bluuebunny/crossref_metadata_2025 huggingface dataset:
The art of “not undermining”: possibilities within existing architecture to improve environmental protections in areas beyond national jurisdiction
Authors: Scanlon Zoe
Published: October 2017

United Nations General Assembly resolution 69/292 provides that in developing an internationally legally binding instrument on the conservation and sustainable use of marine biological diversity in areas beyond national jurisdiction, the process should “not undermine” relevant existing legal instruments and frameworks and relevant global, regional, and sectoral bodies. An analysis of the varied interpretations of this ambiguous expression and its surrounding language raises questions about the role envisaged for such existing architecture. This article considers the practice of regional fisheries management organizations as an illustration of the possibilities and potential for improved practices generated from within existing architecture. It reviews measures taken to protect biodiversity and innovative applications of international law that have improved the ability of RFMOs to take such environmental measures. It seeks to highlight the importance of avoiding too narrow an interpretation of the notion of “not undermining”, and of recognizing the potential in existing architecture when designing an improved regime for the protection of biodiversity beyond national jurisdiction.
Non-Umbilical Quaternionic Contact Hypersurfaces in Hyper-Kähler Manifolds
Authors: Ivanov Stefan , Minchev Ivan , Vassilev Dimiter
Published: October 2017

It is shown that any compact quaternionic contact (qc) hypersurfaces in a hyper-Kähler manifold which is not totally umbilical has an induced qc structure, locally qc homothetic to the standard 3-Sasakian sphere. In the non-compact case, it is proved that a seven-dimensional everywhere non-umbilical qc-hypersurface embedded in a hyper-Kähler manifold is qc-conformal to a qc-Einstein structure which is locally qc-equivalent to the 3-Sasakian sphere, the quaternionic Heisenberg group or the hyperboloid.
Targeted antibody therapy and relevant novel biomarkers for precision medicine for rheumatoid arthritis
Authors: Kaneko Yuko , Takeuchi Tsutomu
Published: October 2017

Over the past two decades, the management of rheumatoid arthritis (RA) has progressed remarkably, encompassing the development of new diagnostic tools and efficacious biological agents, such as monoclonal antibodies against inflammatory cytokines and surface markers on immune cells. In addition to the significant efficacy of these biological agents, biomarkers for RA are under consideration for their potential to classify heterogeneous patients into several groups based on clinical and immunological phenotypes for the prediction of clinical course and prognosis and the facilitation of appropriate and precise treatment with the appropriate therapeutic monoclonal antibodies. Biomarkers, particularly those for the prediction and monitoring of the responses to therapeutic monoclonal antibodies for RA, are in demand, with many approaches examined in recent years. In this article, we have summarized the background research on biomarkers and introduced recent topics in the field that enable the possible clinical applications of biomarkers, especially those related to pathogenic cytokines, to guide the treatment of RA.
Introduction: Narratives of OCD
Authors: Aboujaoude Elias , Pittenger Christopher
Published: October 2017

This chapter provides an overview of the clinical presentation and characteristics of obsessive-compulsive disorder (OCD), with an emphasis on the striking heterogeneity of the condition. Three cases that illustrate this heterogeneity are described in detail. These cases are used to frame a discussion of core clinical features and treatment principles, all of which are presented in more detail in later chapters in this volume. This introductory chapter provides a clinical frame for the more detailed treatments of various aspects of OCD phenomenology, pathophysiology, and treatment that follow.
Scrupulosity and Slowness in OCD
Authors: Ojserkis Rachel , McKay Dean
Published: October 2017

Obsessive-compulsive disorder (OCD) is a heterogeneous condition in which two difficult-to-treat subtypes—scrupulosity and obsessional slowness—have received comparably less empirical attention than other presentations. Perfectionism has been shown to play a role in the etiology and maintenance of OCD generally, and these two symptom subtypes in particular. This chapter reviews literature on the phenomenology of perfectionism, and its relation to scrupulosity and slowness. A model is then proposed for the role of perfectionism in scrupulosity and slowness OCD presentations. Recommendations for treatment and future research are considered throughout the chapter, addressing perfectionism, scrupulosity, and slowness in OCD.
Clinical Rating Scales for OCD
Authors: McGuire Joseph F. , Storch Eric A. , Goodman Wayne
Published: October 2017

Evidence-based assessment is a cornerstone for evidence-based treatment. This chapter provides an introduction to commonly used rating scales of OCD symptom severity for an evidence-based assessment. This includes clinician-administered measures, self-report, and parent-and-child report rating scales. Given the importance of OCD symptom dimensions, this chapter also presents measures to assess specific OCD symptom dimensions. The chapter concludes with considerations for selecting rating scales as part of an evidence-based assessment for children and adults with OCD.
Neuropsychological Function in OCD
Authors: Abramovitch Amitai
Published: October 2017

