bluuebunny/crossref_metadata_2025 huggingface dataset:
Infection After Orthopaedic Trauma: Prevention and Treatment
Authors: Yun Heather C. , Murray Clinton K. , Nelson Kenneth J. , Bosse Michael J.
Published: September 2016

Trauma to the extremities is disproportionately represented in casualties of recent conflicts, accounting for >50% of injuries sustained during operations in Iraq and Afghanistan. Infectious complications have been reported in >25% of those evacuated for trauma, and 50% of such patients were treated in the intensive care unit (ICU). Osteomyelitis has been reported in 9% (14% of intensive care unit patients), and deep-wound infection in 27% of type III open-tibia fractures. Infections complicating extremity trauma are frequently caused by multidrug-resistant bacteria and have been demonstrated to lead to failure of limb salvage, unplanned operative take-backs, late amputations, and decreased likelihood of returning to duty. Invasive fungal infections of extremities have also presented a unique challenge in combat-injured patients, particularly in those with blast injuries with massive transfusion requirements and high injury severity scores. Infection prevention should begin at the time of injury and, although context-specific depending on the level of care, includes appropriate irrigation, surgical debridement, wound care and coverage, fracture fixation, and antibiotic prophylaxis, in addition to basic infection prevention measures. Clinical practice guidelines to address infection prevention after combat trauma (including extremity infection) were developed in 2007 and revised in 2011, with endorsement from the Surgical Infection Society and the Infectious Disease Society of America. Nevertheless, significant challenges remain, including austere environments of care, multiple transitions of care, and lack of coordinated efforts in prevention. Treatment of established infections is optimally multidisciplinary, particularly when deep wounds, bone, and joints are involved. Surgical debridement of overtly infected or necrotic tissue is necessary, with particularly aggressive margins if invasive fungal infection is suspected. Infected nonunion frequently requires the use of prosthetic materials for fixation, potentiating biofilm formation, and complicating medical therapy. Antibiotic therapy should be targeted at results of deep wound and bone cultures. However, this is complicated by frequent contamination of wounds, requiring differentiation between potential pathogens in terms of their virulence and decreased culture recovery in patient who have frequently received previous antibiotics. Lessons learned in infection prevention and treatment of orthopaedic trauma from combat can serve to inform the care of patients injured in natural disasters and noncombat trauma.
Comprehensive Rehabilitation Following Combat Extremity Trauma: Evolution and Its Impact on Outcomes
Authors: Rivera Jessica C. , Pasquina Paul F.
Published: September 2016

Recent military combat operations have resulted in a high burden of extremity-related long-term disability due to limb amputation and persistent deficits despite limb reconstruction. The US Army amputee care programs, established at focused centers with interdisciplinary care teams, have redefined the standard of how rehabilitation following limb loss is undertaken as the limb reconstruction is just one part of the entire patient's restoration of wellness and reintegration. Inspired by this approached, comprehensive rehabilitation programs designed for patients with limb reconstruction have also excelled rehabilitation following a spectrum of severe limb trauma. These programs, which include advances in orthotics and orthosis training, have improved function and military retention among the limb salvage patient population. Lessons learned from comprehensive rehabilitation efforts emphasize the value of highly skilled, interprofessional care teams and the overall wellness of the patients. Although this approach is resource intensive and not available in all health care systems, civilian trauma counterparts can learn from the example of holistic attention to the patient's recovery.
Current Issues Affecting the Practice of Pediatric Orthopaedic Surgeons: Results of the 2014 Workforce Survey of American Academy of Pediatrics Section on Orthopaedics
Authors: Hosseinzadeh Pooya , Copley Lawson , Ruch-Ross Holly , Schwend Richard M. , Sawyer Jeffrey R.
Published: September 2016

Introduction:

The opinions of the pediatric orthopaedic workforce are shaped by market forces, regulatory processes, and local experience. The purpose of this report is to summarize the findings of the recent Workforce Survey of the American Academy of Pediatrics (AAP) Section on Orthopaedics (SOOr). This submission has been reviewed and approved by the Board of Directors of the Pediatric Orthopaedic Society of North America (POSNA).

Methods:

In 2014, the AAP generated a survey to assess perceptions of pediatric orthopaedic surgeons about current issues that affect practice. The survey was sent to 856 POSNA and 141 AAP-SOOr members. Responses were topically organized to report current workforce composition, practice patterns, and perceptions about electronic medical records (EMRs).

Results:

Responses were collected from August to December, 2014, from 496 (50%) survey recipients including 83 of 141 (59%) AAP-SOOr members and 413 of 856 (48%) POSNA members. Analyses were restricted to the 397 respondents who reported that they are currently practicing pediatric orthopaedics. Nearly all of these (390/391, 100%) indicated that they provide direct patient care and work an average of 60 hours per week. Many (105/378, 28%) indicated that they would soon limit their practice or retire. A majority (299/394, 76%) indicated that they face competition in their geographic area, predominantly due to pediatric orthopaedic subspecialists (269/299, 90%). Major business changes had recently occurred or were anticipated by 21% of participants. Respondents reported that use of EMR makes them less efficient (252/397, 63%) and interferes with the patient-physician relationship (172/397, 43%).

