bluuebunny/crossref_metadata_2025 huggingface dataset:
Haglund’s syndrome: classification system and surgical protocol
Authors: Diab Hossam S.
Published: October 2016

Background:

Haglund’s deformity is not an uncommon cause of retrocalcaneal pain. Currently, there is neither a classification system nor a standard surgical protocol for this condition. The purpose of this study was to evaluate the outcome after Achilles tendon debridement, partial detachment, and anchor reattachment of the tendon, osteotomy of the Haglund deformity, and excision of the retrocalcaneal bursa. An MRI-based classification system is proposed that relies on the extent of Achilles tendon pathology in the presence of the Haglund deformity.

Methods:

Fifty heels in 46 patients were surgically treated with the proposed surgical protocol. Patients were evaluated using the Tegner Activity Level and the Foot and Ankle Outcome (FAOS) scores.

Results:

The mean Tegner Activity Level score improved from a preoperative mean of 3.44 to a mean of 6.56 at 6 mo, then to a mean of 6.84 at 12 mo follow-up. The mean FAOS score improved from 47.60 preoperatively to a mean of 66.50 at 6 mo and to a mean of 79.49 at 12 mo follow-up.

Conclusions:

Surgical treatment of Haglund’s deformity with tendon debridement, partial detachment, calcaneal osteotomy, and bursal debridement provides good results and functional outcomes that continues to improve over 12 mo follow-up.
Patient satisfaction after total hip arthroplasty in an Egyptian population as an example of a developing country
Authors: Issa Khaled H. , Shehata Ehab M. , El-Tantawy Ahmad , Samy Ahmed M.
Published: October 2016

Background:

Cementless total hip arthroplasty is a solution for advanced hip arthritis. Although in many patients the operation appears successful clinically and radiographically, often many are not completely satisfied. This study was done to evaluate the intermediate results of cementless total hip replacement and its relation to satisfaction in Egyptian patients.

Methods:

This was a prospective study of 129 patients (153 hips) who had cementless total hip replacement. Clinical evaluation was done using the Harris Hip Score, a modified questionnaire, and radiographic evaluation. Statistical analysis was conducted.

Results:

The mean Harris Hip Score improved from 44.10 preoperatively to 90.40 at the end of follow-up and this was statistically significant (P<0.001). Range of motion and lower limb discrepancy improved postoperatively and this also was statistically significant (P<0.001). In regard to the modified questionnaire, 51 of 129 (39.5%) respondents noted that their expectations regarding the outcome of total hip arthroplasty had not been fulfilled 2 yr postoperatively, and this dissatisfaction continued until final follow-up despite 43 patients scoring over 90 on the Harris Hip Score. The correlation between the Harris Hips Score and the modified questionnaire was not significant.

Conclusions:

Although cementless total hip arthroplasty is a successful salvage operation for many hip problems, it still did not completely fulfill the daily requirements and habits of patients in our developing country.
Does the Level of Cervical Disc Herniation Surgery Affect Performance-based Outcomes in National Football League Athletes?
Authors: Mai Harry T. , Burgmeier Robert J. , Mitchell Sean M. , Hecht Andrew C. , Maroon Joseph C. , Nuber Gordon W. , Hsu Wellington K.
Published: October 2016

Study Design.

Retrospective cohort study.

Objective.

The aim of this study was to determine whether the level of a cervical disc herniation (CDH) procedure will uniquely impact performance-based outcomes in elite athletes of the National Football League (NFL).

Summary of Background Data.

Comparative assessments of postsurgical outcomes in NFL athletes with CDH at different levels are unknown. Further, the surgical decision-making for these types of injuries in professional football athletes remains controversial.

Methods.

NFL players with a CDH injury at a definitive cervical level were identified through a review of publicly available archives. Injuries were divided into upper- (C2-C4) and lower-level (C4-T1) CDH. The impact on player outcomes was determined by comparing return to play statistics and calculating a “Performance Score” for each player on the basis of pertinent statistical data, both before and after surgery.

Results.

A total of 40 NFL athletes met inclusion criteria. In the upper-level group, 10 of 15 (66.6%) players successfully returned to play an average of 44.6 games over 2.6 years. The lower-level cohort had 18 of 25 (72%) players return to play with an average of 44.1 games over 3.1 years. There was no significant difference in the rate of return to play (P = 0.71). Postsurgical performance scores of the upper and lower-level groups were 1.47 vs. 0.69 respectively, with no significant difference between these groups (P = 0.06). Adjacent segment disease requiring reoperation occurred in 10% of anterior cervical discectomy and fusion patients. In 50% of foraminotomy patients, a subsequent fusion was required.

Conclusion.

A uniquely high percentage of upper-level disc herniations develop in NFL athletes, and although CDH injuries present career threatening implications, an upper-level CDH does not preclude a player from successfully returning to play at a competitive level. In fact, these athletes showed comparable postsurgical performance to those athletes who underwent CDH procedures at lower cervical levels.