This chapter reviews the neuropsychological literature in adult and pediatric OCD, and then reviews the limitations, current controversies, and caveats in this area. Characterization of neuropsychological deficits associated with psychological problems has the potential to integrate neurobiological and psychopathological research. The cognitive neuropsychology of Obsessive-Compulsive Disorder (OCD) has been extensively studied over the past three decades. This impressive body of literature indicates that individuals diagnosed with OCD tend to exhibit moderate underperformance on neuropsychological tests in most, although not all, cognitive domains. However, neuropsychological research in OCD has been notoriously inconsistent. Moreover, the presence of broad though modest deficits, rather than large discrete ones, raises serious challenges for attempts to integrate neuropsychological constructs into neurobiological and psychological models of OCD.
Habits and Goals in OCD
Authors: Gillan Claire M.
Published: October 2017

This chapter gives a broad overview of the “habit hypothesis” of obsessive-compulsive disorder (OCD). Most patients with OCD recognize that becoming trapped in seemingly never-ending streams of repetitive ritualistic behaviors defies reason. Importantly, this recognition is not enough to put a halt to these behaviors. It has been proposed that these compulsions are “bad habits”: that external cues trigger an urge to perform a familiar response, which the patient cannot resist. The chapter presents the basics of what habits are, and how they relate to what we call “goal-directed control” over action. Next, an in-depth analysis of a series of empirical investigations that tested this hypothesis will be presented. In the final section, the habit hypothesis of OCD will be put into the broader context of “compulsivity” as a putative trans-diagnostic trait that is relevant for many psychiatric disorders.
Task-Based Functional Neuroimaging Studies of Obsessive-Compulsive Disorder: A Hypothesis-Driven Review
Authors: Vaghi M. M , Robbins T. W
Published: October 2017

The neurobiological basis of Obsessive Compulsive Disorder (OCD) has been probed using functional magnetic resonance in hundreds of studies over three decades. This complex literature can be syntheized using a theory-informed approach. At a theoretical level, separable, independent, constructs of relevance to OCD have been identified. At the experimental level, extensive translational evidence has provided an account that relates specific brain systems to these neuropsychological constructs. Parallels between neural substrates implicated in OCD and functional specialization of different brain regions suggest that abnormalities within fronto-striatal circuitry impinge on executive functions, and their subcomponents, and on goal-directed learning and habit formation. In OCD, this is reflected at a functional level in patterns of abnormal activations in particular brain regions during specific cognitive tasks. However, many issues still need to be addressed. The authors suggest that the experimental context might represent a pivotal variable that should be taken into account.
Neurotransmitter Dysregulation in OCD
Authors: Graat Ilse , Figee Martijn , Denys Damiaan
Published: October 2017

Obsessive-compulsive disorder (OCD) is associated with abnormalities in the cortico-striatal–thalamic–cortical (CSTC) circuitry, and may be associated with dysregulation of neurotransmitters within this network. The major neurotransmitters of the CSTC are serotonin, dopamine, glutamate and γ‎-aminobutyric acid (GABA. This chapter reviews evidence of the involvement of these neurotransmitters in OCD from pharmaocological, genetic, and imaging studies. yielding an integrated neurotransmitter model of OCD. It concludes that the neurotransmitter model of OCD involves dopaminergic and glutamatergic overactivity in frontostriatal pathways, along with diminished serotonergic and GABAergic neurotransmission in frontolimbic systems. These neurotransmitter imbalances may explain frontostriatal hyperactivity and impaired frontolimbic emotion regulation. Advancing our understanding of neurotransmitter abnormalities in OCD, and how abnormalities in different transmitter systems relate to one another, holds promise for the development of new pharmacotherapies.
Neuropeptides in OCD
Authors: Kabasakalian Anahid , Hollander Eric
Published: October 2017

The chapter considers past investigations of neuropeptides and their dysregulation in obsessive-compulsive disorder (OCD) and related conditions, and future directions for study. It reviews how the diagnostic reclassification of OCD in DSM-5, the stress response, reward mechanisms, as well as neuropsychological, functional imaging and genetic studies contribute to understanding of the role that neuropeptides have played in OCD and related areas. Avenues of further investigation are considered in the context of novel endogenous neuropeptides, newly identified roles for established neuropeptides, and the greater understanding of interactions between neuropeptides both with other neuropeptides and with neurotransmitters.
Influence of Sex Hormones on OCD
Authors: Guglielmi Valeria , Souget Judith , van Elzelingen Wouter , Willuhn Ingo , Vulink Nienke
Published: October 2017

OCD symptoms often seem to correlate with hormonal changes. For example, onset during puberty or in the postpartum period is common, and some female patients report monthly fluctuations in their symptoms. This chapter reviews available evidence about the interaction between the sex hormones estrogen, progesterone, and testosterone, and the neuropeptide oxytocin, and the initiation, amelioration, or exacerbation of OCD symptoms. Human studies as well as animal studies are reviewed. Furthermore, suggestions for clinical practice are provided, including: patient education, screening and treatment of perinatal OCD, cognitive behavioral therapy, and pharmacotherapy. The chapter concludes with suggestions on future research into the onset and exacerbation of OCD in women relative to reproductive cycle events.
Extinction of Conditioned Fear and Avoidance: Relevance for OCD
Authors: Rodriguez-Romaguera Jose , Quirk Gregory J.
Published: October 2017