Discussion:

This workforce survey suggests that pediatric orthopaedic surgeons are concerned with challenges of competition despite concurrent increasing volume and complexity of referrals. External processes such as EMR changes are perceived to negatively impact practice efficiency and satisfaction.
Capital Femoral Epiphyseal Extension May Confer Physeal Stability in Slipped Capital Femoral Epiphysis
Authors: Morris William Z. , Napora Joshua K. , Conry Keegan T. , Liu Raymond W.
Published: September 2016

Background:

Factors including obesity and morphologic parameters around the hip that increase physeal stress are associated with an increased risk of slipped capital femoral epiphysis (SCFE). Recent evidence suggests that superior epiphyseal extension may confer stability to the physis and help protect against SCFE. The purpose of this study is to investigate the relationship between epiphyseal extension and SCFE using an age-matched and sex-matched cohort study.

Methods:

We generated 2 separate cohorts for comparison: 89 patients with unilateral SCFE and 89 healthy subjects with no evidence of hip disease or deformity. We utilized the anterior-posterior and lateral films of the hip to measure the Southwick angle and the epiphyseal extension ratio (EER), defined as the ratio of extension of the capital femoral epiphysis down the femoral neck relative to the diameter of the femoral head. We then compared these measurements between cohorts and in subgroup analysis based on slip stability and whether subjects progressed to a contralateral slip.

Results:

The SCFE cohort demonstrated a decreased superior epiphyseal extension ratio compared with control (superior EER 0.71 vs. 0.68, P=0.002). There was also a significant downward trend in superior EER from the control subjects (0.71±0.07) to the stable slips (0.69±0.06) to the unstable slips (0.65±0.04) with an overall difference between the groups (P=0.001). Eighteen of 44 (41%) subjects with unilateral stable slips and at least 6 months of follow-up went on to develop SCFE of the contralateral limb. The subjects who developed contralateral slips were younger (11.6±1.2 vs. 12.7±1.4 y, P=0.008); however, there was no difference in superior or anterior epiphyseal extension (P=0.75 and 0.23, respectively). There was no significant linear correlation between Southwick angle and superior or anterior EER (r=0.13 and 0.17, respectively, P>0.05 for both).

Conclusions:

Increasing capital femoral epiphyseal extension may confer physeal stability in the setting of SCFE. We propose that this epiphyseal extension reflects an adaptive response to limit physeal stress and reduce the risk for progression to SCFE.

Level of Evidence:

Level III—prognostic study.
Spinal Instrumentation in Growing Children Retards the Natural Development of Pelvic Incidence
Authors: Bekmez Senol , Demirkiran Halil Gokhan , Dede Ozgur , Atici Yunus , Balioglu Mehmet Bulent , Kruyt Moyo , Ward Timothy , Yazici Muharrem
Published: September 2016

Background:

Pelvic incidence increases gradually throughout growth until skeletal maturity. Growing rod instrumentation has been suggested to have a stabilizing effect on the development of the normal sagittal spinal alignment. The purpose of this study is to determine the effect of fixed sagittal plane caused by dual growing rod instrumentation on the natural progression of sagittal spinopelvic parameters in children with idiopathic or idiopathic-like early onset scoliosis.

Methods:

Hospital records of children with growing rod instrumentation from 4 separate institutions were reviewed retrospectively. Inclusion criteria were idiopathic or idiopathic-like early onset scoliosis, treatment with dual growing rods with lower instrumented vertebra L4 or upper and more than 2 years of follow-up. Instrumentation levels, magnitudes of major curve, thoracic kyphosis (T2-T12), lumbar lordosis (L1-S1) and pelvic incidence were recorded from preoperative and postoperative standing whole-spine radiographs. Estimated pelvic incidence was also calculated for each patient as if their spines had not been instrumented using the previous normative data.

Results:

A total of 37 patients satisfied the inclusion criteria. Average age at initial surgery was 7.4±1.8 years (range, 4 to 12 y). Mean follow-up time was 71±26 months (range, 27 to 120 mo). Mean preoperative Cobb angle of 59±13.5 (range, 30 to 86) degrees was reduced to 35.1±17.5 (range, 11 to 78) degrees at the last follow-up. Mean preoperative T2-T12 kyphosis angle was 46.2±14.9 degrees (range, 22 to 84 degrees). At the latest follow-up, it was 44.8±16.2 degrees (range, 11 to 84 degrees) (P=0.93). Mean L1-S1 lordosis angle was 50.5±10.7 degrees (range, 30 to 72 degrees) preoperatively. At the latest follow-up, mean L1-S1 lordosis angle was 48.8±12.7 degrees (range, 26 to 74 degrees) (P=0.29). Mean preoperative pelvic incidence was 45.7±7.9 degrees (range, 30 to 68 degrees). At the latest follow-up, it was 46.7±8.4 degrees (range, 34 to 72 degrees) (P=0.303). The estimated average pelvic incidence was 49.5 degrees (P=0.012).

Conclusions:

Previously reported developmental changes of the sagittal spinal parameters were not observed in children who underwent posterior spinal instrumentation. Our findings suggest that spinal instrumentation impedes the natural development of the sagittal spinal profile.

Level of Evidence:

Level IV—this is a retrospective case-series.
Quality Improvement Initiative for Severe Sepsis and Septic Shock Reduces 90-Day Mortality: A 7.5-Year Observational Study*
Authors: Scheer Christian S. , Fuchs Christian , Kuhn Sven-Olaf , Vollmer Marcus , Rehberg Sebastian , Friesecke Sigrun , Abel Peter , Balau Veronika , Bandt Christoph , Meissner Konrad , Hahnenkamp Klaus , Gründling Matthias
Published: September 2016

Objective:

To investigate the impact of a quality improvement initiative for severe sepsis and septic shock focused on the resuscitation bundle on 90-day mortality. Furthermore, effects on compliance rates for antiinfective therapy within the recommended 1-hour interval are evaluated.