Level of Evidence: 4
Implementation of a Sustainable Ventilator-Associated Pneumonia Prevention Protocol in a Pediatric Intensive Care Unit in Managua, Nicaragua
Authors: Chinnadurai Kelsey , Fenlason Lindy , Bridges Brian , Espahbodi Mana , Chinnadurai Sivakumar , Blood-Siegfried Jane
Published: October 2016

Background:

Ventilator-associated pneumonia (VAP) is a common nosocomial infection in pediatric intensive care units (ICUs). Ventilator-associated pneumonia protocols decrease the incidence of VAP; however, many components of these protocols are not feasible in all settings. This study was done in a large pediatric hospital in Nicaragua.

Objective:

The aim of this study is to implement a sustainable evidence-based VAP protocol, in a different culture, for the purpose of decreasing VAP rates.

Methods:

This quality improvement study used a bidirectional cohort design with the retrospective group as the control and the prospective group as the experimental population. A daily checklist monitored compliance to the implemented protocol in the prospective group. A 2-sided Fisher exact test compared the differences in VAP rates between the 2 populations.

Results:

During the 90-day implementation period, 123 ventilated patients in 3 separate ICU wings were evaluated, with 99 included in the final analysis. These data for 2014 were compared with the VAP rates recorded for the same time period in 2013. The highest adherence to the protocol was demonstrated by ICU wing 1, with a 90% decrease in VAP rates. No statistical difference in VAP rates was demonstrated by ICU 2, and ICU 3 demonstrated an increase in both patient acuity and VAP rates.

Discussion:

Implementation of a sustainable VAP protocol in a pediatric ICU in Nicaragua can reduce the incidence of VAP. Multiple barriers and challenges associated with implementation in a resource-constrained environment are discussed.
Congruence of the Medical Record and Subject Interview on Time of Symptom Onset in Patients Diagnosed With Acute Coronary Syndrome
Authors: Davis Leslie L. , McCoy Thomas P. , Riegel Barbara , McKinley Sharon , Doering Lynn V. , Dracup Kathleen , Moser Debra K.
Published: October 2016

Background:

Past research has shown discrepancies between the time of symptom onset for patients with acute coronary syndrome (ACS) as documented in the medical record (MR) and patients’ recall of the time assessed through subject interviews done later by researchers.

Purpose:

The aim of this study is to determine if there were differences between the time of symptom onset documented in the MR and subject interview taking into consideration sex, age group, and recall period for patients admitted to the emergency department for symptoms suggestive of ACS.

Methods:

A secondary analysis was conducted on data from the PROMOTION (Patient Response to Myocardial Infarction Following a Teaching Intervention Offered by Nurses) trial, a multicenter randomized clinical trial to reduce patient prehospital delay to treatment in ACS.

Results:

Of the 3522 subjects with CAD enrolled into the trial, 3087 subjects completed 2-year follow-up. Of these, 331 subjects sought treatment in the emergency department for ACS symptoms and 276 patients (83%) had complete information on the time of symptom onset from both sources. Of the 276 patients, 25 (9%) had differing times more than 48 hours and were thus excluded. The median difference between the 2 sources was 45.0 minutes. When both times were examined, there were no significant differences in time by sex (P = .720) or by age group (P = .188). The median number of days between the interview and the date of symptom onset was 29.5 days. There was a significant correlation between differences in the time of symptom onset and the length of recall period (rs = 0.148, P = .023). In multivariable modeling, a longer recall period was associated with greater median differences in the symptom onset time (b = 13.2, P = .023).

Conclusion:

These results suggest that the time of symptom onset obtained at the time of the index event and documented in the MR is not interchangeable with data obtained later by research staff, especially if the interview is not conducted near the time of the index event.
Interprofessional Perspectives on ABCDE Bundle Implementation
Authors: Boehm Leanne M. , Vasilevskis Eduard E. , Mion Lorraine C.
Published: October 2016

Background:

The ABCDE bundle is a multifaceted, interprofessional intervention that is associated with reduced ventilator and delirium days as well as increased likelihood of mobility in intensive care.

Objectives:

The aim of this study is to describe organizational domains that contribute to variation in ABCDE bundle implementation as reported by intensive care unit providers and to examine the capability of a conceptual framework for identifying variation in ABCDE bundle implementation.

Methods:

We conducted 2 separate focus groups that included nurses, respiratory therapists, occupational and physical therapists (N = 16) from the surgical and medical intensive care units at 1 academic medical center. All participants had experience performing ABCDE bundle activities.

Results:

Variation in how the ABCDE bundle was interpreted and executed within and across disciplines was noted. Organizational facets, the physical environment, labor quantity and quality, task burden, provider attitudes, and patient characteristics were noted to influence ABCDE bundle execution. The difficulty coordinating and implementing early mobility was emphasized.

Discussion:

The number of disciplines required to perform an activity and individual component complexity was reported to influence ABCDE bundle implementation. Nurses repeatedly described challenges with coordinating care across disciplines. Small tests of change, adequate staffing, interprofessional training and protocol development efforts, and role modeling may be effective methods for successful ABCDE bundle implementation.
The ABCDE Bundle
Authors: Pinto Floriana , Biancofiore Gianni
Published: October 2016

Background:

The ABCDE (
A
wakening and
B
reathing coordination of daily sedation and ventilator removal trials;
C
hoice of sedative or analgesic exposure;
D
elirium monitoring and management; and
E
arly mobility and exercise) bundle is a multidisciplinary set of evidence-based practices for improving patient outcomes in the intensive care unit. Nurses are critical to all the bundle’s requirements. Therefore, understanding their knowledge, attitudes, and perception of the different bundle’s components might help for an easier implementation into everyday clinical practice.