The compulsions seen in obsessive-compulsive disorder (OCD) often reflect a state of elevated fear and anxiety; ritualistic behaviors and/or avoidance may arise as a strategy to manage this anxiety. Treatment for OCD can include exposure-based therapies that attempt to extinguish compulsions. Exposure with response prevention(ERP) is an effective therapy, but approximately 40% of patients fail ERP or drop out. This chapter reviews the role of the medial prefrontal and orbitofrontal cortices in the extinction of conditioned fear and avoidance, in both rodents and humans. Special emphasize is given to how the rodent literature can provide new insights into the pathophysiology and treatment of OCD.
OCD as a Failure to Integrate Goal-Directed and Habitual Action Control
Authors: Bradfield Laura , Morris Richard , Balleine Bernard W.
Published: October 2017

This chapter discusses the considerable research that has identified distinct functional circuits linking frontal cortex with the basal ganglia in the control of goal-directed and habitual actions. OCD is characterized by hyperactivity in a circuit involving some of these regions. Recent accounts of the interaction of goal-directed actions and habits suggest that these control processes interact hierarchically, so one alternative to current theories is that OCD reflects a dysfunction in this interactive process resulting in dysregulated action selection, whether that selection is driven by the outcome itself or by cues predicting the outcome. Importantly, it appears that both sources of action selection depend on the OFC—outcome based retrieval on the medial OFC and cue-related retrieval on the lateral OFC. From this perspective, therefore, hyperactivity of the OFC could produce both elevated outcome retrieval and increased responsiveness to outcomes-related cues, resulting in dysregulated action selection and compulsive action initiation as a consequence.
Overview of the Treatment of OCD
Authors: Simpson H. Blair
Published: October 2017

Obsessive-Compulsive Disorder (OCD) is a chronic and disabling disorder with a lifetime prevalence of 2% to 3%. This chapter briefly introduces the different treatment strategies for OCD and provides a treatment algorithm for use in clinical practice. It discusses aspects of cognitive-behavioral therapy (CBT), including variants such as exposure and response prevention therapy (ERP), and acceptance and commitment therapy (ACT), as well as clinical considerations. It also covers pharmacotherapy for OCD, including serotonin reuptake inhibitors (SRIs) and various augmentation strategies for them such as CBT and antipsychotics. There are sections addressing treatment of children and adolescents, and other treatments for OCD such as transcranial magnetic stimulation (TMS) or surgery. Subsequent chapters review these different treatment strategies in more detail and are referred to throughout this chapter.
Cognitive Therapy for OCD
Authors: Whittal Maureen
Published: October 2017

Cognitive treatment of obsessive compulsive disorder (OCD) offers an alternative to exposure-based treatments. This chapter explicates the theory underpinning the treatment, along with the belief domains targeted. Cognitive treatment of OCD should be seen as a modular treatment, with strategies varying according to the subtype presentations (i.e., cognitive treatment for a primary obsessional can look quite different from cognitive treatment for a doubter/checker). This chapter introduces the various treatment strategies and reviews outcome research using cognitive protocols.
Mindfulness and Acceptance Therapies for OCD
Authors: Morrison Kate L. , Smith Brooke M. , Twohig Michael P.
Published: October 2017

This chapter summarizes mindfulness-based therapies for observe-compulsive disorder (OCD). Mindfulness and acceptance interventions focus on the way in which individuals with OCD address or experience their obsessions, anxiety, uncertainty, and bodily sensations, and how this impacts their behavior. Mindfulness and acceptance interventions include a variety of procedures and treatment packages that center around the common goals of being open, aware, and present with emotional, cognitive, and bodily experiences that can otherwise derail intended actions. Although more evidence is needed, there is sufficient data to suggest that mindfulness and acceptance interventions are reasonable options for the treatment of OCD and related disorders. This chapter summarizes the theory and application of mindfulness and acceptance therapies and the data examining their use for OCD and related disorders.
Standard Evidence-Based Pharmacological Treatment for OCD
Authors: Reid Jemma E , Reghunandanan Samar , Roberts Ann , Fineberg Naomi A
Published: October 2017

This chapter reviews standard pharmacological treatments for OCD and the evidence supporting them. Selective serotonin reuptake inhibitors (SSRIs) remain the pharmacological treatment of choice and are associated with improved health-related quality of life. Improvements are usually sustained over time as long as treatment is continued. Discontinuation is associated with relapse and loss of quality of life, implying that treatment should continue long-term. A substantial minority of patients who fail to respond to SSRIs may benefit from dose elevation, switch to clomipramine, or adjunctive antipsychotic, though long-term trials validating the effectiveness and tolerability of these strategies are relatively lacking.
Family Accommodation in OCD
Authors: Koller Kristin , Lebowitz Eli R.
Published: October 2017

The impact of psychiatric disorders often goes beyond the affected individual, extending to family members, partners, and close friends. This is certainly true in obsessive-compulsive disorder (OCD). Clinical experience and empirical research have long shown that relatives of individuals with OCD commonly become involved in the symptoms of the disorder, through a process known as family accommodation. Family accommodation has important implications for the conceptualization, clinical course, and treatment of OCD. This chapter provides a brief review of family accommodation in OCD and its implications for the disorder’s clinical course. It also addresses the role of family accommodation in treatment response and highlights some novel interventions that have incorporated a focus on family accommodation in OCD treatment programs.
Intensive Treatment Approaches for OCD
Authors: Nadeau Joshua M. , Riemann Bradley C. , Storch Eric A.
Published: October 2017