Design:

Prospective observational before-after cohort study.

Setting:

Tertiary university hospital in Germany.

Patients:

All adult medical and surgical ICU patients with severe sepsis and septic shock.

Intervention:

Implementation of a quality improvement program over 7.5 years.

Measurements:

The primary endpoint was 90-day mortality. Secondary endpoints included ICU and hospital mortality rates and length of stay, time to broad-spectrum antiinfective therapy, and compliance with resuscitation bundle elements.

Main Results:

A total of 14,115 patients were screened. The incidence of severe sepsis and septic shock was 9.7%. Ninety-day mortality decreased from 64.2% to 45.0% (p< 0.001). Hospital length of stay decreased from 44 to 36 days (p< 0.05). Compliance with resuscitation bundle elements was significantly improved. Antibiotic therapy within the first hour after sepsis onset increased from 48.5% to 74.3% (p< 0.001). Multivariate analysis revealed blood cultures before antibiotic therapy (hazard ratio, 0.60–0.84;p< 0.001), adequate calculated antibiotic therapy (hazard ratio, 0.53–0.75;p< 0.001), 1–2 L crystalloids within the first 6 hours (hazard ratio 0.67–0.97;p= 0.025), and greater than or equal to 6 L during the first 24 hours (hazard ratio, 0.64–0.95;p= 0.012) as predictors for improved survival.

Conclusions:

The continuous quality improvement initiative focused on the resuscitation bundle was associated with increased compliance and a persistent reduction in 90-day mortality over a 7.5-year period. Based on the observational study design, a causal relationship cannot be proven, and respective limitations need to be considered.
Development and Validation of a Photonumeric Scale for Assessment of Chin Retrusion
Authors: Sykes Jonathan M. , Carruthers Alastair , Hardas Bhushan , Murphy Diane K. , Jones Derek , Carruthers Jean , Donofrio Lisa , Creutz Lela , Marx Ann , Dill Sara
Published: September 2016

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of chin appearance before and after chin augmentation in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Chin Retrusion Scale.

METHODS

The Allergan Chin Retrusion Scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each scale grade. The clinical significance of a 1-point score difference was evaluated in a review of multiple image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 298) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A difference of ≥1 point on the scale was shown to reflect a clinically meaningful difference (mean [95% confidence interval] absolute score difference, 1.07 [0.94–1.20] for clinically different image pairs and 0.51 [0.39–0.63] for not clinically different pairs). Intrarater agreement between the 2 live-subject validation sessions was substantial (mean weighted kappa = 0.79). Interrater agreement was substantial during the second rating session (0.68, primary end point).

CONCLUSION

The Allergan Chin Retrusion Scale is a validated and reliable scale for physician rating of severity of chin retrusion.
Development and Validation of a Photonumeric Scale for Evaluation of Transverse Neck Lines
Authors: Jones Derek , Carruthers Alastair , Hardas Bhushan , Murphy Diane K. , Sykes Jonathan M. , Donofrio Lisa , Carruthers Jean , Creutz Lela , Marx Ann , Dill Sara
Published: September 2016

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of horizontal neck lines before and after treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Transverse Neck Lines Scale.

METHODS

The Allergan Transverse Neck Lines Scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each scale grade. The clinical significance of a 1-point score difference was evaluated in a review of multiple image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject rating validation study (N = 297) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A difference of ≥1 point on the scale was shown to reflect a clinically significant difference (mean [95% confidence interval] absolute score difference, 1.22 [1.09–1.35] for clinically different image pairs and 0.57 [0.42–0.72] for not clinically different pairs). Intrarater agreement between the 2 live-subject rating validation sessions was substantial (mean weighted kappa = 0.78). Interrater agreement was substantial during the second rating session (0.73, primary end point).

CONCLUSION

The Allergan Transverse Neck Lines Scale is a validated and reliable scale for rating of severity of neck lines.
Intraepithelial Extramammary Paget's Disease of the Vulva: The Clinicopathological Characteristics, Management, and Outcome in a Study of 18 Female Patients
Authors: Fan Lingling , Zhu Jin , Tao Xiang , Xu Congjian
Published: September 2016

OBJECTIVE

This study aimed to analyze the clinicopathologic characteristics, management, and outcome of patients with intraepithelial extramammary Paget's disease of the vulva (EMPDV).

MATERIALS AND METHODS

This retrospective study included medical records and pathological slides of 18 female patients with EMPDV between January 2001 and December 2012. Diagnosis was confirmed using conventional hematoxylin and eosin staining.

RESULTS

The median age was 65 years. The distribution of lesions was from labium majus, labium minus, clitoris, and distal vaginal wall. The appearance was erythematous patches, hypopigmentation, and hyperpigmentation. The symptoms were pruritus, erosions, burning sensation, and pain. The mean duration of symptoms was 24 months. Ten patients received local excision, 3 accepted wide local excisions and successful skin grafting, and 5 underwent vulvectomies. Frozen sections showed that 3 and 15 patients had positive and negative margins, respectively. The average length of follow-up was 70 months. During a follow-up period, 3 patients were lost. One patient with positive margins and one with negative margins recurred and the overall recurrence rate was 11.1%.