Objective:

The aim of this study was to assess nurses’ knowledge, utility, and perception of the ABCDE bundle.

Methods:

An anonymous questionnaire with closed-end questions was administered to the nurses working at the intensive care unit (ICU) of a nationwide teaching hospital.

Results:

Only the 41.6% of the respondents declared to be aware of the bundle; however, the majority of them (67%) agreed with its potential capability of improving patients’ outcomes after reviewing a document as they completed a survey. In addition, 71% of responders judged the Sedation Awakening Trial and the Spontaneous Breathing Trial easy to understand, and 80% found the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU useful to asses and monitor delirium. However, 48% reported that they did not currently use them. Fifty-one percent of respondents reported that they were not aware of or had used the Exercise/Mobility Safety Screen. Fifty-three respondents reported that multidisciplinary rounds were not performed at their ICU but judged them as a positive activity. Only 34% of the respondents considered the ABCDE bundle applicable at their own ICU.

Discussion:

A substantial need for educational improvement and cultural change is needed. The results of this study may help other facilities to identify contextual and professionals-related factors possibly hindering the bundle’s implementation.
A Systems Approach to Improving Care for All Bereaved Families
Authors: Jenko Mimi , Short Nancy M.
Published: October 2016

Bereavement services for families are an established part of hospice and palliative care. However, patients also die in the acute care and long-term care environments. Often, hospice is not involved, creating a potential gap in care. This article recounts a journey to improve care for all families of deceased patients, despite the presence or absence of hospice. A palliative care clinical nurse specialist led a quality improvement team, which used a systems thinking approach to develop and implement a downloadable bereavement booklet for families. Expected and unexpected outcomes are discussed for this replicable project.
HIGH MYOPIA AND DIABETIC RETINOPATHY
Authors: Bazzazi Nooshin , Akbarzadeh Siamak , Yavarikia Minoo , Poorolajal Jalal , Fouladi Daniel F.
Published: October 2016

Purpose:

To examine an association between high myopia and diabetic retinopathy (DR) in diabetic patients with high myopic anisometropia.

Methods:

A total of 116 white diabetic patients (232 eyes) with high myopia (spherical equivalent > −5.00 diopters, D) anisometropia (difference ≥ −6 D) were enrolled in this cross-sectional, contralateral eye study. The frequency of DR was compared between the high myopic and the contralateral eyes.

Results:

Compared with the fellow eyes, DR was significantly less frequent in high myopic side (27.6% vs. 100%, P < 0.001; relative risk, 0.28 with 95% confidence interval of 0.21–0.37). Similar significant trends were found for the incidence of nonproliferative (27.6% vs. 69%, P < 0.001) and proliferative DR (0% vs. 31%, P < 0.001). Diabetic retinopathy was also less severe in the same group.

Conclusion:

Using a contralateral eye study design prevented the influence of potential confounding factors inherent in similar previous case–control studies. On this basis, a protective role for high myopia against DR was established.
DOME-SHAPED MACULOPATHY: ENHANCED VISUALIZATION WITH RADIAL OPTICAL COHERENCE TOMOGRAPHY SCANS
Authors: Christenbury Joseph G. , Phasukkijwatana Nopasak , Tan Anna , Freund K. Bailey , Sarraf David
Published: October 2016

Purpose:

To describe two cases of dome-shaped macula (DSM) and serous macular detachment, the diagnosis of which was enhanced with a radial optical coherence tomography (OCT) scanning protocol.

Methods:

Retrospective case series of DSM associated with serous macular detachment. Multimodal retinal imaging was performed including spectral domain OCT with a radial scan protocol and en face OCT angiography. Anatomical outcomes before and after therapy are presented.

Results:

Two cases of DSM associated with serous macular detachment are described. The dome-shaped macular bulge was more clearly elicited as the cause of serous macular detachment with the employment of a radial OCT scanning protocol. Subretinal fluid resolved in both cases using either intravitreal aflibercept injection or half-fluence photodynamic therapy. En face OCT angiography of the choroid demonstrated reduction in the caliber of choroidal vessels after treatment.

Conclusion:

A radial OCT scanning protocol should be considered in eyes with suspicion of DSM, especially in myopic eyes with subretinal fluid. Intravitreal aflibercept therapy or photodynamic therapy may be considered as a treatment for serous macular detachment because of DSM.
VITRECTOMY FOR PHACOANAPHYLACTIC GLAUCOMA SECONDARY TO POSTERIOR CAPSULAR RUPTURE IN AN ADULT WITH PERSISTENT HYPERPLASTIC PRIMARY VITREOUS
Authors: Brennan Nicholas , Petrou Petros , Reekie Ian , Pasu Saruban , Kinsella Matthew , Da Cruz Lyndon
Published: October 2016

Purpose:

Persistent hyperplastic primary vitreous (PHPV) is a developmental anomaly in which the normal regression of the primary vitreous and hyaloid vasculature does not occur. In the literature, there are a few cases of PHPV in adulthood. We report the novel presentation of phacoanaphylactic glaucoma secondary to posterior capsular rupture in an adult with PHPV. We discuss the best management of this condition with a review of the literature on this topic.