This chapter provides a review of the varied levels of care for OCD, including intensive outpatient (IOP), day treatment or partial hospitalization (PHP), and residential treatment programming, and concludes with a discussion of future directions for the practice. Obsessive-compulsive disorder (OCD) is associated with significant functional impairment. Although there is a strong evidence base to support treatment for OCD in both youth and adults, namely cognitive-behavioral therapy and antidepressant medications, many patients do not respond fully to first-line interventions and there are multiple barriers to treatment which limit access. Intensive treatment has the potential for addressing many such barriers (i.e., augmentation, access to care, etc.).
Trichotillomania and Skin Picking Disorder
Authors: Grant Jon E. , Redden Sarah A. , Leppink Eric W.
Published: October 2017

This chapter summarizes the clinical characteristics and treatment of trichotillomania and skin picking disorder (excoriation), collectively known as body focused repetitive behavior disorders. These two conditions are found in the new chapter on OCD and related disorders in DSM-5; skin picking disorder is a new DSM diagnosis. They are conceptualized as related to OCD due to the repetitive nature of the symptomatology, but they also differ in important ways. The neural underpinnings of these disorder are only beginning to come into focus, and much work is needed. The best-proven psychotherapy for these conditions is a form of CBT known as habit reversal therapy. Principles of pharmacotherapy are not clearly established, though there have been promising early studies of a number of agents.
Mood and Anxiety Disorder Comorbidity in OCD
Authors: Baer L. , Fang A. , Berman N. C. , Minichiello W. E.
Published: October 2017

Primary OCD, like primary anxiety disorders, has high rates of both current and lifetime comorbidity, with a range of mood and anxiety disorders typically greater than 50% and 75%, respectively. This chapter begins with a review of several recent large-scale studies of OCD sufferers on three continents, indicating high levels of mood and anxiety comorbidity. Possible explanations for this high degree of comorbidity are reviewed, including flaws in the current diagnostic system and personality, neurobiological, and cognitive problems that may underlie both OCD and comorbid disorders; this may also account for their considerable phenomenological overlap. It reviews the lack of strong evidence for a negative impact of mood or anxiety comorbidity on OCD treatment outcome, and provides guidance for clinicians in: (1) differential diagnosis between OCD and related conditions including social anxiety, generalized anxiety, illness anxiety, and depression, and (2) suggestions to tailor exposure-based treatment for OCD sufferers with these comorbidities.
Personality Pathology in OCD
Authors: Wheaton Michael G. , Pinto Anthony
Published: October 2017

This chapter reviews the literature on personality pathology in obsessive-compulsive disorder (OCD). It begins by comparing and contrasting OCD with obsessive-compulsive personality disorder (OCPD). These two conditions have a longstanding yet frequently misunderstood relationship. Though they share some overlapping features, recent research has established OCD and OCPD as distinct conditions. Even so, OCD and OCPD frequently cooccur. The chapter reviews the literature on comorbidity and the impact of OCPD on the clinical course and treatment of OCD, including evidence that OCPD may complicate OCD treatment. It also describes other personality disorders observed in OCD. Finally, it describes recent advances in the conceptualization of personality disorders, including dimensional approaches, and concludes with directions for future research.
Living with OCD
Authors: McIngvale Elizabeth
Published: October 2017

Living with obsessive-compulsive disorder raises lifelong challenges—not only the daily struggle with symptoms, but also challenges to educate oneself, one’s family, and one’s peers; the search for effective treatment; and the ongoing battle with stigma. This closing chapter provides a personal narrative of one individual’s experience.
Instant Neurological Diagnosis
Authors: Hawkes Christopher H. , Sethi Kapil D. , Swift Thomas R.
Published: October 2017

Experienced neurologists work fast. They ask few questions, maybe perform a brief examination, and come up with the right answer. Sometimes they do neither and their conclusions are accurate—but how do they do it? Traditionally, the diagnostic process includes pattern recognition and probabilistic, causal, or deterministic methods. The aeronautical expert uses so-called demons—which are essentially memorized diagnostic shortcuts that help to solve problems rapidly. In this text they are called Handles. Another complementary diagnostic process is the use of caveats, or Red Flags, which are negative Handles in the sense that if one encounters a Red Flag, then the diagnosis should be reconsidered. This book provides diagnostic shortcuts, collected by the authors through their own observations, with many others identified at grand rounds and conferences. Thus a diagnosis may be reached rapidly by applying a mixture of Handles and Flags. The Handles and Flags are grouped into regions based on standard neurological history and examination, and others in relation to specific diseases. The book contains thirteen chapters, which for the most part focus on a particular neurological condition, namely demyelination, headache, epilepsy and sleep, myopathy and motor neuron disorders, movement disorders, stroke, peripheral neuropathy, cerebellar ataxia, and dementia. The remaining chapters are concerned with the clinician’s initial impressions (first encounters), cranial nerves, limbs and trunk, spinal lesions, and cerebrospinal fluid. At the end of each chapter is a summary of the salient points and a few key references. Most Handles, are illustrated by a table, figure, or video clip to reinforce a particular message.
Clinical approach
Authors: Firth Helen V. , Hurst Jane A.
Published: October 2017

