bluuebunny/crossref_metadata_2025 huggingface dataset:
Two-year Follow-up of Patients With Unstable Angina/Non-ST Segment Elevation Myocardial Infarction Undergoing Early Invasive Strategy: Predictors of Normal or Near-Normal Coronary Angiography and Mortality
Authors: Jenab Yaser , Kassaian Ebrahim , Pourhosseini Hamid Reza , Salarifar Mojtaba , Jalali Arash , Talasaz Azita Hajhossein
Published: February 2018

Background:

Predictors of normal or near-normal coronary angiography (NONCAG) in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and their importance regarding the prognosis are not understood. Accordingly, we determined these predictors as well as mortality risk factors at 2-year follow-up of UA/NSTEMI patients managed by the early invasive strategy.

Methods:

We prospectively studied consecutive patients with UA/NSTEMI managed with the early invasive strategy at Tehran Heart Center, in 1-year period. Echocardiography was performed before coronary angiography (CAG) for all the patients. Baseline characteristics, laboratory parameters, echocardiographic findings, invasive treatment modalities, and survival status after 2 years of follow-up were collected. We identified the predictors of NONCAG in the first phase of the study and then the risk factors of mortality in the second phase.

Results:

In the study period, 298 patients including 211 (71%) males, with the age of 59.31 ± 10.72 years were enrolled. The following factors were predictors of NONCAG: the female sex (P < 0.001); negative family history of CAD (P = 0.028); Thrombolysis in Myocardial Infarction (TIMI) risk score (P < 0.001); and early transmitral flow velocity/mean mitral annular velocity (E/E′mean) (P = 0.003). The following items were significant protective factors against mortality: percutaneous coronary intervention (PCI) (P = 0.012), age (P = 0.001), and E/E′mean (P = 0.020).

Conclusion:

Patients’ baseline characteristics as well as echocardiographic data could help in predicting those with NONCAG and PCI can be considered as the treatment of strategy with the most protection against mortality.
Positive Predictive Value of Noninvasive Stress Testing Is Poor in the Real World
Authors: Dang Geetanjali , Shahreyar Muhammad , Oktay Ahmet Afşin , Sulaiman Samian , Husein Husein , Inashvili Ana , Elhangouche Nadia , Subramanian Preethi , Bashir Mohammad Waqas , Pathak Aradhna , Chan Shu B , Dadkhah Shahriar
Published: February 2018

Abnormal noninvasive stress test (NIST) findings do not always correlate with angiographically significant (luminal obstruction ≥50%) coronary artery disease. Positive predictive value (PPV) of NIST in the real clinical practice is not well known. The goal of this retrospective study was to determine the PPV of NIST and assess the factors affecting PPV in a US community hospital. This study included all consecutive patients (n = 355) who underwent invasive coronary angiography after a positive NIST within ~1-year duration at our institution. Three hundred twenty-four patients were included in the analysis after exclusion of 31 patients. Sixty percent of patients were female and mean age was 63.2 (SD 12.4). Myocardial perfusion imaging, echocardiogram (treadmill or dobutamine), and treadmill electrocardiogram were the tests of choice in 95% (n = 307), 4% (n = 14), and 1% (n = 3) of patients, respectively. Overall PPV of NIST was 36.4% (118/324). When patients were stratified by age (<50 years, 50–65 years, ≥65 years), older age groups had significantly higher PPV (<0.001). When patients were grouped by body mass index (<25, 25–30, ≥30), those in lower body mass index groups had higher PPV (
P
= 0.01). Stress echocardiogram had significantly higher PPV compared with myocardial perfusion imaging stress test (71% vs. 35%;
P
< 0.005). Stress test site (in-hospital vs. outpatient office) or specialty of interpreting physician did not significantly impact PPV. Multivariable logistic regression analysis revealed that older age, male sex, and total number of cardiac risk factors were significant determinants of higher PPV. Our single-center study revealed that overall PPV of NIST is poor (36.4%), more notably in young, female, or obese patients.
Clinical Outcomes of Transferred Versus Onsite Primary Percutaneous Coronary Intervention for Patients With STEMI: Time to Look Beyond Door to Balloon Time
Authors: Mallidi Jaya , Visintainer Paul , Pallekonda Indupriya , Fisher Daniel , Barringhaus Kurt , Kugelmass Aaron , Lotfi Amir
Published: February 2018

Background:

It is currently unknown if the delay due to practical aspects associated with transfer of patients from a non-percutaneous coronary intervention (PCI) facility to a primary PCI facility is associated with adverse outcomes.

Methods:

We conducted a retrospective cohort study of all patients who presented with ST-segment elevation myocardial infarction (STEMI) and underwent primary PCI in 2 large regional STEMI centers in Massachusetts between January 2005 and June 2009. The cohort was divided into onsite patients who presented directly to the primary PCI center and transferred patients referred from another facility. The primary outcome was a composite of in-hospital major cardiovascular events (death, myocardial infarction, and stroke). Secondary outcomes were the individual components of the composite endpoint and bleeding complications.

Results:

The cohort included a total of 1236 patients. Among them, 426 (34%) patients were transferred patients and 810 (66%) were onsite patients. The median door to balloon time was significantly higher at for transferred patients (124 vs. 71 minutes). There was no significant difference in primary composite endpoint between the 2 groups (onsite 3.8% vs. transfer 5.3%, odds ratio 1.50, 95% confidence interval 0.79–2.84; P = 0.21). Adjusted risk estimates did not show a statistical difference in all-cause bleeding rates between the groups (onsite 10.1% vs. transfer 7.3%, odds ratio 0.68, 95% confidence interval 0.41–1.14; P = 0.14).

