bluuebunny/crossref_metadata_2025 huggingface dataset:
Treating Pulsatile Exophthalmos in Child with Minimally Invasive Approach and Custom-made Titanium Mesh Plate
Authors: Moriwaki Yuta , Tomioka Yoko , Imai Hideaki , Iida Takuya , Yamashita Shuji , Kanayama Koji , Iwamoto Naoaki , Okazaki Mutsumi
Published: February 2019

Orbital roof fracture is a relatively rare trauma. In most cases, surgical intervention is not needed since the fracture is slight. However, invasive surgical procedures are inevitable once pulsatile exophthalmos occurs if vision impairment is to be avoided. We report our rare experience of orbital roof fracture in a child with pulsatile exophthalmos. Good reconstruction of the anterior cranial base was achieved using a custom-made titanium mesh and a minimally invasive approach. A 3-year-old girl who had been diagnosed with subdural hematoma, brain contusion, and fracture of the right orbital roof caused by facial bruising underwent emergent external decompression by coronal skin incision and a transcranial approach on the same day as the trauma. Cranioplasty using autologous frozen bone in the same approach was performed 103 days posttrauma, but this was followed by pulsatile exophthalmos. After recovering from critical stage, the girl was brought to our department for reconstruction of the anterior base. Risk of vision impairment was also one reason for reconstruction, but the neurosurgeon hesitated to approach the region using a coronal approach considering the possibility of infection in the frozen autologous bone. Through cross-team discussion, reconstruction using a subeyebrow incision was performed with a custom-made titanium mesh plate. Pulsatile exophthalmos completely disappeared. Pulsatile exophthalmos is a very rare but serious complication that carries a risk of vision impairment. By applying a custom-made titanium mesh plate, precise reconstruction was enabled with minimal invasiveness and low risk.
Collagenase Management of Multicord Dupuytren’s Disease under Intravenous Sedation: A Prospective Cohort Study
Authors: Wiseman Jeremy , Tree Kevin , Guio-Aguilar Pedro , Pratt George , Nizzaro Danielle , Leung Michael , Leong James
Published: February 2019

Background:

Surgery has been the standard of care in managing Dupuytren’s disease (DD). Recently collagenase of Clostridium histolyticum (CCH) has provided a less invasive alternative. The purpose of the current study is to present the early outcomes of a protocol for CCH involving treatment of multi-cord disease, and large patient cohorts.

Methods:

A cohort of 137 consecutive patients (Mean age 66 years, SD 9.85) with 225 joint contractures was treated with CCH at our institution between December of 2014 and January of 2017. A single standardized concentration of collagenase 2.31 mg/ml or 0.58 mg/dose was used for the treatment of up to 5 cords at a single session, and manipulation was 48 hours post-injection under intravenous sedation (IV). Patient complications, reduction in joint contracture, patient satisfaction and patient reported functional outcomes were assessed after one month.

Results:

137 patients received a total of 214 doses 0.58mg of CCH to treat 225 PIP and MCP joint contractures. The mean correction of joint contractures was 39.8 ± 2.2 and 27.9 ± 3.9 degrees for MCP and PIP joints respectively. 80% of patients, reported improved function and 89% of patients who were satisfied with the treatment.

Conclusions:

This study demonstrates a protocol for high throughput management of DD using collagenase and IV sedation for manipulation, logistically suited to the hospital setting. Efficacy was demonstrated treating patients with up to 5 cords, including those with bilateral disease. Future studies are needed to evaluate the durability of response in the medium and long term, and to evaluate cost benefits.
Dorsal Wrist Placement for Vascularized Submental Lymph Node Transfer Significantly Improves Breast Cancer–Related Lymphedema
Authors: Aljaaly Hattan A. , Fries Charles Anton , Cheng Ming-Huei
Published: February 2019

Background:

Vascularized submental lymph node flap transfer to the wrist is an effective treatment for breast cancer–related lymphedema. Dorsal placement was hypothesized to offer superior outcomes due to favorable venous drainage; however, the flap is more visible in this position compared with the volar side and was a cosmetic concern for patients. This study compared the treatment response of breast cancer–related lymphedema with the placement of vascularized submental lymph node flaps at the wrist, between dorsal and volar recipient sites.

Methods:

A retrospective longitudinal study examined 15 patients receiving vascularized submental lymph node flaps at the wrist performed by a single surgeon with a mean follow-up of 17 months. Clinical and biometric analyses, including quality of life questionnaires, circumference measurements, and number of infections were conducted.

Results:

All patients showed improvements in quality of life, reduced episodes of cellulitis, and reduced limb circumference measurements compared with preoperative data. Dorsal placement (n = 7) delivered significant reductions in limb circumference at all levels after 1 year (P = 0.04) and in overall function domains in the Lymphedema Specific Quality of Life Questionnaires (P = 0.04) compared with volar placement (n = 8). Venous outflow was greater in the dorsal recipient veins (P < 0.0001).