This chapter introduces a list of clinical presentations seen in a genetics clinic or on the ward such as ambiguous genitalia including sex reversal, anterior segment eye malformations, ataxic adult, broad thumbs, cataract, cerebral palsy, cleft lip and palate, coloboma, congenital heart disease, developmental regression, dysmorphic child, dystonia, ear anomalies, floppy infant, fractures, holoprosencephaly, hydrocephalus, hypermobile joints, large fontanelle, limb reduction defect, lumps and bumps, microcephaly, nasal anomalies, nystagmus, overgrowth, post-axial polydactyly, retinal dysplasia, scalp defects, and more. The chapter outlines a practical clinical approach with relevant investigations to help to achieve an accurate genetic diagnosis, together with genetic advice, and a list of support groups.
Common consultations
Authors: Firth Helen V. , Hurst Jane A.
Published: October 2017

This chapter presents some of the disorders more commonly seen in a genetics clinic from achondroplasia to autosomal dominant polycystic kidney disease, Alport syndrome, androgen insensitivity syndrome, Angelman syndrome, Beckwith–Wiedemann syndrome, congenital adrenal hyperplasia, glaucoma, haemochromatosis, hereditary spastic paraplegias, Leigh encephalopathy, Marfan’s syndrome, Noonan syndrome, and many others. It gives an explanation of the clinical approach, the history, the examination, the investigation, and the diagnosis and lists the support groups.
Chromosomes
Authors: Firth Helen V. , Hurst Jane A.
Published: October 2017

This chapter lists a range of chromosomal disorders: the 22q11 deletion syndrome, Down’s syndrome (trisomy 21), Edwards’ syndrome (trisomy 18), ring chromosomes, sex chromosome mosaicism, triploidy, Turner syndrome, and others. For each of the syndromes, special focus is given to the main clinical features. The chapter goes on to outline the main clinical features and management, as well as listing the support groups.
Teaching Medical Students to Communicate With Empathy and Clarity Using Improvisation
Authors: Kaplan-Liss Evonne , Lantz-Gefroh Valeri , Bass Elizabeth , Killebrew Deirdre , Ponzio Nicholas M. , Savi Christine , O’Connell Christine
Published: October 2017

Problem

Medical educators widely accept that health care providers need strong communication skills. The authors sought to develop a course incorporating improvisation to teach health professions students communication skills and build empathy.

Approach

Teaching health care professionals to communicate more effectively with patients, the public, and each other is a goal of the Alan Alda Center for Communicating Science at Stony Brook University. The authors designed an interprofessional elective for medical, nursing, and dental students that differed in several respects from traditional communication training. The Communicating Science elective, which was offered by the Alda Center from 2012 to 2016, used verbal and nonverbal exercises, role-playing, and storytelling, including improvisation exercises, to teach students to communicate with empathy and clarity.

Outcomes

In course evaluations completed by 76 students in 2012 and 2013, 100% said they would recommend the course to fellow students, saw the relevance of the course content to their careers, and desired more of the course content in their school’s curriculum. As a result of this positive feedback, from 2014 to 2016, 10 hours of instruction pairing empathy and communication training was embedded in the preclinical curriculum at the Stony Brook University School of Medicine.

Next Steps

This course could be an effective model, and one that other institutions could employ, for improving communication skills and empathy in the next generation of health care professionals. Next steps include advocating for communication skills training to be embedded throughout the curriculum of a four-year medical school program.
Effects of Forced Air Warming on Airflow around the Operating Table
Authors: Shirozu Kazuhiro , Kai Tetsuya , Setoguchi Hidekazu , Ayagaki Nobuyasu , Hoka Sumio
Published: October 2017

Background

Forced air warming systems are used to maintain body temperature during surgery. Benefits of forced air warming have been established, but the possibility that it may disturb the operating room environment and contribute to surgical site contamination is debated. The direction and speed of forced air warming airflow and the influence of laminar airflow in the operating room have not been reported.

Methods

In one institutional operating room, we examined changes in airflow speed and direction from a lower-body forced air warming device with sterile drapes mimicking abdominal surgery or total knee arthroplasty, and effects of laminar airflow, using a three-dimensional ultrasonic anemometer. Airflow from forced air warming and effects of laminar airflow were visualized using special smoke and laser light.

Results

Forced air warming caused upward airflow (39 cm/s) in the patient head area and a unidirectional convection flow (9 to 14 cm/s) along the ceiling from head to foot. No convection flows were observed around the sides of the operating table. Downward laminar airflow of approximately 40 cm/s counteracted the upward airflow caused by forced air warming and formed downward airflow at 36 to 45 cm/s. Downward airflows (34 to 56 cm/s) flowing diagonally away from the operating table were detected at operating table height in both sides.