CONCLUSION

The diagnosis of EMPDV is often delayed but has good prognosis. A complete surgical resection is an effective treatment. Skin grafting may be a good method to promote incision healing.
Benign Breast Diseases: Evaluation and Management
Authors: ORR BRIAN , KELLEY JOSEPH L.
Published: September 2016

Benign breast disease is a spectrum of common disorders. The majority of patients with a clinical breast lesion will have benign process. Management involves symptom control when present, pathologic-based and imaging-based evaluation to distinguish from a malignant process, and counseling for patients that have an increased breast cancer risk due to the benign disorder.
DELAYED-ONSET BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION ASSOCIATED WITH GASTRIC ADENOCARCINOMA
Authors: Dolz-Marco Rosa , Vilaplana Ferran , Gallego-Pinazo Roberto , Freund K. Bailey
Published: September 2016

Purpose:

To report an unusual case of delayed-onset bilateral diffuse uveal melanocytic proliferation in a patient with a remote history of gastric adenocarcinoma 17 years earlier.

Methods:

Case report of a patient with bilateral diffuse uveal melanocytic proliferation including comprehensive systemic and ocular examinations.

Results:

A 78-year-old man presented with a history of progressive bilateral vision loss during the 4 previous years associated with fever of unknown origin. He underwent total gastrectomy 17 years earlier as a treatment for gastric adenocarcinoma. Funduscopic examination revealed multiple subretinal pigmented and nonpigmented lesions involving the posterior pole of both eyes. These lesions showed early hyperfluorescence on fluorescein angiography, producing a giraffe pattern. Spectral-domain optical coherence tomography showed intraretinal and subretinal fluid with multiple hyperreflective mounds involving the retinal pigment epithelium. Treatment with the intravitreal anti–vascular endothelial growth factor agent, ranibizumab, produced anatomical improvement in both eyes but visual improvement in just the right eye.

Conclusion:

Although delayed-onset bilateral diffuse uveal melanocytic proliferation may occur, it is important to rule out a second malignancy. To the knowledge of the authors, this is the first report of delayed-onset bilateral diffuse uveal melanocytic proliferation associated with gastric adenocarcinoma. Treatment with intravitreal anti–vascular endothelial growth factor therapy warrants further evaluation.
Clinical Performance of a Spherical Hybrid Lens Design in High Regular Astigmatism
Authors: Abou Samra Waleed Ali , El-Emam Dalia Sabry , Kasem Manal Ali
Published: September 2016

Objectives:

To evaluate safety, efficacy, and comfort of a spherical hybrid contact lens design in management of the regular astigmatic cornea.

Methods:

This prospective study included 18 eyes from 18 subjects with regular corneal astigmatism greater than −3.00 diopters. All patients were fitted with optimal hybrid contact lenses. Demographic data and fitting parameters were recorded. Patient refraction, visual outcomes, contrast sensitivity, and glare levels were measured 2 weeks, 3 months, and 6 months after the start of lens use. Duration of lens use, comfort grades, causes of lens discontinuation, and any noticed complications were recorded.

Results:

An average of 1.8 lenses (range 1–3) was required to achieve the optimal fit. Average logMAR visual acuity had improved significantly from 0.92±0.03 to 0.03±0.04 (P<0.001) at the last follow-up. Contrast sensitivity and glare tests were also significantly improved. Statistical analysis of the subjective responses indicated a strong acceptance of the lens by most of the patients. Mean wearing time of lenses was 10.1±3.2 hr/d−1. Causes of discontinuation were discomfort (2 patients), high lens price (2 patients), and handling problems (1 patient). Minimal complications were demonstrated in wearers of the lenses during follow-up visits.

Conclusion:

Spherical hybrid contact lenses provide a good option for patients with regular astigmatic corneas. They provide optimal visual function with high comfort and patient satisfaction, especially when surgery is undesirable or contraindicated.
Comparative Evaluation of the Ostium After External and Nonendoscopic Endonasal Dacryocystorhinostomy Using Image Processing (Matlabs and Image J) Softwares
Authors: Ganguly Anasua , Kaza Hrishikesh , Kapoor Aditya , Sheth Jenil , Ali Mohammad Hasnat , Tripathy Devjyoti , Rath Suryasnata
Published: September 2016

Purpose:

The purpose of this study was to compare the characteristics of the ostium after external dacryocystorhinostomy and nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR).

Methods:

This cross-sectional study included patients who underwent a successful external dacryocystorhinostomy or NEN-DCR and had ≥1 month follow up. Pictures of the ostium were captured with a nasal endoscope (4 mm, 30°) after inserting a lacrimal probe premarked at 2 mm. Image analyses were performed using Image J and Contour softwares.

Results:

Of the 113 patients included, external dacryocystorhinostomy group had 53 patients and NEN-DCR group had 60 patients. The mean age of patients in the NEN-DCR group (38 years) was significantly (p < 0.05) lower than the external dacryocystorhinostomy group (50 years). There was no statistically significant difference (2 sample t test, p > 0.05) in mean follow up (6 vs. 4 months), maximum diameter of ostium (8 vs. 7 mm), perpendicular drawn to it (4 vs. 4 mm), area of ostium (43 vs. 36 mm2), and the minimum distance between common internal punctum and edge of the ostium (1 vs. 1 mm) between the external and NEN-DCR groups.