Conclusions:

This study confirms that well-established and integrated regional STEMI programs provide equivalent care to transferred patients and onsite patients. Parameters beyond door to balloon times should be investigated for their contributions to improve patient outcomes.
ECG-to-Decision Time Impact on 30-Day Mortality and Reperfusion Times for STEMI Care
Authors: Mullvain Richard , Saman Daniel M. , Rostvedt Ashlee , Landgren Pauline
Published: February 2018

Objectives:

Little data are published on the unique care performance metric of electrocardiogram-to-decision time (E2Decide) for primary percutaneous coronary intervention (PCI) treatment of ST-elevation myocardial infarction (STEMI). The objective of this study is to evaluate E2Decide time on mortality and delayed reperfusion.

Methods:

This was a retrospective study of STEMI activations treated with primary PCI at 2 PCI-capable hospitals located in Duluth, Minnesota, and Fargo, North Dakota, originating in 3 different settings: (1) primary PCI-capable hospital emergency departments, (2) non-PCI facilities, and (3) in the field by emergency medical services. Analysis of variance, generalized linear modeling, and logistic regression models were used in this study.

Results:

There were 289 (96 females) STEMI patients included in our analyses. Non significant differences were observed in E2Decide time between male and female patients (9.7 vs. 11.1 min, respectively). Generalized linear modeling revealed that only non-PCI facilities significantly affected E2Decide time [β = 6.29; P = 0.007; 95% confidence interval (CI), 1.7–10.9] relative to PCI-capable hospitals. We found that E2Decide time was significantly associated with the metric decision-to-PCI, and that for every additional E2Decide minute, the decision-to-PCI increased by another 1.21 minutes (P < 0.001; 95% CI, 0.873–1.56). We also found a 20.3% increased odds of 30-day mortality for every 5-minute increase in E2Decide time (estimated odds ratio = 1.20; 95% CI, 1.04–1.38).

Conclusions:

We observed that a delay in E2Decide time was significantly associated with a subsequent delay in decision-to-PCI time. E2Decide time was significantly associated with increased odds in 30-day mortality. This study demonstrates the potential value of the metric E2Decide time.
Single-Port Thoracoscopic Pericardial Window under Local Anesthesia
Authors: Park Chang Y. , McGonigle Niall C.
Published: February 2018

There are numerous surgical approaches for the treatment of pericardial effusions but no clear consensus of best management. We present a 44-year-old woman with metastatic breast cancer presenting with a new 2-cm pericardial effusion on ultrasound. In light of the patient's palliative condition and the urgent need for chemotherapy, careful consideration was made for her surgical drainage of the pericardial effusion. Because of the patient's medical comorbidities, a general anesthetic was deemed not to be in the patient's best interest. Furthermore, the invasive subxiphoid or thoracotomy approach for a pericardial window would have risked delaying her much needed chemotherapy. A single-port thoracoscopic pericardial window was performed under light sedation, ventilating spontaneously on supplementary oxygen through nasal cannula only. The patient was positioned in a supine position, and a single 8-mm port was inserted into the left hemithorax at the 5th intercostal space, midaxillary line under local anesthetic, and a pericardial window made. This minimally invasive approach, without the need for intubation or ventilation, allowed for rapid relief of symptoms and discharge for the patient to begin her chemotherapy in a timely manner. By undergoing the procedure awake and through a single port, the patient was discharged after a short inpatient stay. This novel approach can be advocated for patients where a general anesthetic or invasive surgical procedure is not suitable in the treatment of their pericardial effusion.
Economic Evaluation of Selective Neonatal Bacillus Calmette-Guérin Vaccination of High-risk Infants in Ireland
Authors: Teljeur Conor , Moran Patrick S. , Harrington Patricia , Butler Karina , Corcoran Brenda , O’Donnell Joan , Usher Cara , O’Flanagan Darina , Connolly Kevin , Ryan Máirín
Published: February 2018

Background:

In Western Europe, currently only Ireland and Portugal continue to provide universal neonatal bacillus Calmette-Guérin (BCG) vaccination programs, despite not being considered as high tuberculosis (TB) incidence countries. Other European countries only vaccinate infants considered at high risk of contracting TB. We evaluated the cost-effectiveness of selective BCG vaccination compared with strategies of universal and no vaccination.

Methods:

An economic model was used to simulate a cohort from birth to life expectancy, taking the perspective of the publicly funded healthcare system. BCG protection was modeled to last 15 years. International vaccine efficacy data were combined with Irish epidemiologic and cost data. The model took into account long-term sequelae associated with TB meningitis and severe adverse reactions relating to the BCG vaccine. A fully probabilistic model was used to incorporate uncertainty across all parameters.

Results:

At €139,557 per quality-adjusted life year, selective vaccination was not cost-effective relative to a program of no vaccination. The incremental cost-effectiveness of universal vaccination was €2.55 million per quality-adjusted life year relative to selective vaccination. There was substantial uncertainty regarding the effectiveness of BCG vaccination. The cost-effectiveness of selective vaccination could be substantially improved by reducing the cost of administering the vaccine.