Conclusions

Airflow caused by forced air warming is well counteracted by downward laminar airflow from the ceiling. Thus it would be less likely to cause surgical field contamination in the presence of sufficient laminar airflow.
NICU Bereavement Care and Follow-up Support for Families and Staff
Authors: Levick Judy , Fannon Jane , Bodemann Janet , Munch Shari
Published: October 2017

Background:

Experiencing the death of an infant in the neonatal intensive care unit (NICU) affects both families and staff, creating challenges and opportunities for best practices.

Purpose:

This practice-based article describes a comprehensive approach to delivering bereavement services to NICU families, as well as education and support to NICU staff.

Methods:

Bereaved NICU parent and staff survey feedback, including quotes describing individual experiences and suggestions for improved service delivery.

Results:

Bereaved NICU families and caregivers find meaning and purpose in the act of creating keepsake memories at the time of the infant's death. Mutual healing takes place with subsequent, individualized follow-up contacts by staff familiar to the bereaved parents over the course of a year.

Implications for Practice:

Those staff involved in the care of a NICU infant and family, during and after the infant's death, attest to the value in providing tangible keepsakes as well as continuing their relationship with the bereaved parents. An effective administrative infrastructure is key to efficient program operations and follow-through.

Implications for Research:

Studying different methods of in-hospital and follow-up emotional support for NICU bereaved families. Identifying strategies for staff support during and after NICU infant loss, and the impact a formal program may have on staff satisfaction and retention.
Decreased Time to Antibiotic Prophylaxis for Open Fractures at a Level One Trauma Center
Authors: Johnson Joey P. , Goodman Avi D. , Haag Adam M. , Hayda Roman A.
Published: October 2017

Objective:

To determine whether time to administration of antibiotics decreased after the implementation of an open fracture working group and antibiotic prophylaxis protocol.

Design:

Retrospective cohort study.

Setting:

One Level 1 Trauma Center.

Patients:

Patients 18 years of age and older who sustained an open fracture and presented directly to our emergency department.

Intervention:

Prompt irrigation and debridement in the operating room and fracture stabilization dictated by the treating surgeon. Fifty patients were reviewed as the preintervention group, comprising the period before conception and before intervention. Fifty patients were included after the initiation of our protocol during the same time period 1 year later.

Main Outcome Measurements:

Time from entrance to the emergency department to ordering of antibiotics, time from ordering to administration of antibiotics, and time from entrance to the emergency department to administration of antibiotics.

Results:

After protocol implementation, time from admission to antibiotic administration decreased significantly from 123.1 to 35.7 minutes (P = 0.0003). Each component decreased significantly: admission to order decreased from 94.1 to 26.1 minutes, and order to administration decreased from 29.0 to 9.5 minutes (P = 0.0046 and P = 0.0003).

Conclusion:

Our study demonstrates a significantly reduced time to antibiotic prophylaxis for patients with open fractures after the implementation of a multidisciplinary working group. We hope that this provides a model for institutions to improve care and outcomes of these injuries.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Supracondylar Humeral Fracture Pearls and Pitfalls
Authors: Frick Steven L. , Mehlman Charles T.
Published: October 2017

Supracondylar humeral fractures are the most common type of pediatric elbow fracture. With proper treatment, these injuries usually heal well and the patients return to full function. However, a small percentage of these injuries may result in devastating complications and, thus, provoke anxiety in many surgeons treating them. This article provides tips for successful management of these injuries without complications and provides references for further study.
The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Ankle Fracture Pearls and Pitfalls
Authors: Parikh Shital N. , Mehlman Charles T.
Published: October 2017

Pediatric ankle fractures are common and have unique fracture characteristics because of the presence of distal tibial and fibular physes. When displaced (>3 mm widening of the physis or >2 mm intra-articular gap/step-off), these fractures are typically treated with anatomical reduction and internal fixation. Computed tomography is recommended for preoperative evaluation and surgical planning for intra-articular fractures. These fractures in younger children with substantial growth remaining should be followed closely to monitor for any growth disturbance. Pearls and pitfalls related to the treatment of these fractures would emphasize the physeal-respecting approach to their management.
The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Femoral Shaft Fracture Pearls and Pitfalls
Authors: Gordon J. Eric , Mehlman Charles T.
Published: October 2017

Pediatric femoral shaft fractures present many challenging patient care decisions. Nonoperative treatment approaches still dominate care of the youngest age groups while surgical intervention is commonplace in virtually all older children. Treatment is determined primarily by patient age as modified by clinical factors including mechanism of injury, weight, and skeletal maturity. Infants can be successfully treated by placement into a Pavlik harness, whereas children younger than 5 years are most commonly treated by early reduction and spica cast immobilization. Children aged up to 11 years are most commonly treated by flexible intramedullary nailing, whereas older children and adolescents, particularly with length unstable fractures should be treated with more rigid fixation such as lateral entry locked nails or submuscular plating.
The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Tibia Fracture Pearls and Pitfalls
Authors: Lovejoy Steven A. , Mehlman Charles T.
Published: October 2017

Tibial fractures in children present a wide array of challenges to the managing orthopaedic surgeon. Injuries cover a spectrum from subtle tibial spine fractures to comminuted high-energy shaft fractures requiring free flap coverage. Significant risks range from malunion and leg length discrepancy to infected nonunions and Volkmann ischemic contracture. This article offers evidence and experience-based advice that is aimed at helping the community orthopaedic surgeon taking call.
The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Forearm Shaft Fracture Pearls and Pitfalls
Authors: Herman Martin J. , Simon Matthew , Mehlman Charles T.
Published: October 2017