Methods:

Case report and literature review.

Results:

Medical management was unsuccessful in this case and vitrectomy and fragmatome lensectomy improved vision from PL to counting fingers.

Conclusion:

This case is unusual in the age of the patient in question as PHPV usually presents in childhood, as such there are few accounts in the literature to guide optimum management of adult PHPV. We suggest that surgical management of late-presenting PHPV should be considered to improve functional outcome.
RETINAL DEEP CAPILLARY PLEXUS ISCHEMIA IN A CASE WITH ANTIPHOSPHOLIPID SYNDROME
Authors: Arf Serra , Sayman Muslubas Isil , Hocaoglu Mumin , Karacorlu Murat
Published: October 2016

Purpose:

To report visualization of a case of retinal deep capillary plexus ischemia with antiphospholipid syndrome.

Methods:

A 53-year-old woman was referred with a 1-week history of sudden onset of decreased vision in the right eye. Her symptoms were evaluated by clinical examination, infrared reflectance, fundus autofluorescence, fluorescein angiography, spectral-domain optical coherence tomography, microperimetry, and multifocal electroretinography.

Results:

The patient's visual acuity on presentation was 0.4 (Snellen) in the right eye and 0.7 in the left eye. Spectral-domain optical coherence tomography showed increased reflectivity of inner nuclear and inner plexiform layers of the right eye. Laboratory evaluation revealed abnormal titers of lupus anticoagulant antibodies. After 6 months, her visual acuity was finger counting at 1 m in the right eye and 0.4 in the left eye. Spectral-domain optical coherence tomographic image demonstrated a diffuse thinning of those retinal layers in the right eye. These findings are consistent with the clinical characteristics of retinal deep capillary ischemia in association with antiphospholipid syndrome.

Conclusion:

Deep capillary ischemia has some characteristic findings, and on spectral-domain optical coherence tomography, outcomes in conjunction with multimodal imaging are helpful for the diagnosis of the acute and the chronic stages of retinal deep capillary plexus ischemia.
Comparison of Different Measurement Tools and Dimensional Parameters of Pterygium to Investigate its Impact on Refractive Indices and Ocular Aberrations
Authors: Gumus Koray , Guven Aysegul , Altinkaynak Miray , Keskin Merve
Published: October 2016

Objectives:

The aim of this study was to compare different measurement tools and parameters, including a new computer-assisted image processing technique for the quantitative analysis of the percentage of pterygium on the corneal surface, horizontal/vertical lengths obtained using slitlamp beam and surgical compass.

Methods:

A total of 21 pterygia of 17 patients were included in the study. The pterygia were measured by three different methods: a slitlamp beam, a surgical compass, and a new computer-assisted image processing method. Refractive indices and higher-order aberrations were analyzed in all cases.

Results:

The new computer-assisted image processing technique revealed excellent intraclass correlation coefficients for intraobserver and interobserver reliability (0.999 and 0.995, respectively). However, horizontal and vertical lengths revealed more deviation between the measurements obtained with slitlamp beam and surgical compass. Although uncorrected visual acuity did not show any significant correlation between horizontal and vertical lengths of pterygia measured by either slitlamp beam or surgical compass, it was correlated with the digital pterygium ratio (rho, 0.462; P=0.035). All ocular aberration (total, higher-order, coma, trefoil, quatrefoil, spherical, and higher-order astigmatism) Root-mean-square values more strongly correlated with higher percentage values of pterygium that covers the cornea, measured by the new computer-assisted image processing technique.

Conclusion:

The percentage of pterygium covering the corneal surface seems to be more associated with the pterygium-related visual disturbances than with horizontal and vertical lengths measured by conventional techniques. Moreover, the new computer-assisted image processing technique can accurately and reliably measure the percentage extension of pterygium on cornea.
Investigating generalizability of results from a randomized controlled trial of the management of chronic widespread pain: the MUSICIAN study
Authors: Jones Gareth T. , Jones Elizabeth A. , Beasley Marcus J. , Macfarlane Gary J. ,   On behalf of the MUSICIAN study team
Published: October 2016

The generalisability of randomised controlled trials will be compromised if markers of treatment outcome also affect trial recruitment. In a large trial of chronic widespread pain, we aimed to determine the extent to which randomised participants represented eligible patients, and whether factors predicting randomisation also influenced trial outcome. Adults from 8 UK general practices were surveyed to determine eligibility for a trial of 2 interventions (exercise and cognitive behavioural therapy [CBT]). Amongst those eligible, logistic regression identified factors associated with reaching the randomisation step in the recruitment process. The main trial analysis was recomputed, weighting for the inverse of the likelihood of reaching the randomisation stage, and the numbers needed to treat were calculated for each treatment. Eight hundred eighty-four persons were identified as eligible for the trial, of whom 442 (50%) were randomised. Several factors were associated with the likelihood of reaching the randomisation stage: higher body mass index (odds ratio: 1.99; 0.85-4.61); more severe/disabling pain (1.90; 1.21-2.97); having a treatment preference (2.11; 1.48-3.00); and expressing positivity about interventions offered (exercise: 2.66; 1.95-3.62; CBT: 3.20; 2.15-4.76). Adjusting for this selection bias decreased the treatment effect associated with exercise and CBT but increased that observed for combined therapy. All were associated with changes in numbers needed to treat. This has important implications for the design and interpretation of pain trials generally.
Identifying patients with chronic widespread pain in primary care
Authors: Mansfield Kathryn E. , Sim Julius , Croft Peter , Jordan Kelvin P.
Published: October 2016

