with NeuroGam analysis in Moyamoya disease after surgical revascularization
Authors: Lou Jingjing , Liu Zhuang , Xu Bin , Wang Yuan-Kai , Liu Cong-Jin , Liu Miao , Liu Xing-Dang
Published: November 2019

To evaluate the clinical value of NeuroGam software in assessing the brain foci perfusion changes by 99mTC-ECD single photon emission computed tomography/computed tomography (SPECT/CT) brain imaging in patients with Moyamoya Disease (MMD).

Seventy-two patients with MMD who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) surgical revascularization were included. Baseline and follow-up 99mTC-ECD SPECT/CT brain scans were performed on all patients at least twice before and after operation. Pre- and post-SPECT dicom images were reoriented into Talairach space using NeuroGam Software package. Additional visual analysis was performed. Differences mean pixel value between pre- and post- operation brain perfusion were assessed with paired t test and McNemar test.

Significant differences in the number of hypoperfusion foci were found between visual assessment and NeuroGam aided assessment. More hypoperfusion foci were found by NeuroGam software aided assessment in the frontal, parietal, temporal, occipital lobe, thalamus, basal ganglia and cerebellum before and after surgery (P < .0001). According to NeuroGam software assessment, the perfusion of frontal, parietal, temporal lobe, anterior and middle cerebral regions on the operative side significantly improved before and after surgery (t = –3.734, t = –3.935, t = –5.099, t = –4.006, t = –5.170, all P < .001). However, no significant differences were found in the occipital lobe (t = –1.962, P = .054), thalamus (t = 1.362, P = .177), basal ganglia (t = –2.394, P = .019), and cerebellum (t = 1.383, P = .171) before and after surgery.

The NeuroGam software provides a quantitative approach for monitoring surgical effect of MMD in a variable time (3–12 months after surgery). It could discover the perfusion changes that are neglected in conventional visual assessment.