Pediatric forearm shaft fractures are the third most common fracture in children, and the forearm is the third most mobile joint in the body (with a nearly 180 degree arc of motion). The goals of treatment are aimed squarely at achieving satisfactory anatomic alignment (within defined parameters) as the consequences of malunion can be permanent forearm stiffness and deformity. Nonoperative treatment approaches still dominate care of the youngest age groups while surgical intervention has become increasingly common in older children. This article will offer evidence and experience-based tips intended to benefit the community orthopedic surgeon caring for children during the course of their on-call duties.
Aorto-Atrial Fistulas
Authors: Fierro Elizabeth A. , Sikachi Rutuja R. , Agrawal Abhinav , Verma Isha , Ojrzanowski Marcin , Sahni Sonu
Published: October 2017

Aorto-atrial fistulas (AAFs) are a relatively rare, but potentially life-threatening condition, where an anomalous connection forms between the aortic structures and the cardiac atria. AAFs are most often the result of an underlying condition concerning the cardiac structures. It may be congenital, secondary to conditions such as aortic dissection, infective endocarditis, or valve replacement, or iatrogenic in nature. Secondary causes incite local deterioration of cardiac wall integrity leading to formation of fistulous connections, whereas iatrogenic causes are more traumatic in nature. Signs and symptoms include those of volume overload and heart failure, with patients often presenting with fever, regurgitative murmurs, cardiac chamber dilation, and pedal edema. The diagnosis of AAFs requires a high degree of clinical suspicion necessitating imaging techniques such as echocardiography, computer tomography, and more invasive procedures. Management is dependent on underlying conditions and include the use of antibiotics, percutaneous closure, and in many cases, open heart surgery. It is important for physicians to be aware of this pathological condition to aid in timely management and favorable outcomes. This review attempts to summarize the various causes and clinical presentations of AAFs over the past decades.
Cutaneous Presentation of Mesothelioma With a Sarcomatoid Transformation
Authors: Klebanov Nikolai , Reddy Bobby Y. , Husain Sameera , Silvers David N. , Grossman Marc E. , Tsao Hensin
Published: October 2017

Malignant pleural mesothelioma is a rare neoplasm of mesodermal origin. Cutaneous involvement of malignant pleural mesothelioma is a very rare entity, with only 11 cases reported in the literature. Here, we describe the case of a 75-year-old man with stage IV epithelioid pleural mesothelioma, presenting with a cutaneous eruption 5 months after initial diagnosis, which revealed sarcomatoid features on skin biopsy. Histological analysis of malignancy progression through immunohistochemical staining of the pleural, lymph node, and skin tissue revealed gradual loss of calretinin and gain of desmin, supporting a transformation from epithelioid to sarcomatoid tissue. To our knowledge, this is the first reported case of an epithelioid to sarcomatoid transformation of malignant pleural mesothelioma manifesting in a cutaneous presentation.
Polyalkylimide: A Nonstable Filler Over Time
Authors: Schelke Leonie W. , Velthuis Peter J. , van Dijk Marijke R.
Published: October 2017

BACKGROUND

Polyalkylimide hydrogel is supposed to be a permanent, biocompatible implant. However, years after subcutaneous implantation clinical complications are seen.

OBJECTIVE

To increase the understanding of the changes that occur over time in this subdermal implanted filler.

MATERIALS AND METHODS

The extruded filler material of 34 patients was evaluated by histologic examination.

RESULTS

In most patients who had cosmetic disturbances but no complaints, histology showed no immune cells in or around the filler material. In patients with an acute inflammatory response, giant cell invasion was seen in and around the filler material. Patients with chronic complaints showed a neutrophilic cell influx in the extruded filler. In all patients, degeneration and calcification of the material was noted. The polyalkylimide hydrogel changed over time, both macroscopically and microscopically. As in most of the patients no immune response was seen around the filler material, this may indicate that the material is biocompatible.

CONCLUSION

The authors conclude that a dermal filler should not be judged solely on its biocompatible characteristics but also on the degradation process over time in the human body.
Selective ß1-Blockers Are Not Associated With New-onset Diabetes Mellitus in Hypertensive Patients
Authors: Park Yoonjee , Choi Byoung Geol , Rha Seung-Woon , Baek Man Jong , Ryu Yang Gi , Choi Se Yeon , Byun Jae Kyeong , Shim Min Suk , Mashaly Ahmed , Li Hu , Jang Won Young , Kim Woohyeun , Kang Jun Hyuk , Choi Jah Yeon , Park Eun Jin , Park Sung Hun , Lee Sunki , Na Jin Oh , Choi Cheol Ung , Lim Hong Euy , Kim Eung Ju , Park Chang Gyu , Seo Hong Seog , Oh Dong Joo
Published: October 2017

Background:

Although ß-blockers are known to increase new-onset diabetes mellitus (DM), previous evidence have been controversial. It has been suggested that newer vasodilatory ß-blockers yield better glycemic control than older nonselective agents. The aim of this study was to evaluate the diabetogenicity of currently used newer ß-blockers based on ß1 receptor selectivity in a series of Asian population.