Chronic widespread pain (CWP) is common in the general population. It is unclear how people reporting this problem present in primary care; they may regularly consult for regional pains without being recognized as having a generalized condition. Our objectives were to determine the prevalence of people consulting in primary care for musculoskeletal conditions in different body regions on different occasions (recurrent regional pain consultation), the proportion with diagnosed generalized pain and survey-reported widespread pain, and if they have features characteristic of CWP. Phase 1 used electronic records from 12 general practices in North Staffordshire (Consultations in Primary Care Archive) from 2005 to 2009. Phase 2 used linked self-reported health and primary health care data from 8286 people aged >50 years in 8 general practices (North Staffordshire Osteoarthritis Project) between 2002 and 2005. In Phase 1, 11% of registered patients fulfilled criteria for recurrent regional pain consultation. Three-quarters had no recorded CWP-related generalized pain condition (eg, fibromyalgia). In Phase 2, 53% of recurrent regional pain consulters had survey-reported widespread pain and 88% had consulted for somatic symptoms. Self-reported general health was worse in recurrent regional pain consulters than in single-region consulters and poorest in those who also reported persistent widespread pain. Recurrent regional pain consulters are a heterogeneous group of frequent consulters sharing features with CWP (eg, somatic symptoms) but including those less severely affected. They lie on the spectrum of polysymptomatic distress characteristic of CWP and represent a group whose needs may be better met by earlier diagnosis of multisite pain.
Laser acupuncture reduces pain in pediatric kidney biopsies: a randomized controlled trial
Authors: Oates Aris , Benedict Kelly A. , Sun Karen , Brakeman Paul R. , Lim Jessica , Kim Cynthia
Published: October 2016

Evaluate laser acupuncture (LA) as an adjuvant therapy in pain management during percutaneous kidney biopsy procedure in children and adolescents. This prospective, double-blinded, randomized controlled trial enrolled patients aged 7 to 26 years admitted to a children's hospital for percutaneous kidney biopsy. Patients received LA to treatment points (acupuncture group) or sham points (control group) before the procedure. The laser delivered a dose of 42 J/cm2 over 10 acupoints. Patients and parents rated the pain during and after the biopsy, and change in pain scores were calculated for each patient. Anxiety, vital signs, sedation medication, and patient's biopsy experience were secondary outcomes. Sixty-nine treatments (33 in the acupuncture group and 36 in the control group) were eligible for analysis. Patients in the acupuncture group reported a significantly improved change in the pain score after the biopsy compared with the controls (0.8 vs −0.5, P = 0.044). Patients in the acupuncture group had a statistically significant decrease in procedure vital signs including heart rate (−1.8 vs 5.6, P = 0.043) and respiratory rate (−2.4 vs 0.4, P = 0.045) when compared with controls. Parents also perceived a correspondingly greater improvement in their child's pain for those in the acupuncture group compared with the controls (2.3 vs 0.3, P = 0.04). Adjunctive LA significantly improved pain after pediatric percutaneous kidney biopsies.
Temporal change in headache and its contribution to the risk of developing first-onset temporomandibular disorder in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study
Authors: Tchivileva Inna E. , Ohrbach Richard , Fillingim Roger B. , Greenspan Joel D. , Maixner William , Slade Gary D.
Published: October 2016

While cross-sectional studies have demonstrated an association between headache and temporomandibular disorder (TMD), whether headache can predict the onset of TMD is unknown. The aims of this study were to evaluate the contribution of headache to the risk of developing TMD and describe patterns of change in headache types over time. An initially TMD-free cohort of 2410 persons with low frequency of headache completed quarterly questionnaires assessing TMD and headache symptoms over a median 3.0-year follow-up period. First-onset TMD was confirmed by clinical examination in 199 participants. Baseline reports of migraine (hazard ratio [HR] = 1.67, 95% confidence interval [CI]: 1.06-2.62) or mixed headache types (HR = 4.11, 95% CI: 1.47-11.46), or headache frequency (HR = 2.13, 95% CI: 1.31-3.48) predicted increased risk of developing TMD. In addition, headache dynamics across the follow-up period before the TMD onset were evaluated in a nested case–control study where 248 incident TMD cases were matched to 191 TMD-free controls. Both headache prevalence and frequency increased across the observation period among those who developed TMD but not among controls. Patients with TMD were more likely to experience worsening in the headache type compared with that by controls, eg, prevalence of definite migraine among TMD cases increased 10-fold. Among all headache types experienced by patients with TMD before the TMD onset, migraine had the highest odds of progression relative to remission (odds ratio = 2.8, 95% CI: 1.6-4.8), whereas for controls this ratio was significant only for the tension-type headache (odds ratio = 2.1, 95% CI: 1.2-3.9). The important clinical implication of these findings is that adequate treatment of migraine may reduce the risk for developing TMD.
SIRT1 attenuates neuropathic pain by epigenetic regulation of mGluR1/5 expressions in type 2 diabetic rats
Authors: Zhou Cheng-Hua , Zhang Ming-Xing , Zhou Sha-Sha , Li Huan , Gao Jian , Du Lei , Yin Xiao-Xing
Published: October 2016