Conclusions:

In the absence of changes to other aspects of TB control, a switch to selective vaccination will result in increased cases of childhood TB. Although not considered cost-effective, selective vaccination may be preferable to no vaccination until other changes to TB control may be implemented to reduce the risk of TB in children.
Reducing morbidity and complications after major head and neck cancer surgery: the (future) role of enhanced recovery after surgery protocols
Authors: Huber Gerhard F. , Dort Joseph C.
Published: February 2018

Purpose of review

To review the development and the benefits of enhanced recovery after surgery (ERAS) protocols in non-head and neck disciplines and to describe early implementation efforts in major head and neck surgeries.

Recent findings

Several groups have adopted ERAS protocols for major head and neck surgery and demonstrated its feasibility and effectiveness.

There is growing evidence that clinical and financial outcomes for patients undergoing major head and neck surgery rehabilitation can be significantly improved by standardizing preoperative, intraoperative, and postoperative treatment protocols. Current experience is limited to single centers. A future goal is to broaden the adoption of ERAS in head and neck surgical oncology to include national and international collaboration, data sharing, and learning.
Prematurity and future kidney health: the growing risk of chronic kidney disease
Authors: Starr Michelle C. , Hingorani Sangeeta R.
Published: February 2018

Purpose of review

The purpose of this review is to describe the role prematurity plays in the development of chronic kidney disease (CKD) and to discuss potential reasons for this association including decreased nephron mass, as well as postnatal insults such as neonatal acute kidney injury (nAKI).

Recent findings

New observational studies in humans and experimental studies in animal models have strengthened the association between prematurity, low birth weight and CKD. Growing evidence suggests increased susceptibility to CKD is caused by decreased nephron mass at birth. Beginning with a low nephron count may cause only subtle abnormalities during childhood, however may result in CKD, hypertension and albuminuria in adolescence or adulthood. Recent studies in premature infants reveal a high incidence of nAKI, which may also contribute to ongoing CKD risk.

Children born at low birth weights (both due to prematurity and/or intrauterine growth restriction) show increased risk of kidney dysfunction during adulthood. A better understanding of the modulators of nephron mass in premature infants as well as the effects of the extrauterine environment is essential. Additionally, improved awareness of at-risk infants is important as is early evaluation and detection of kidney dysfunction, allowing interventions to slow the progression to CKD.
Superficial Solitary Fibrous Tumor
Authors: Feasel Patrick , Al-Ibraheemi Alyaa , Fritchie Karen , Zreik Riyam T. , Wang Wei-Lien , Demicco Elizabeth , Saeb-Lima Marcela , Goldblum John R. , Rubin Brian P. , McKenney Jesse K. , Ko Jennifer S. , Billings Steven D.
Published: February 2018

While superficial (cutaneous/subcutaneous) solitary fibrous tumor (SFT) have been described, definitive diagnosis is difficult due to overlapping features with other tumors. We describe the largest series to date of superficial SFT. For inclusion, SFT had to arise in dermis or subcutis. Twenty-six cases were identified. Patients ranged from 16 to 80 years (mean, 47 y) with a marked female predominance (19 F; 7 M). Tumors involved the head (11), thigh (7), back (3), shoulder (2), upper arm (1), ankle (1), and great toe (1). Mean size was 2.9 cm (range, 1.0 to 7.0 cm). The majority (n=19) had typical histologic features (cellular SFT) with irregular fascicles of spindled cells, staghorn-like blood vessels, and variable amounts of collagen. Necrosis was evident in 3 cases (all <25%). Mitotic activity ranged from 0 to 10 mitotic figures/10 high-power fields (mean, 2 mitotic figures/10 high-power fields). Seventeen of the 18 were positive for STAT6, whereas 21/22 expressed CD34. All were low risk (23/23) by proposed criteria (Demicco and colleagues), including 2 cases with malignant histology. Three could not be risk stratified due to lack of information on tumor size. Follow-up, available on 7 cases, showed no recurrence/metastasis (mean follow-up, 100 mo; range, 2 to 241 mo). Cutaneous SFT are more common in women and most often involve the head. They are usually low risk by proposed criteria and appear to behave in an indolent manner, though larger studies are needed to confirm this. Recognition that SFT may present as a superficial mass will avoid misclassification as other CD34-positive neoplasms that frequently arise in the skin and subcutaneous tissue.
Neutrophil Extracellular Traps in Children With Meningococcal Sepsis
Authors: Hoppenbrouwers Tamara , Boeddha Navin P. , Ekinci Ebru , Emonts Marieke , Hazelzet Jan A. , Driessen Gertjan J. , de Maat Moniek P.
Published: February 2018

Objectives:

Children with meningococcal sepsis are highly at risk for fulminant disease, multiple organ failure, and death. Recently, neutrophil extracellular traps levels have been indicated as a marker for severity in different kinds of sepsis. Our aim was to study the role of neutrophil extracellular traposis in meninogococcal sepsis in children.

Design:

We measured myeloperoxidase-DNA, a marker for neutrophil extracellular traps, in serum of meningococcal sepsis patients upon admission to PICU, at 24 hours, and at 1 month and studied the association with clinical outcome. Subsequently, we tested whether Neisseria meningitidis, isolated from children with meningococcal sepsis, were able to induce neutrophil extracellular traposis, using confocal microscopy live imaging.

Setting:

We used enzyme-linked immunosorbent assays to measure myeloperoxidase-DNA in patient serum. We also included inflammatory markers that were previously measured in this group.

Patients:

We included exclusively children with meningococcal sepsis.

Interventions:

From each patient, serum was collected for analysis.