Methods:

We investigated a total of 65,686 hypertensive patients without DM from 2004 to 2014. Patients with hemoglobin (Hb) A1c ≤6.0%, fasting blood glucose ≤110 mg/dL, and no history of diabetes or diabetic treatment were enrolled for analysis. Patients were divided into the ß-blockers group and non-ß-blockers group. Propensity score matching (PSM) analysis using a logistic regression model was performed to adjust for potential confounders. The primary end point was the cumulative incidence of new-onset DM, defined as a fasting blood glucose ≥126 mg/dL or HbA1c ≥6.5%, and major adverse cardiac and cerebral events (MACCE), defined as a composite of total death, nonfatal myocardial infarction, and cerebrovascular accidents. We investigated predictors of new-onset DM and MACCE based on 2 models, including clinical risk factors and co-medications, respectively.

Results:

Mean follow-up duration was 30.91 ± 23.14 months in the entire group before adjustment. The ß-blockers group had a significantly higher incidence of new-onset DM and MACCE than the non-ß-blockers group. After PSM, analysis of a total of 2284 patients (1142 pairs, C-statistic = 0.752) showed no difference between the 2 groups in new-onset DM or MACCE. In multivariate analysis after PSM, baseline HbA1c, stroke, heart failure, nonselective ß-blockers, and age were independent predictors of new-onset DM. Selective ß1-blockers did not increase new-onset DM after adjustment for other antihypertensive medication and statins.

Conclusions:

In the era of newer ß-blockers, selective ß1-blockers were not associated with new-onset DM. More evidence is needed to verify this relationship and the underlying mechanisms.
Dose–Effect of Irbesartan on Cyclooxygenase-2 and Matrix Metalloproteinase-9 Expression in Rabbit Atherosclerosis
Authors: Li Lihua , Li Juan , Yi Jing , Liu Hang , Lei Han
Published: October 2017

Irbesartan has previously shown antiatherosclerotic effects on human carotid atherosclerotic plaques. Our study aimed to assess the dose–effect of irbesartan on cyclooxygenase-2 (COX-2) and matrix metalloproteinase-9 (MMP-9) in rabbit atherosclerotic aorta. New Zealand rabbits were randomly divided into 6 groups: normal control (NC), high cholesterol (HC), low-dose (10 mg·kg−1·day−1), medium-dose (20 mg·kg−1·d−1), and high-dose (30 mg·kg−1·d−1) irbesartan and celecoxib (20 mg·kg−1·d−1). Except for the NCs, rabbits were fed a HC diet for 14 weeks to induce atherosclerosis. Aortic atherosclerotic lesions and messenger RNA and protein expression of COX-2, MMP-9, and nuclear factor-κB (NF-κB) were subsequently measured. The surface area of aortic atherosclerotic lesions was visibly larger in the HC group than in NCs (P < 0.01), but showed considerable reduction with medium- and high-dosage irbesartan and celecoxib treatments (P < 0.01). In medium- and high-dosage irbesartan and celecoxib groups, COX-2 and MMP-9 expression and NF-κB activity were significantly lower than in the high-cholesterol group (P < 0.01). No significant differences in treatment effects were observed between the high-dosage irbesartan and celecoxib groups (P > 0.05). Our results indicate that medium and high doses of irbesartan and celecoxib have antiatherosclerotic effects in aortic plaques via inhibition of COX-2 and MMP-9 by suppressing NF-κB activation. High-dose irbesartan has effects similar to celecoxib.
An Algorithmic Approach to Operative Management of Complex Pediatric Dog Bites: 3-Year Review of a Level I Regional Referral Pediatric Trauma Hospital
Authors: Alizadeh Kaveh , Shayesteh Ali , Xu Min Li
Published: October 2017

Background:

Incidence of dog bites continues to rise among the pediatric population and serves as a public health threat for the well-being of children. Plastic surgeons are at the forefront of initial management and eventual outcome of these devastating injuries. This study set out to determine the nature of dog bite injuries treated over a 3-year period at a large level 1 pediatric trauma center.

Methods:

A retrospective review of emergency room records of all pediatric patients (age, 0–18 years old) who sustained dog bites between January 2012 and December 2014 were gathered. All details about age of patient, location and severity of dog bites, type of dog breed, antibiotics given, and emergency versus operative treatment were recorded and analyzed.

Results:

One hundred eight patients aged 5 months to 18 years old were treated in the emergency department after suffering dog bite injuries during the study period. The highest incidence of dog bites occurred in preschool children. The mean age for patients who required operative repair was lower than the mean age for patients who underwent primary closure in the emergency department. The location of injury was most commonly isolated to the head/neck region. Of the 56 cases that had an identified dog breed, pit bulls accounted for 48.2% of the dog bites, and 47.8% of pit bull bites required intervention in the operating room.

Conclusion:

Children with large dog bite injuries require more immediate care in a level 1 pediatric trauma hospitals in order to optimize their hospitalization course and eventual outcome.