Accumulating evidence has demonstrated that epigenetic modification-mediated changes in pain-related gene expressions play an important role in the development and maintenance of neuropathic pain. Sirtuin 1 (SIRT1), a nicotinamide adenine dinucleotide (NAD+)-dependent deacetylase, is involved in the development of chronic pain. Moreover, SIRT1 may be a novel therapeutic target for the prevention of type 2 diabetes mellitus (T2DM). But the role of SIRT1 in T2DM-induced neuropathic pain remains unknown. In this study, we found that spinal SIRT1 expression and activity were downregulated significantly in high-fat-fed/low-dose streptozotocin-induced neuropathic pain rats. SIRT1 localized in spinal neurons but not in astrocytes or microglia. Furthermore, the expressions of metabotropic glutamate receptor (mGluR1) and mGluR5, which play a key role in central sensitization and neuropathic pain, and H3 acetylation levels at Grm1/5 (encoding mGluR1/5) promoter regions were increased in diabetic neuropathic pain rats. SIRT1 activator SRT1720 reversed thermal hyperalgesia and mechanical allodynia and spinal neuronal activation in diabetic neuropathic pain rats. Concurrently, increased expressions of mGluR1/5 and H3 acetylation levels at Grm1/5 promoter regions were reversed by SIRT1 activation. In addition, knockdown of SIRT1 by Ad-SIRT1-shRNA induced pain behaviors and spinal neuronal activation in normal rats, which was accompanied by the increased expressions of mGluR1/5 and H3 acetylation levels at Grm1/5 promoter regions. Therefore, we concluded that SIRT1-mediated epigenetic regulation of mGluR1/5 expressions was involved in the development of neuropathic pain in type 2 diabetic rats.
Emergency readmission following acute upper gastrointestinal bleeding
Authors: Strömdahl Martin , Helgeson Johan , Kalaitzakis Evangelos
Published: October 2016

Objective

To assess the occurrence, clinical predictors, and associated mortality of all-cause emergency readmissions after acute upper gastrointestinal bleeding (AUGIB).

Patients and methods

All patients with AUGIB from an area of 600 000 inhabitants in Sweden admitted in a single institution in 2009–2011 were retrospectively identified. All medical records were scrutinized and relevant data (such as comorbid illness and medications, endoscopy, rebleeding, inhospital mortality, and 30-day emergency readmission) were extracted. The Charlson comorbidity index was calculated.

Results

A total of 174 out of 1056 patients discharged alive following AUGIB (16.5%) had an emergency readmission within 30 days. Nineteen percent of readmissions were because of rebleeding, whereas the rest were because of other reasons, mainly bacterial infections (9.8%) and cardiovascular events (8%). Inhospital mortality did not differ significantly between index admissions and readmissions (13.7 vs. 9.8%, P=0.181). In logistic regression analysis, only a higher Charlson comorbidity index [odds ratio (OR): 1.154, 95% confidence interval (CI): 1.056–1.261] was related to emergency readmission. Bisphosphonate use (OR: 3.933, 95% CI: 1.264–12.233), previous AUGIB (OR: 2.407, 95% CI: 1.157–5.009), and length of stay at index admission (>5 days; OR: 0.246, 95% CI: 0.093–0.649) were found to be independent predictors of postdischarge rebleeding.

Conclusion

All-cause emergency readmission following AUGIB is frequent. It is related to rebleeding in one-fifth of cases and mortality is similar to that in index admissions. The presence of comorbid illness appears to predict readmissions. Reduced length of stay and bisphosphonate use appear to be important, potentially modifiable, predictors of postdischarge rebleeding.
Effect of lower limb closed kinematic chain exercises on balance in patients with chemotherapy-induced peripheral neuropathy: a pilot study
Authors: Fernandes Jorida , Kumar Sanjiv
Published: October 2016

Because of the rising prevalence of cancer, many individuals are living with the side effects of cancer and its treatment. One of the possible side effects is chemotherapy-induced peripheral neuropathy (CIPN). The purpose of the study was to examine the effect of lower limb closed kinematic chain exercises on balance in patients with CIPN. The study design was a single group pre–post experimental one. The study was conducted at a tertiary care cancer hospital. A total of 25 individuals with CIPN and aged 30 years and older were recruited using the Modified Total Neuropathy Score higher than 5. Closed kinematic chain exercises were administered for a total of 15 sessions over 3 weeks. Patients were assessed at baseline using the mTNS and Berg Balance Scale and reassessed after 15 sessions. mTNS score decreased from 13.88 at baseline to 6.5 at the end of intervention, and the Berg Balance Scale increased from 26 at baseline to 42 after intervention, with a P-value of 0.00001. Exercises were effective in reducing symptoms in neuropathy and improving balance.
2016 Update for the Rogers’ Textbook of Pediatric Intensive Care: Recognition and Initial Management of Shock
Authors: Fitzgerald Julie C. , Weiss Scott L. , Kissoon Niranjan
Published: October 2016

Objective:

To review important articles in the field of pediatric shock and pediatric septic shock published subsequent to the Fifth Edition of the Rogers’ Textbook of Pediatric Intensive Care.