Conclusions:

Image processing softwares offer simple and objective method to measure the ostium. While ostia are comparable in size, their relative position differs with posteriorly placed ostia in external compared with inferior in NEN-DCR.
Amyloid Pseudo-Dacryolith and Nasolacrimal Obstruction in a 67-Year-Old Male
Authors: Levine Mark R. , Seipel Shane B. , Plesec Thomas P. , Costin Bryan R.
Published: September 2016

A 67-year-old male with a 35-year history of left-sided epiphora presented with a nonpainful, noninflamed, left medial canthal mass and complete left nasolacrimal obstruction. During routine dacryocystorhinostomy, a lesion was present within the lacrimal sac that mimicked a lacrimal stone in appearance but with a consistency concerning for malignancy. Histologically, the lesion displayed apple-green birefringence on polarized light microscopy and Congo red staining. The patient was referred to the hematology service for evaluation, which failed to reveal systemic disease. There is 1 previous report of localized amyloidosis to the nasolacrimal excretory system in which the lesion was invasive and caused bony erosion. The authors present a second case of localized, nasolacrimal amyloidosis mimicking both neoplasm and dacryolith without bony erosion.
Transplant Survival After Berlin Heart EXCOR Support
Authors: Bryant Roosevelt , Zafar Farhan , Castleberry Chesney , Jefferies John L. , Lorts Angela , Chin Clifford , Morales David L. S.
Published: September 2016

The Berlin Heart EXCOR pediatric ventricular assist device (VAD) is approved by the Food and Drug Administration for bridge to cardiac transplantation (BTT) in children. As the clinical outcomes of the EXCOR continue to be evaluated in the United States, data on post-transplant survival are needed. The UNOS database was used to identify patients <18 years old undergoing orthotopic heart transplantation (OHT) from June 2004 to June 2014. Patients undergoing BTT with the EXCOR were identified. A matched cohort of (358) patients undergoing OHT without pretransplant mechanical circulatory support (no-MCS) was also identified as control subjects. The post-transplant survival between the two groups was compared. There were 2,885 pediatric OHT during the study period. Of these, 358 (50%) patients were BTT with the EXCOR. At time of listing, inotrope use was 51.7% vs. 53.4%, (p = 0.653) in the EXCOR cohort and the no-MCS cohort, respectively. At the time of transplantation, end-organ function was equivalent with same median creatinine levels (0.4, p = 0.203) and median total bilirubin (0.5, p = 0.682) for the EXCOR and the no-MCS cohorts. Kaplan–Meier post-transplantation survival did not differ between the two cohorts (30 day, 1 year, and 5 year post-transplant survival was 94%, 90%, and 72% [EXCOR cohort] vs. 98%, 91%, and 77% [no-MCS cohort]; p = 0.160). Short- and mid-term post-transplant survival using the EXCOR Pediatric VAD as a BTT in children is equivalent to patients who underwent OHT without pretransplant MCS.
Multi-Sense CardioPatch: A Wearable Patch for Remote Monitoring of Electro-Mechanical Cardiac Activity
Authors: Marcelli Emanuela , Capucci Alessandro , Minardi Gabriele , Cercenelli Laura
Published: September 2016

This study describes the conceptual design and the first prototype implementation of the Multi-Sense CardioPatch, a wearable multi-sensor patch for remote heart monitoring aimed at providing a more detailed and comprehensive heart status diagnostics. The system integrates multiple sensors in a single patch for detection of both electrical (electrocardiogram, ECG) and mechanical (heart sounds, HS) cardiac activity, in addition to physical activity (PA). The prototypal system also comprises a microcontroller board with a radio communication unit and it is powered by a Li-Ion rechargeable battery. Results from preliminary evaluations on healthy subjects have shown that the prototype can successfully measure electro-mechanical cardiac activity, providing useful cardiac indexes. The system has potential to improve remote monitoring of cardiac function in chronically diseased patients undergoing home-based cardiac rehabilitation programs.
Appointment Wait Time, Primary Care Provider Status, and Patient Demographics are Associated With Nonattendance at Outpatient Gastroenterology Clinic
Authors: Shrestha Manish P. , Hu Chengcheng , Taleban Sasha
Published: September 2016

Goals:

We intended to identify the factors associated with missed appointments at a gastroenterology (GI) clinic in an academic setting.

Background:

Missed clinic appointments reduce clinic efficiency, waste resources, and increase costs. Limited data exist on subspecialty clinic attendance.

Study:

We performed a case-control study using data from the electronic health record of patients scheduled for an appointment at the adult GI clinic at the Banner University Medical Center between March and October of 2014. Patients who missed their appointment during the study period served as cases. Controls were randomly selected from patients who completed their appointment during the study period. Analysis included univariate and multivariate logistic regression analysis.

Results:

Of 2331 scheduled clinic appointments, 195 (8.4%) were missed appointments. Longer waiting time from referral to scheduled appointment was significantly associated with missed appointment (AOR=1.014; 95% CI, 1.01-1.02; P<0.001). Patients with primary care providers (PCPs) were less likely to miss their appointment than those without PCPs (AOR=0.35; 95% CI, 0.18-0.66; P=0.001). Among patient demographic characteristics, ethnicity and marital status were associated with missed appointment.