Measurements and Main Results:

Myeloperoxidase-DNA levels at admission (n = 35; median, 0.21 AU/mL; interquartile range, 0.12–0.27) and at 24 hours (n = 39; median, 0.14 AU/mL; interquartile range, 0.09–0.25) were significantly higher than the myeloperoxidase-DNA levels after 1 month (controls: n = 36; median, 0.07 AU/mL; interquartile range, 0.05–0.09; p < 0.001). We did not observe a correlation between myeloperoxidase-DNA levels and mortality, cell-free DNA, or other inflammatory markers. In addition, N. meningitidis are fast and strong inducers of neutrophil extracellular traposis.

Conclusions:

Children admitted to PICU for meningococcal sepsis have higher neutrophil extracellular traps levels at admission and after 24 hours than controls. Neutrophil extracellular traps levels were not associated with outcome, cell-free DNA, or other inflammatory markers. These neutrophil extracellular traps may be induced by N. meningitidis, since these are strong neutrophil extracellular traposis inducers.
Comparison of Transplant Waitlist Outcomes for Pediatric Candidates Supported by Ventricular Assist Devices Versus Medical Therapy
Authors: Law Sabrina P. , Oron Assaf P. , Kemna Mariska S. , Albers Erin L. , McMullan D. Michael , Chen Jonathan M. , Law Yuk M.
Published: February 2018

Objectives:

Ventricular assist devices have gained popularity in the management of refractory heart failure in children listed for heart transplantation. Our primary aim was to compare the composite endpoint of all-cause pretransplant mortality and loss of transplant eligibility in children who were treated with a ventricular assist device versus a medically managed cohort.

Design:

This was a retrospective cohort analysis.

Settings:

Data were obtained from the Scientific Registry of Transplant Recipients.

Patients:

The at-risk population (n = 1,380) was less than 18 years old, either on a ventricular assist device (605 cases) or an equivalent-severity, intensively medically treated group (referred to as MED, 775 cases).

Interventions:

None.

Measurements and Main Results:

The impact of ventricular assist devices was estimated via Cox proportional hazards regression (hazard ratio), dichotomizing 1-year outcomes to “poor” (22%: 193 deaths, 114 too sick) versus all others (940 successful transplants, 41 too healthy, 90 censored), while adjusting for conventional risk factors. Among children 0–12 months old, ventricular assist device was associated with a higher risk of poor outcomes (hazard ratio, 2.1; 95% CI, 1.5–3.0; p < 0.001). By contrast, ventricular assist device was associated with improved outcomes for ages 12–18 (hazard ratio, 0.3; 95% CI, 0.1–0.7; p = 0.003). For candidates 1–5 and 6–11 years old, there were no differences in outcomes between the ventricular assist device and MED groups (hazard ratio, 0.8 and 1.0, p = 0.43 and 0.9). The interaction between ventricular assist devices and age group was strongly significant (p < 0.001).

Conclusions:

This is a comparative study of ventricular assist devices versus medical therapy in children. Age is a significant modulator of waitlist outcomes for children with end-stage heart failure supported by ventricular assist device, with the impact of ventricular assist devices being more beneficial in adolescents.
Interhospital Transport of Critically Ill Children to PICUs in the United Kingdom and Republic of Ireland: Analysis of an International Dataset*
Authors: Ramnarayan Padmanabhan , Dimitriades Konstantinos , Freeburn Lynsey , Kashyap Aravind , Dixon Michaela , Barry Peter W. , Claydon-Smith Kathryn , Wardhaugh Allan , Lamming Caroline R. , Draper Elizabeth S.
Published: February 2018

Objectives:

International data on characteristics and outcomes of children transported from general hospitals to PICUs are scarce. We aimed to 1) describe the development of a common transport dataset in the United Kingdom and Ireland and 2) analyze transport data from a recent 2-year period.

Design:

Retrospective analysis of prospectively collected data.

Setting:

Specialist pediatric critical care transport teams and PICUs in the United Kingdom and Ireland.

Patients:

Critically ill children less than 16 years old transported by pediatric critical care transport teams to PICUs in the United Kingdom and Ireland.

Interventions:

None.

Measurements and Main Results:

A common transport dataset was developed as part of the Paediatric Intensive Care Audit Network, and standardized data were collected from all PICUs and pediatric critical care transport teams from 2012. Anonymized data on transports (and linked PICU admissions) from a 2-year period (2014–2015) were analyzed to describe patient and transport characteristics, and in uni- and multivariate analyses, to study the association between key transport factors and PICU mortality. A total of 8,167 records were analyzed. Transported children were severely ill (median predicted mortality risk 4.4%) with around half being infants (4,226/8,167; 51.7%) and nearly half presenting with respiratory illnesses (3,619/8,167; 44.3%). The majority of transports were led by physicians (78.4%; consultants: 3,059/8,167, fellows: 3,344/8,167). The median time for a pediatric critical care transport team to arrive at the patient’s bedside from referral was 85 minutes (interquartile range, 58–135 min). Adverse events occurred in 369 transports (4.5%). There were considerable variations in how transports were organized and delivered across pediatric critical care transport teams. In multivariate analyses, consultant team leader and transport from an intensive care area were associated with PICU mortality (p = 0.006).