Data Sources:

The U.S. National Library of Medicine PubMed (www.ncbi.nlm.nih.gov/pubmed) was searched for combination of the term “pediatric” and the following terms: “sepsis, septic shock, shock, antibiotics, extracorporeal membrane oxygenation, and steroid.” The abstract lists generated by these searches were screened for potential inclusion. The authors were also aware of a number of key recent articles in pediatric shock, and these were also screened.

Study Selection and Data Extraction:

Promising articles published subsequent to the fifth edition of the textbook were included based on the consensus of the authors and via the peer review process.

Data Extraction:

Articles were grouped by category. Each author was assigned categories and extracted data from articles in that category. All authors contributed to final review of extracted data.

Data Synthesis:

Articles in the following categories were included: epidemiology and recognition of shock; laboratory markers of shock; antimicrobial therapy; vasoactive therapy; extracorporeal therapies; mortality patterns, prediction, and risk stratification; bundled approaches to shock recognition and management; and corticosteroid use.

Conclusion:

Research efforts in pediatric shock have largely centered on pediatric septic shock, with significant progress in the understanding of sepsis epidemiology, the use of extracorporeal therapies in critically ill children with sepsis, the role of hyperlactatemia and risk stratification in pediatric septic shock, and the impact of bundled care for pediatric sepsis, including evaluation of individual bundle elements such as the optimal timing of antibiotic administration and vasoactive medication choice. A consistent theme in the literature is the beneficial role of a bundled approach to septic shock recognition and management to improve both care and outcomes.
Early Noninvasive Neurally Adjusted Ventilatory Assist Versus Noninvasive Flow-Triggered Pressure Support Ventilation in Pediatric Acute Respiratory Failure: A Physiologic Randomized Controlled Trial*
Authors: Chidini Giovanna , De Luca Daniele , Conti Giorgio , Pelosi Paolo , Nava Stefano , Calderini Edoardo
Published: October 2016

Objective:

Neurally adjusted ventilatory assist has been shown to improve patient-ventilator interaction in children with acute respiratory failure. Objective of this study was to compare the effect of noninvasive neurally adjusted ventilatory assist versus noninvasive flow-triggered pressure support on patient-ventilator interaction in children with acute respiratory failure, when delivered as a first-line respiratory support.

Design:

Prospective randomized crossover physiologic study.

Setting:

Pediatric six-bed third-level PICU.

Patients:

Eighteen children with acute respiratory failure needing noninvasive ventilation were enrolled at PICU admission.

Interventions:

Enrolled children were allocated to receive two 60-minutes noninvasive flow-triggered pressure support and noninvasive neurally adjusted ventilatory assist trials in a crossover randomized sequence.

Measurements and Main Results:

Primary endpoint was the asynchrony index. Parameters describing patient-ventilator interaction and gas exchange were also considered as secondary endpoints. Noninvasive neurally adjusted ventilatory assist compared to noninvasive flow-triggered pressure support: 1) reduced asynchrony index (p = 0.001) and the number of asynchronies per minute for each type of asynchrony; 2) it increased the neuroventilatory efficiency index (p = 0.001), suggesting better neuroventilatory coupling; 3) reduced inspiratory and expiratory delay times (p = 0.001) as well as lower peak and mean airway pressure (p = 0.006 and p = 0.038, respectively); 4) lowered oxygenation index (p = 0.043). No adverse event was reported.

Conclusions:

In children with mild early acute respiratory failure, noninvasive neurally adjusted ventilatory assist was feasible and safe. Noninvasive neurally adjusted ventilatory assist compared to noninvasive flow-triggered pressure support improved patient-ventilator interaction.
The Utility of Brain Natriuretic Peptide in Pediatric Cardiology: A Review
Authors: Neves Ana L. , Henriques-Coelho Tiago , Leite-Moreira Adelino , Areias José C.
Published: October 2016

Objective:

The aim of this article is to evaluate the clinical utility of brain natriuretic peptide in pediatric patients, examining the diagnostic value, management, and prognostic relevance, by critical assessment of the literature.

Data Sources:

In December 2015, a literature search was performed (PubMed access to MEDLINE citations; http://www.ncbi.nlm.nih.gov/PubMed/) and included these Medical Subject Headings and text terms for the key words: “brain natriuretic peptide,” “amino-terminal pro-brain natriuretic peptide,” “children,” “neonate/s,” “newborn/s,” “infant/s,” and “echocardiography.”

Study Selection:

Each article title and abstract was screened to identify relevant studies. The search strategy was limited to published studies in English language concerning brain natriuretic peptide/amino-terminal pro-brain natriuretic peptide in pediatric patients.