Conclusions:

Wait time, ethnicity, marital status, and PCP status were associated with missed GI clinic appointments. Further investigations are needed to assess the effects of intervention strategies directed at reducing appointment wait time and increasing PCP-based care.
Diagnostic accuracy of confocal laser endomicroscopy for the characterization of liver nodules
Authors: Pierangelo Angelo , Fuks David , Validire Pierre , Benali Ali , Gayet Brice
Published: September 2016

Objectives

Probe-based confocal laser endomicroscopy (pCLE) is a promising new imaging technique enabling in-vivo analysis of tissues at the cellular level, in real time. The aim of the present study was to prospectively evaluate the feasibility and accuracy of indocyanine green-aided pCLE for the diagnosis of malignant liver nodules.

Patients and methods

From October 2014 to July 2015, liver specimens from 30 consecutive patients were analyzed ex vivo using pCLE directly after resection, with indocyanine green as contrast agent. The final diagnosis was obtained histologically, as per standard of care. In phase 1, a pathologist and a physicist established pCLE image criteria to distinguish normal parenchyma, malignant nodules, and metastases that had completely responded to chemotherapy. In phase 2, a pathologist and a surgeon reviewed selected videos retrospectively to assess the effectiveness of these.

Results

In phase 1, the healthy nodules were characterized by fluorescent hepatocytes with nonfluorescent nuclei and the malignant nodules were identified as strongly fluorescent, irregular cancer-cell clusters. The extracellular matrix was substantially less fluorescent compared with the cancerous clusters of cells. After chemotherapy, a very dense and strongly fluorescent fibrosis replaced tubular structures of cancerous cells. The retrospective evaluation in phase 2 resulted in 78 and 100% sensitivity, 100 and 89% specificity, 90 and 100% positive predictive value, and 90 and 100% negative predictive value for the surgeon and the pathologist, respectively, for the detection of malignant nodules.

Conclusion

This series emphasized that characterization of liver metastases is possible with pCLE, with high performance results.
Antithrombin Concentrate Use in Pediatric Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study*
Authors: Wong Trisha E. , Nguyen Thuan , Shah Samir S. , Brogan Thomas V. , Witmer Char M.
Published: September 2016

Objective:

To describe antithrombin concentrate use and to compare thrombotic and hemorrhagic outcomes throughout the hospital stay in pediatric subjects who received extracorporeal membrane oxygenation in a Pediatric Health Information System–participating children’s hospital.

Design:

Retrospective, multi-center, cohort study.

Setting:

Forty-three free-standing children’s hospitals participating in Pediatric Health Information System.

Subjects:

Children older than or equal to 18 years of age who underwent extracorporeal membrane oxygenation between 2003 and 2012.

Interventions:

Subjects were classified as receiving antithrombin if they received at least one dose of antithrombin while on extracorporeal membrane oxygenation.

Measurements and Main Results:

International Classification of Diseases, Ninth Revision, Clinical Modification codes codes were used to identify hemorrhagic and thrombotic complications during their hospitalization. Pediatric Health Information System data were analyzed to determine hospital-length of stay and in-hospital mortality. A total of 1,931 of 8,601 eligible subjects (21.5%) received at least one dose of antithrombin during their extracorporeal membrane oxygenation course. Antithrombin use during extracorporeal membrane oxygenation increased from 2.4% to 51.9% (p < 0.001) over the 10-year study period. Subjects who received antithrombin while on extracorporeal membrane oxygenation were younger (p = 0.02), had more chronic conditions (p < 0.001), and longer hospital stays (p < 0.001). On multivariate analysis, antithrombin use was associated with thrombotic events (odds ratio, 1.55; 95% CI, 1.36–1.77; p < 0.001), hemorrhagic events (odds ratio, 1.27; 95% CI, 1.14–1.42; p < 0.001), and longer hospital length of stays (slope coefficient, 1.05 d; 95% CI, 1.04–1.06; p < 0.001). No difference was observed in mortality (odds ratio, 0.99; 95% CI, 0.89–1.11; p = 0.90).

Conclusions:

In this multicenter retrospective cohort study, subjects who received antithrombin during extracorporeal membrane oxygenation had a higher number of thrombotic and hemorrhagic events throughout the hospitalization and longer length of stays without an associated difference in mortality. While limitations exist with this analysis and results should be interpreted with caution, the fact remains that over half of pediatric patients on extracorporeal membrane oxygenation are currently receiving antithrombin without clear benefit, with extra cost, and potential harms, there needs to be strong consideration for a clinical trial.
Outcomes for Students Receiving School-Based Physical Therapy as Measured by the School Function Assessment
Authors: Effgen Susan K. , McCoy Sarah Westcott , Chiarello Lisa A. , Jeffries Lynn M. , Starnes Catherine , Bush Heather M.
Published: September 2016

Purpose:

To describe School Function Assessment (SFA) outcomes after 6 months of school-based physical therapy and the effects of age and gross motor function on outcomes.

Methods:

Within 28 states, 109 physical therapists and 296 of their students with disabilities, ages 5 to 12 years, participated. After training, therapists completed 10 SFA scales on students near the beginning and end of the school year.

Results:

Criterion scores for many students remained stable (46%-59%) or improved (37%-51%) with the most students improving in Participation and Maintaining/Changing Positions. Students aged 5 to 7 years showed greater change than 8- to 12-year-olds on 5 scales. Students with higher gross motor function (Gross Motor Function Classification System levels I vs IV/V and II/III vs IV/V) showed greater change on 9 scales.