Conclusions:

Variations exist in United Kingdom and Ireland services for critically ill children needing interhospital transport. Future studies should assess the impact of these variations on long-term patient outcomes taking into account treatment provided prior to transport.
Duration to Establish an Emergency Vascular Access and How to Accelerate It: A Simulation-Based Study Performed in Real-Life Neonatal Resuscitation Rooms
Authors: Schwindt Eva M. , Hoffmann Florian , Deindl Philipp , Waldhoer Thomas J. , Schwindt Jens C.
Published: February 2018

Objectives:

To compare the duration to establish an umbilical venous catheter and an intraosseous access in real hospital delivery rooms and as a secondary aim to assess delaying factors during establishment and to provide recommendations to accelerate vascular access in neonatal resuscitation.

Design:

Retrospective analysis of audio-video recorded neonatal simulation training.

Settings:

Simulation training events in exact replications of actual delivery/resuscitation rooms of 16 hospitals with different levels of care (Austria and Germany). Equipment was prepared the same way as for real clinical events.

Subjects:

Medical teams of four to five persons with birth-related background (midwives, nurses, neonatologists, and anesthesiologists) in a realistic team composition.

Interventions:

Audio-video recorded mannequin-based simulated resuscitation of an asphyxiated newborn including the establishment of either umbilical venous catheter or intraosseous access.

Measurements and Main Results:

The duration of access establishment (time from decision to first flush/aspiration), preparation (decision to start of procedure), and the procedure itself (start to first flush/aspiration) was significantly longer for umbilical venous catheter than for intraosseous access (overall duration 199 vs 86 s). Delaying factors for umbilical venous catheter establishment were mainly due to the complex approach itself, the multitude of equipment required, and uncertainties about necessary hygiene standards. Challenges in intraosseous access establishment were handling of the unfamiliar material and absence of an intraosseous access kit in the resuscitation room. There was no significant difference between the required duration for access establishment between large centers and small hospitals, but a trend was observed that duration for umbilical venous catheter was longer in small hospitals than in centers. Duration for intraosseous access was similar in both hospital types.

Conclusions:

Vascular access establishment in neonatal resuscitation could be accelerated by infrastructural improvements and specific training of medical teams. In simulated in situ neonatal resuscitation, intraosseous access is faster to establish than umbilical venous catheter. Future studies are required to assess efficacy and safety of both approaches in real resuscitation settings.
Optimizing Pulmonary Embolism Computed Tomography in the Age of Individualized Medicine
Authors: Hendriks Babs M.F. , Eijsvoogel Nienke G. , Kok Madeleine , Martens Bibi , Wildberger Joachim E. , Das Marco
Published: February 2018

Purpose

The aim of the study was to simultaneously optimize contrast media (CM) injection and scan parameters for the individual patient during computed tomography pulmonary angiography (CTPA).

Methods

In this study (NCT02611115), 235 consecutive patients suspected of having pulmonary embolism were prospectively enrolled. Automated kV selection software on a third-generation multidetector computed tomography adapted tube voltage to the individual patient, based on scout scans. The contrast injection protocol was adapted to both patient body weight and kV-setting selection via a predefined formula, based on previous research. Injection data were collected from a contrast media and radiation dose monitoring software. Attenuation was measured in Hounsfield units (HU) in the pulmonary trunk (PT); attenuation values 200 HU or greater were considered diagnostic. Subjective image quality was assessed by using a 4-point Likert scale at the level of the PT, lobar, segmental, and subsegmental arteries. Results between groups were reported as mean ± SD.

Results

Two hundred twenty-two patients (94%) were scanned at a kV setting below 100 kV: n = 108 for 70 kV, n = 82 for 80 kV, and n = 32 for 90 kV. Mean CM bolus volume (in milliliters) and total iodine load (in grams of iodine) for 70 to 90 kV were as follows: 24 ± 3 mL and 7 ± 1 g I, 29 ± 4 mL and 9 ± 2 g I, and 38 ± 4 mL and 11 ± 1 g I, respectively. Mean flow rates (in milliliters per second) and iodine delivery rates (in grams of iodine per second) were 3.0 ± 0.4 mL/s and 0.9 ± 0.1 g I/s (70 kV), 3.6 ± 0.4 mL/s and 1.0 ± 0.1 g I/s (80 kV), and 4.7 ± 0.5 mL/s and 1.3 ± 0.1 g I/s (90 kV). Mean radiation doses were 1.3 ± 0.3 mSv at 70 kV, 1.7 ± 0.4 mSv at 80 kV, and 2.2 ± 0.6 mSv at 90 kV. Mean vascular attenuation in the PT for each kV group was as follows: 397 ± 101 HU for 70 kV, 398 ± 96 HU for 80 kV, and 378 ± 100 HU for 90 kV, P = 0.59. Forty-six patients (21%) showed pulmonary embolism on the CTPA. One scan (90 kV) showed nondiagnostic segmental pulmonary arteries, and 5% of subsegmental arteries were of nondiagnostic image quality. All other segments were considered diagnostic-excellent subjective image quality.

Conclusions

Simultaneously optimizing both CM injections and kV settings to the individual patient in CTPA results in diagnostic attenuation with on average 24 to 38 mL of CM volume and a low radiation dose for most patients. This individualized protocol may help overcome attenuation-variation problems between patients and kV settings in CTPA.
Clinical Impact of Radioguided Localization in the Treatment of Solitary Pulmonary Nodule
Authors: Manca Gianpiero , Davini Federico , Tardelli Elisa , De Liperi Annalisa , Falaschi Fabio , Melfi Franca , Colletti Patrick M. , Rubello Domenico , Volterrani Duccio , Boni Giuseppe
Published: February 2018

Purpose

Incidental solitary pulmonary nodules (SPNs) have become an increasingly common CT finding worldwide. Although there are currently many imaging strategies for evaluating SPNs, the differential diagnosis and management of SPNs remains complex because of overlap between benign and malignant processes. Moreover, transbronchial or percutaneous CT-guided biopsies do not always allow definitive diagnoses. In such cases, video-assisted thoracic surgery (VATS) has become the preferred surgical procedure for diagnosis and, in selected cases, for treatment of indeterminate SPNs. The difficulties in localizing smaller, deeper, and ground-glass nodules have been approached with different techniques. The aim of this study was to report 20 years of experience with radioguided thoracoscopic resection of SPNs at the Regional Centre of Nuclear Medicine of Pisa.