Data Extraction:

Data on age, gender, type of clinical condition, brain natriuretic peptide assay method, cardiac function variables evaluated by echocardiography, and prognosis were extracted.

Data Synthesis:

Brain natriuretic peptide reference values in healthy newborns, infants, and children are presented. Brain natriuretic peptide diagnostic accuracy in newborns, infants, and children suspected to have congenital heart defects is discussed, and brain natriuretic peptide prognostic value reviewed. The data suggest that the determination of brain natriuretic peptide levels improves the diagnostic accuracy in the assessment of heart disease in the pediatric population. Brain natriuretic peptide assay may increase the accuracy of neonatal screening programs for diagnosing congenital heart defects. Echocardiographic variables correlated to brain natriuretic peptide levels. Additionally, brain natriuretic peptide levels predicted adverse outcomes in the postoperative period.

Conclusions:

Brain natriuretic peptide assessment is a reliable test to diagnose significant structural or functional cardiovascular disease in children. In the integrated follow-up of these cases, several physiologic and clinical variables must be considered; brain natriuretic peptide may be an additional helpful marker. Nevertheless, larger prospective studies are warranted to elucidate the true prognostic value of brain natriuretic peptide in pediatric patients.
Cervical Spine Injuries in Children Associated With Sports and Recreational Activities
Authors: Babcock Lynn , Olsen Cody S. , Jaffe David M. , Leonard Julie C.
Published: October 2016

Objective

The aim of this study was to ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities.

Methods

This is a secondary analysis of a multicenter retrospective case-control study involving children younger than 16 years who presented to emergency departments after blunt trauma and underwent cervical spine radiography. Cases had cervical spine injury from sports or recreational activities (n = 179). Comparison groups sustained (1) cervical spine injury from other mechanisms (n = 361) or (2) other injuries from sports and recreational activities but were free of cervical spine injury (n = 180).

Results

For children with sport and recreational activity–related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity–related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5–9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9–5.0), were injured diving (OR, 43.5; 95% CI, 5.9–321.3), or sustained axial loading impacts (OR, 2.2; 95% CI, 1.3–3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury.

Conclusions

In children injured during sports and recreational activities, focal neurologic findings, neck pain, axial loading impacts, and the possibility of spinal cord injury without radiographic abnormality should guide the diagnostic evaluation for potential cervical spine injuries. Certain activities have a considerable frequency of cervical spine injury, which may benefit from activity-specific preventive measures.
Association of Delay in Appendectomy With Perforation in Children With Appendicitis
Authors: Meltzer James A. , Kunkov Sergey , Chao Jennifer H. , Tay Ee Tein , George Jerry P. , Borukhov David , Alerhand Stephen , Harrison Prince A. , Hom Jeffrey , Crain Ellen F.
Published: October 2016

Objective

The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation.

Methods

We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression.

Results

Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9–15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8–15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00–1.04).

Conclusions

Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.
Distance to the Pediatric Emergency Department and Nonurgent Visits in Friuli Venezia Giulia, Italy
Authors: Valent Francesca , Busolin Anna
Published: October 2016

Objectives

Our objective was to assess how the distance from home to the closest pediatric emergency department (ED) affects nonurgent emergency room visits among the child population of the Northeastern Italian region of Friuli Venezia Giulia.

Methods

The study was based on the administrative databases of the Regional Health Information System of Friuli Venezia Giulia. For the year 2014, we abstracted the records of all white-triage–tag visits of children younger than 16 years from the databases of the 3 regional pediatric EDs located in the 3 main cities. Those records were individually linked to the regional population's georeferenced address database through an anonymous univocal identifier. For each child younger than 16 years living within 20 km from an ED, we calculated the linear distance between the ED and home address. Distances were grouped into 7 circular distance bands: less than 2, 2 to 4, 4 to 6, 6 to 8, 8 to 10, 10 to 15, and 15 to 20 km. Within each band, we calculated the rate of ED visits during the year.

Results

In 2014, there were 12,055 white-triage–tag visits accounting for 24.7% of all visits in the regional pediatric EDs. Although the overall rate of ED visits was different among the EDs, it decreased significantly with increasing distance to the ED, with a 6-fold difference between the innermost and the outermost bands.

Conclusions

In Friuli Venezia Giulia, short distance is a prompter for inappropriate pediatric ED attendance. Further research is needed in this region to understand the parental standpoint to implement strategies promoting uniform behaviors within the regional boundaries.
Complete Recovery After Acute Zonisamide Overdose in an Adolescent Female
Authors: McStay Charlayne , Pierce Richard , Riley Carley
Published: October 2016

Zonisamide is a sulfonamide drug used primarily for the treatment of partial seizures in adults. We describe the case of a 15-year-old woman with a mood disorder who survived without complications after ingestion of an estimated 7.5 g of zonisamide. To the best of our knowledge, there are 4 case reports of individuals with intentional ingestion of more than 4 g of zonisamide as a single agent. Our patient developed coma and hypotension 4 hours after ingestion and was treated with a catecholamine infusion, endotracheal intubation, and mechanical ventilation. She had mild electrocardiographic abnormalities and fully recovered after 4 days. This report contributes to the understanding of acute zonisamide poisoning.