Conclusions:

Positive SFA change was recorded in students receiving school-based physical therapy; however, the SFA is less sensitive for older students and those with lower functional movement.
Layout for Assessing Dynamic Posture: Development, Validation, and Reproducibility
Authors: Noll Matias , Candotti Cláudia Tarragô , da Rosa Bruna Nichele , Sedrez Juliana Adami , Vieira Adriane , Loss Jefferson Fagundes
Published: September 2016

Purpose:

To determine the psychometric properties of the layout for assessing dynamic posture (LADy).

Methods:

The study was divided into 2 phases: (1) development of the instrument and (2) determination of validity and reproducibility. The LADy was designed to evaluate the position adopted in 9 dynamic postures.

Results:

The results confirmed the validity and reproducibility of the instrument. From a total of 51 criteria assessing 9 postures, 1 was rejected. The reproducibility for each of the criteria was classified as moderate to excellent.

Conclusions:

The LADy constitutes a valid and reproducible instrument for the evaluation of dynamic postures in children 11 to 17 years old. It is low cost and applicable in the school environment.
A Modified Version of the Timed Up and Go Test for Children Who Are Preschoolers
Authors: Verbecque Evi , Vereeck Luc , Boudewyns An , Van de Heyning Paul , Hallemans Ann
Published: September 2016

Purpose:

This study investigated factors predicting the Timed Up and Go (TUG) test in children who are preschoolers, using a modified protocol of the TUG.

Method:

This was a cross-sectional study of children 3 to 5 years old (n = 192). Regression analysis identified predictive factors for TUG performances. Differences in mean values (standard deviation) were calculated for each age group.

Results:

The results of 172 children were analyzed. Age and ethnicity were predictive of TUG performance (R
2 = 0.280). Children who are preschoolers with Flemish ethnicity need less time to perform the TUG than their peers with another ethnicity (P < .05), but this difference is not significant for the age groups. The TUG performance differs significantly among all age groups (P < .05).

Conclusions:

A modified protocol for the TUG, which is sensitive to age-related changes in dynamic balance control, is proposed for children who are preschoolers.
Reliability and Responsiveness of the Timed Up and Go Test in Children With Cerebral Palsy
Authors: Carey Helen , Martin Kathy , Combs-Miller Stephanie , Heathcock Jill C.
Published: September 2016

Purpose:

The purpose of this study was to determine the absolute reliability and responsiveness of the Timed Up and Go (TUG) test, as measured using minimal detectable change (MDC) and minimal clinical important difference (MCID) values.

Methods:

Prospective observational study of children aged 3 to 10 years with cerebral palsy (CP) in Gross Motor Function Classification System levels I-III who completed the TUG test. Minimal detectable change estimates were calculated using baseline data. MCID estimates for each Gross Motor Function Classification System (GMFCS) level were calculated using distribution- and anchor-based methods.

Results:

Minimal detectable change values ranged from 1.40 to 8.74 seconds and MCID estimates ranged from 0.22 to 5.31 seconds.

Conclusions:

The TUG test is a reliable and responsive measure of balance and mobility for children with CP between 3 and 10 years of age in GMFCS levels I-III. Study results support improved use of the TUG test in clinical and research settings by providing reliability values and estimates of meaningful change.

Video Abstract:

For more insights from the authors, see Supplemental Digital Content 1, available at http://links.lww.com/PPT/A117.
Primary Mucinous Carcinoma of the Fallopian Tube: Case Report and Review of Literature
Authors: Wheal Abigail , Jenkins Robert , Mikami Yoshiki , Das Nagindra , Hirschowitz Lynn
Published: September 2016

Primary mucinous carcinoma of the fallopian tube is extremely rare. We report the detailed characterization of a mucinous carcinoma arising in the fimbrial end of the fallopian tube in a 74-yr-old woman. The patient presented with recurrent urinary tract infection and urinary tract obstruction secondary to a large right ovarian mass. She had an appendicectomy as an 11 yr old. Serum CA-125 was raised at 239 U/mL. Computed tomographic scans showed bilateral, cystic ovarian tumors but no other intra-abdominal abnormality. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omental biopsy. Microscopy showed mucinous carcinoma arising from the left tubal fimbriae, in association with mucinous metaplasia over the uninvolved fimbrial folds. There was no mucinous metaplasia in the contralateral fallopian tube, endometrial lining, cervix, or on the uterine serosal surface. A mucinous borderline tumor of gastrointestinal subtype was identified in the left ovary. The right ovary contained a benign mucinous cystadenoma of mixed gastrointestinal and endocervical-like/Müllerian subtype. The fallopian tube tumor expressed CK7, claudin 18, and MUC6, but not CK20, CDX2, CEA, pyloric gland mucin (recognized by HIK1083), ER, or vimentin. The immunolabelling pattern for p53 was wild-type, and p16 expression was nonblock. The metaplastic mucinous tubal epithelium also marked for CK7, CK20, CDX2, and CEA but had mutation-type p53 labelling (p53 null), a low Ki-67 index, and was immunopositive for HIK1083, MUC6, and claudin 18. This is the first detailed characterization of a primary mucinous fallopian tube carcinoma and the adjacent metaplastic mucinous epithelium, and confirms it to be of gastric type.
The Settings, Pros and Cons of the New Surgical Robot da Vinci Xi System for Transoral Robotic Surgery (TORS): A Comparison With the Popular da Vinci Si System
Authors: Kim Da Hee , Kim Hwan , Kwak Sanghyun , Baek Kwangha , Na Gina , Kim Ji Hoon , Kim Se Heon
Published: September 2016