Methods

Three hundred ninety-five patients with SPNs less than 2 cm and deeper than 5 mm below the visceral pleura underwent CT-guided injection of a suspension composed of 0.1 to 0.2 mL 99mTc-labeled human albumin macroaggregates (99mTc-MAA) and of 0.2 to 0.3 mL of nonionic contrast medium into or adjacent to the SPN. During VATS, the pulmonary area with the highest target/background ratio identified by an 11-mm-diameter collimated thoracoscopic gamma probe was resected.

Results

From 1997 to 2016, approximately 395 patients with SPN underwent VATS wedge resection using the radioguided technique. Mean SPN size was 13 mm (range, 5–20 mm) with mean distance of 15 mm (range, 6–39 mm) from the visceral pleura. Mean VATS procedural time was 40 minutes (range, 20–90 minutes), with an average time of 3 minutes (range, 1–5 minutes) to localize the nodule. Neither mortality nor major perioperative complication was reported. The success rate of VATS with radioguidance in our series was 99%. Histological examination revealed 206 benign lesions (52%), 59 primary lung tumors (15%), and 130 metastatic nodules (33%).

Conclusions

This study demonstrates that radioguided SPN localization by VATS is a feasible, safe, and rapid procedure with highly successful rate of SPN resection.
18F-FDG PET/CT Findings in a Patient With IgG4-Related Sclerosing Mesenteritis
Authors: Fu Zhanli , Chen Guoqian , Liu Meng , Li Ziao , Li Qian
Published: February 2018

A large mass in the abdomen was revealed by ultrasonography on a 68-year-old woman presenting with abdominal pain and weight loss. To exclude the malignancy, an 18F-FDG PET/CT was performed, which showed a solitary soft tissue mass with heterogeneous 18F-FDG avidity at the root of small bowel mesentery. Because of the elevation of inflammatory markers and serum IgG4 level, IgG4-related sclerosing mesenteritis was suspected, which was proved by the subsequent biopsy. The mass gradually shrunk and ultimately disappeared in 6 months after a low-dose steroid therapy.
Does Periosteal Graft Combined With Platelet-Rich Plasma Enhance the Healing of Bone Defect?
Authors: Türkseven Arzu , Özçelik Derya , Çaliş Mert , Celik Hakan Hamdi , Yilmaz Fahri , Önbaş Ömer , Vatansever Alper , Toplu Gaye
Published: February 2018

Introduction:

This study investigated the effect of periosteal graft + platelet-rich plasma (PRP) combination on facial bone defect healing.

Methods:

Five-millimeter critical sized defects in zygomatic arches of 12 adult New Zealand rabbits were created. Rabbits were randomly divided into 3 groups: First group (control group): bone defects of left zygomatic arches of 6 rabbits were wrapped with a silicone tube. Second group (periosteal graft group): bone defects of left zygomatic arches of 6 rabbits were wrapped with periosteal graft. Third group (experimental group): bone defects of right zygomatic arches of 12 rabbits were wrapped with periosteal graft–PRP combination. New bone formation was evaluated at 8th and 16th weeks. One rabbit was sacrificed at 8th week. Remaining 11 rabbits were imaged with 3-dimensional computed tomography (CT) at 16th week; then, zygomatic arches were removed for micro-CT and histologic examinations.

Results:

Three-dimensional CT analysis at 16th week revealed no significant difference between groups regarding new bone formation (P = 0.232). Micro-CT analysis of new regenerated bone at 16th week displayed significant differences between groups 1 and 3 regarding mean bone volume (BV, mm3) (P = 0.028) and mean bone mineral density (BMD, mm2) (P = 0.001). There was no difference between groups 2 and 3 or between groups 1 and 2, regarding BV or BMD. Histological Bone Regeneration Scorings at 16th week displayed significant difference between groups (P = 0.015). Negative correlation between 3-dimensional CT and histologic results (r = 0.120); positive correlations between BV/BMD values in micro-CT and histologic results (r = 0.524 and r = 0.456) were found.

Conclusions:

By enhancing bone formation capacity of periosteal grafts, periosteal graft–PRP combination provided bone formation having more volume and density comparing with silicone tube application.
Surgical Outcome After Less “Rigid” Fixation in Open Cranial Vault Remodeling for Craniosynostosis
Authors: Koh Khai Luen , Zain Ali
Published: February 2018

Open cranial vault remodeling techniques require rigid fixation with hardware such as plates and screws; however, complications can occur. The purpose of this study was to assess the surgical outcome after open reconstruction for craniosynostosis with less rigid fixation using nonabsorbable suture.

Methods:

Retrospective review of patients who underwent open craniofacial reconstruction for craniosynostosis at the Hospital Kuala Lumpur between January 2011 and December 2016 were performed. Demographic data, surgical complications, and postoperative aesthetic outcomes and reoperations were evaluated using Whitaker classification. Statistical analyses were performed using SPSS.