The da Vinci system (da Vinci Surgical System; Intuitive Surgical Inc.) has rapidly developed in several years from the S system to the Si system and now the Xi System. To investigate the surgical feasibility and to provide workflow guidance for the newly released system, we used the new da Vinci Xi system for transoral robotic surgery (TORS) on a cadaveric specimen. Bilateral supraglottic partial laryngectomy, hypopharyngectomy, lateral oropharyngectomy, and base of the tongue resection were serially performed in search of the optimal procedures with the new system. The new surgical robotic system has been upgraded in all respects. The telescope and camera were incorporated into one system, with a digital end-mounted camera. Overhead boom rotation allows multiquadrant access without axis limitation, the arms are now thinner and longer with grabbing movements for easy adjustments. The patient clearance button dramatically reduces external collisions. The new surgical robotic system has been optimized for improved anatomic access, with better-equipped appurtenances. This cadaveric study of TORS offers guidance on the best protocol for surgical workflow with the new Xi system leading to improvements in the functional results of TORS.
Gastrointestinal Stromal Tumor of Stomach: A Gentle Enemy of the Surgeon. Our Experience in Confronting the Disease
Authors: Bard Vyacheslav , Menasherov Nikolai , Morgenstern Sara , Haddad Riad , Kashtan Hanoch
Published: September 2016

Background:

Surgical resection is considered to be the best treatment for gastrointestinal stromal tumor (GIST), the most common mesenchymal tumor of the gastrointestinal tract. Tumor size, mitotic rate, and anatomic locations are directly related to the potential malignancy, surgical approach, oncological treatment, and recurrence rate.

Materials and Methods:

This was a retrospective study of 40 patients who underwent surgical resection of histologically or immunohistochemistry-proven GIST of the stomach at the Rabin and Kaplan Medical Center between 2004 and 2013. Tumor size, location, margin status, pathologic characteristics, surgical approach, surgical outcome, and long-term follow-up were analyzed from hospital records.

Results:

The most common presentation was upper gastrointestinal bleeding (40%), although 30% of cases were asymptomatic. A laparoscopic approach was the preferred technique whenever feasible; 85% of tumors were localized in the proximal stomach, with a median size of 5.6 cm. Most of the resected tumors revealed a low mitotic rate and thus had low-moderate risks of malignancy. All tumors were completely resected with free surgical margins. The median follow-up period was 40 months with 93% disease-free survival.

Conclusions:

Gastric GIST is a snake in the grass and its diagnosis is often incidental to endoscopy and computed tomographic scan. The most important technical point is to avoid tumor rupture during removal.
Neuroleptics in the management of delirium in patients with advanced cancer
Authors: Hui David , Dev Rony , Bruera Eduardo
Published: September 2016

Purpose of review

Delirium is the most common and distressing neuropsychiatric syndrome in cancer patients. Few evidence-based treatment options are available due to the paucity of high quality of studies. In this review, we shall examine the literature on the use of neuroleptics to treat delirium in patients with advanced cancer. Specifically, we will discuss the randomized controlled trials that examined neuroleptics in the front line setting, and studies that explore second-line options for patients with persistent agitation.

Recent findings

Contemporary management of delirium includes identification and management of any potentially reversible causes, coupled with nonpharmacological approaches. For patients who do not respond adequately to these measures, pharmacologic measures may be required. Haloperidol is often recommended as the first-line treatment option, and other neuroleptics such as olanzapine, risperidone, and quetiapine represent potential alternatives. For patients with persistent delirium despite first-line neuroleptics, the treatment strategies include escalating the dose of the same neuroleptic, rotation to another neuroleptic, or combination therapy (i.e., the addition of a second neuroleptic or other agent). We will discuss the advantages and disadvantages of each approach, and the available evidence to support each strategy.

Adequately powered, randomized trials involving proper control interventions are urgently needed to define the optimal treatment strategies for delirium in the oncology setting.
Recent insights into the function of autophagy in cancer
Authors: Amaravadi Ravi , Kimmelman Alec C. , White Eileen
Published: September 2016

Macroautophagy (referred to here as autophagy) is induced by starvation to capture and degrade intracellular proteins and organelles in lysosomes, which recycles intracellular components to sustain metabolism and survival. Autophagy also plays a major homeostatic role in controlling protein and organelle quality and quantity. Dysfunctional autophagy contributes to many diseases. In cancer, autophagy can be neutral, tumor-suppressive, or tumor-promoting in different contexts. Large-scale genomic analysis of human cancers indicates that the loss or mutation of core autophagy genes is uncommon, whereas oncogenic events that activate autophagy and lysosomal biogenesis have been identified. Autophagic flux, however, is difficult to measure in human tumor samples, making functional assessment of autophagy problematic in a clinical setting. Autophagy impacts cellular metabolism, the proteome, and organelle numbers and quality, which alter cell functions in diverse ways. Moreover, autophagy influences the interaction between the tumor and the host by promoting stress adaptation and suppressing activation of innate and adaptive immune responses. Additionally, autophagy can promote a cross-talk between the tumor and the stroma, which can support tumor growth, particularly in a nutrient-limited microenvironment. Thus, the role of autophagy in cancer is determined by nutrient availability, microenvironment stress, and the presence of an immune system. Here we discuss recent developments in the role of autophagy in cancer, in particular how autophagy can promote cancer through suppressing p53 and preventing energy crisis, cell death, senescence, and an anti-tumor immune response.