Results:

Thirty-four (n = 34) cases were included in this review consisting of 16 males and 18 females (ratio 1:1.25). Sixteen patients were syndromic with multiple suture synostoses: Apert syndrome (n = 8), Crouzon syndrome (n = 6), and Muenke's syndrome (n = 2). Eighteen patients were nonsyndromic: isolated single-suture craniosynostosis (n = 12) and multiple suture involvement (n = 6). Mean age of presentation was 17.4 months (4–16 months) with mean age of surgery of 23.8 months (6–68 months). Mean length of surgery was 6.1 hours (range 3–10 hours) and mean length of hospital stay was 10 days (mean 7–20 days). Mean duration of follow-up was 2.2 years (6 month–4 years). There were a total of 9 complications postoperatively: massive blood loss (n = 4), seroma (n = 2), exposure keratitis (n = 1), hand extravasation (n = 1), and occipital sore (n = 1). Analysis showed multiple suture craniosynostoses were associated with longer operative times (4.3 hours vs 6.5 hours, P = 0.0082 < 0.05) and higher blood transfusion (170 mL vs 275 mL, P = 0.0274 < 0.05). Older age was also associated with higher blood transfusion (135.5 mL; <12 months vs 250.2 mL; 12–24 months vs 302.1 mL; >24 months of age, P = 0.00059). Patients were categorized as 88.2% (n = 30) Whitaker I and II and 11.8% (n = 4) Whitaker III and IV. Reoperation rates were 2.9% (n = 1). Whitaker III and IV class were higher among patients with syndromic synostosis, unicoronal and multiple suture synostoses.

Conclusions:

Our technique of open cranial reconstruction with nonabsorbable suture nylon 2/0 as sole method of fixation has resulted in good aesthetic outcome with low reoperations and complications rate. Longer follow-up is needed to ascertain our long-term results.
Seasonal Variation of Epistaxis in Germany
Authors: Seidel David Ulrich , Sesterhenn Andreas M. , Kostev Karel
Published: February 2018

Aim:

The goal of the present study was to analyze the seasonal variation of epistaxis in ear, nose, and throat (ENT) practices in Germany in 2016.

Methods:

The present study sample included patients who received a first epistaxis diagnosis from physicians in 114 ENT practices in Germany between January 2016 and December 2016. The number of epistaxis patients per practice was calculated for each month. A logistic regression model, adjusted for age and sex, was used to calculate the association between epistaxis diagnosis and the month.

Results:

The authors found a total of 15,523 patients with epistaxis in 114 ENT practices. Of these patients, 55.9% were men and the mean age was 47.8 ± 27.6 years. The highest number of epistaxis patients was found in February (14.89 patients per practice) and the lowest in August (7.22 patients per practice). The age- and sex-adjusted risk of epistaxis was significantly higher in the months of February (OR = 1.32), March (OR = 1.37), April (OR = 1.34), May (OR = 1.35), and December (OR = 1.33) compared with August.

Conclusions:

The presentation of patients with epistaxis at German ENT practices shows a marked seasonal variation with a low in the summer, an increase in fall and winter, and a peak in February, March, and April.
A Review of Phytoestrogens and Their Association With Pelvic Floor Conditions
Authors: Cardenas-Trowers Olivia , Meyer Isuzu , Markland Alayne D. , Richter Holly E. , Addis Ilana
Published: February 2018

Introduction

Urinary incontinence, pelvic organ prolapse, and fecal incontinence are pelvic floor disorders (PFDs) disproportionately experienced by postmenopausal women. Limited data exist suggesting that phytoestrogens may have an impact on the pathophysiology and symptom of PFDs.

Purpose of Review

The aim of the study was to review the current literature addressing the role of phytoestrogens on PFDs, including the pathophysiology, symptom, treatment, and possible prevention.

Findings

Qualifying literature spans from 2003 to 2017 and included 14 studies ranging from in vitro, animal, and observational studies to randomized clinical trials.

Although the literature is limited, most studies on phytoestrogens and PFDs support associations with pathophysiologic mechanisms, symptoms, and treatment for urinary incontinence and pelvic organ prolapse, but not fecal incontinence. Less is known regarding the prevention of PFDs with phytoestrogen intake over time. Overall, the potential influence of phytoestrogens on PFDs is not well understood, and more research is needed.
Calcitonin-gene-related peptide pathway mAbs and migraine prevention
Authors: Paemeleire Koen , MaassenVanDenBrink Antoinette
Published: February 2018

Purpose of review

Monoclonal antibodies (mAbs) targeting the calcitonin-gene-related peptide (CGRP) pathway have been developed for episodic and chronic migraine prevention, either through binding the CGRP ligand (eptinezumab, fremanezumab, galcanezumab) or the CGRP receptor (erenumab). We provide an update on published Phase 2 and Phase 3 trials, safety/tolerability data, pharmacokinetics and mechanism of action of these biologicals.

Recent findings

The efficacy data from Phase 2 trials are corroborated by those from published Phase 3 trials, with a multitude of publications expected in 2018. Review of safety data concluded there was no difference in total adverse events or main adverse events (including upper respiratory tract infection, nasopharyngitis, nausea, injection-site pain and back pain) between the mAbs and placebo injections except apparently for dizziness. The site of action of these mAbs is not fully elucidated but current insight is that their effect resides in the periphery; a contribution of central effect(s) can however not be excluded at present.

Although efficacy of all four drugs is modest over placebo in episodic and chronic migraine prevention and overall comparable with available oral preventive treatments, current tolerability and (short-term) safety data of this new treatment approach certainly promise a major step forward for migraine patients.
A Well-Tolerated and Effective Antiepileptic Drug for Patients With Myasthenia Gravis at Last?
Authors: Sánchez-Villalobos José Manuel , Villegas-Martínez Irene , Pérez-Vicente José Antonio
Published: February 2018

Antiepileptic drugs have been known to worsen myasthenia gravis (MG) symptoms, and therefore, in patients who suffer both conditions (myasthenia and epilepsy), treatment selection is difficult. We report 2 cases of patients with MG who were safely treated with lacosamide. Evidence about antiepileptic drug treatment and adverse effects in MG is reviewed.
Effect of Concomitant Medications on the Safety and Efficacy of Extended-Release Carbidopa-Levodopa (IPX066) in Patients With Advanced Parkinson Disease: A Post Hoc Analysis
Authors: LeWitt Peter A. , Verhagen Metman Leo , Rubens Robert , Khanna Sarita , Kell Sherron , Gupta Suneel
Published: February 2018

Objectives

Extended-release (ER) carbidopa-levodopa (CD-LD) (IPX066/RYTARY/NUMIENT) produces improvements in “off” time, “on” time without troublesome dyskinesia, and Unified Parkinson Disease Rating Scale scores compared with immediate-release (IR) CD-LD or IR CD-LD plus entacapone (CLE). Post hoc analyses of 2 ER CD-LD phase 3 trials evaluated whether the efficacy and safety of ER CD-LD relative to the respective active comparators were altered by concomitant medications (dopaminergic agonists, monoamine oxidase B [MAO-B] inhibitors, or amantadine).

Methods

ADVANCE-PD (n = 393) assessed safety and efficacy of ER CD-LD versus IR CD-LD. ASCEND-PD (n = 91) evaluated ER CD-LD versus CLE. In both studies, IR- and CLE-experienced patients underwent a 6-week, open-label dose-conversion period to ER CD-LD prior to randomization. For analysis, the randomized population was divided into 3 subgroups: dopaminergic agonists, rasagiline or selegiline, and amantadine. For each subgroup, changes from baseline in PD diary measures (“off” time and “on” time with and without troublesome dyskinesia), Unified Parkinson Disease Rating Scale Parts II + III scores, and adverse events were analyzed, comparing ER CD-LD with the active comparator.

Results and Conclusions

Concomitant dopaminergic agonist or MAO-B inhibitor use did not diminish the efficacy (improvement in “off” time and “on” time without troublesome dyskinesia) of ER CD-LD compared with IR CD-LD or CLE, whereas the improvement with concomitant amantadine failed to reach significance. Safety and tolerability were similar among the subgroups, and ER CD-LD did not increase troublesome dyskinesia. For patients on oral LD regimens and taking a dopaminergic agonist, and/or a MAO-B inhibitor, changing from an IR to an ER CD-LD formulation provides approximately an additional hour of “good” on time.
Generative inference for cultural evolution
Authors: Kandler Anne , Powell Adam
Published: February 2018

One of the major challenges in cultural evolution is to understand why and how various forms of social learning are used in human populations, both now and in the past. To date, much of the theoretical work on social learning has been done in isolation of data, and consequently many insights focus on revealing the learning processes or the distributions of cultural variants that are expected to have evolved in human populations. In population genetics, recent methodological advances have allowed a greater understanding of the explicit demographic and/or selection mechanisms that underlie observed allele frequency distributions across the globe, and their change through time. In particular, generative frameworks—often using coalescent-based simulation coupled with approximate Bayesian computation (ABC)—have provided robust inferences on the human past, with no reliance ona prioriassumptions of equilibrium. Here, we demonstrate the applicability and utility of generative inference approaches to the field of cultural evolution. The framework advocated here uses observed population-level frequency data directly to establish the likely presence or absence of particular hypothesized learning strategies. In this context, we discuss the problem of equifinality and argue that, in the light of sparse cultural data and the multiplicity of possible social learning processes, the exclusion of those processes inconsistent with the observed data might be the most instructive outcome. Finally, we summarize the findings of generative inference approaches applied to a number of case studies.

This article is part of the theme issue ‘Bridging cultural gaps: interdisciplinary studies in human cultural evolution’.
Cultural complexity and evolution in fluctuating environments
Authors: Fogarty Laurel
Published: February 2018

The effect of environmental change on the rate of innovation and level of cultural complexity in a population is a theoretically understudied piece of an important puzzle at the heart of cultural evolution. Many mathematical models of cultural complexity have focused on the role of demographic factors such as population size or density. However, statistical studies often point to environmental variability as an important factor determining complexity in many cases. The aim of this study is to explore the interaction between environmental fluctuations and the rate of cultural innovation within a population and to examine the relationship between rates of innovation and the probability of maintaining a complex cultural repertoire in a changing environment. Two models are presented that draw on previous models used to examine rates of genetic mutation. The models show that, as in a genetic system, the stable rate of cultural innovation in a population decreases with environmental stability and increases in unstable environments. This effect is similar but quantitatively different for different modes of cultural transmission (success bias, conformity bias and random oblique learning). The model shows that innovation can increase diversity but that this relationship depends critically on learning mode and learning parameters.

This article is part of the theme issue ‘Bridging cultural gaps: interdisciplinary studies in human cultural evolution’.