Conclusions:

Patients electing to undergo vascularized lymph node transfer to the wrist should be aware that when both options are effective, dorsal placement offers improvement in outcomes despite reduced cosmesis. These results have been incorporated into an evidence-based treatment algorithm that can inform the patient and physician on the decision-making in the breast and plastic surgical spheres.
Unilateral Reconstruction of the Large Breast: Combining Prosthetic and Autologous Methods for Improved Symmetry
Authors: Schwartz Jean-Claude
Published: February 2019

Postmastectomy reconstruction in patients with significant macromastia and/or large chest wall dimensions can be challenging. Implants have a limited size range and may not be large enough to adequately reconstruct a wide, obese patient. Abdominally based flaps may be unsafe in these patients if they have significant obesity and or other comorbidities and may still be insufficient to adequately fill a very large breast footprint. These problems are compounded in the patient who is not a candidate for an abdominal flap and who undergoes unilateral mastectomy as the contralateral breast, even after aggressive reduction, may still require volume and dimensions that cannot be easily replicated with prosthetic methods alone. Therefore, it seems reasonable to supplement our implant-based reconstructions with additional autologous tissue to reconstruct the breast after mastectomy to obtain acceptable symmetry with the large, contralateral native breast. Here, we report a case of combining the largest available anatomic implant with an extended lateral intercostal artery perforator flap to reconstruct a large breast and obtain symmetry with the native breast.
Relationship Between Optical Coherence Tomography Angiography Peripapillary Vessel Density and Lamina Cribrosa Depth
Authors: Eah Kyu Sang , Shin Joong Won , Sung Kyung Rim
Published: February 2019

Précis:

Peripapillary vessel density (pVD) assessed by optical coherence tomography angiography (OCT-A) has poor global and regional correlations with lamina cribrosa depth (LCD), except for the inferotemporal area.

Purpose:

To investigate the global and regional relationship between the pVD assessed by OCT-A and LCD assessed by enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT).

Methods:

A total of 38 eyes of 38 healthy subjects and 38 eyes of 38 glaucoma patients were included. Peripapillary microvasculature and lamina cribrosa were imaged by OCT-A and enhanced depth imaging SD-OCT, respectively. The pVD and LCD were measured at temporal, superotemporal, superonasal, nasal, inferonasal, and inferotemporal sectors. Global and regional correlations between pVD and LCD were evaluated in all subjects.

Results:

The pVD (59.0±2.6 vs. 54.4±5.4%) and LCD (318.5±76.4 vs. 404.6±92.5 μm) were significantly different between healthy and glaucoma subjects. The average pVD assessed by OCT-A was not significantly correlated with average LCD assessed by SD-OCT (r=−0.160, P=0.167). Regional correlation between pVD and LCD was statistically significant only in the inferotemporal sector (r=−0.301 and P=0.008). In the linear regression analysis, reduced pVD was independently associated with decreased visual field mean deviation and peripapillary retinal nerve fiber layer thickness but not with increased LCD.

Conclusions:

Global and regional correlations between pVD and LCD were poor except for the inferotemporal sector. This finding suggests that peripapillary microvascular impairment may not result directly from posterior lamina cribrosa displacement.
Risk Factors for Glaucoma Drainage Device Exposure in a Middle-Eastern Population
Authors: Al-Beishri Ali S. , Malik Rizwan , Freidi Alia , Ahmad Sameer
Published: February 2019

Précis:

In this case-control study, female sex, and older age were risk factors for tube exposure; risk was related to the number of prior ocular surgeries and scleral patch graft (compared with pericardial graft) was found to protect against exposure.

Purpose:

Identification of potential risk factors for glaucoma drainage device (GDD) exposure may help to prevent this potentially blinding complication. The purpose of this study was to evaluate the possible risk factors for GDD exposure in a tertiary eye care center in the Middle-East.

Methods:

A retrospective case-control study was undertaken for a 7-year period (2008 to 2015 inclusive). All patients who presented with a GDD incident exposure were identified and were compared with a similar number of controls (without exposure) identified during the same period. Demographic factors, past ocular history, treatment, and surgical technique were recorded for both groups. Bivariate and multivariable analyses were used to identify possible risk factors for tube exposure.

Results:

A total of 836 patients underwent GDD surgery during this time period and 53 patients were identified with exposure, giving a cumulative incident exposure rate of 6.3% (0.9% per year). Bivariate analysis showed that the median age of cases (51 years) was similar to controls (53 years) (P=0.95), while there was a greater proportion of women with exposure (49%) compared with the control group (28%) with a statistically significant difference (P=0.028). The number of previous surgeries (3.77±2.1) was significantly higher (P=0.018) in the exposure group (4.25±2.0) compared with controls (3.3±2.0). With each unit increase in the number of previous surgeries, the odds of exposure significantly increased by 1.29 (95% confidence interval, 1.05-1.57). In the multivariable regression, female sex (P=0.006) and older age (P=0.025) were significant risk factors and use of a scleral patch (P=0.02) graft potentially protective.

Conclusions:

Previous surgery, female sex, and older age are potential risk factors identified in our study. The use of scleral patch graft is potentially protective against GDD extrusion. Further study is needed to elucidate the reasons for these causative and protective factors.
Combined Left Ventricular Assist Device and Coronary Artery Bypass Grafting Surgery: Should We Bypass the Bypass?
Authors: Mehta Priya , Imamura Teruhiko , Juricek Colleen , Sarswat Nitasha , Kim Gene , Raikhelkar Jayant , Song Tae , Ota Takeyoshi , Jeevanandam Valluvan , Sayer Gabriel , Uriel Nir
Published: February 2019

Left ventricular assist devices (LVADs) have become a mainstay of therapy for advanced heart failure. Although selected patients undergo concomitant coronary artery bypass grafting (CABG) at the time of LVAD implantation, the detailed implication of this combined surgical approach is not yet well studied. In this study, all ischemic cardiomyopathy patients who underwent concomitant CABG during LVAD implantation between 2010 and 2016 were enrolled. A control group matching for age, gender, and device type, were selected. Of 79 LVAD patients finally included, 28 patients underwent concomitant CABG (CABG group); whereas 51 did not (non-CABG group). There was no difference in the baseline characteristics between groups. There was a trend toward longer cardiopulmonary bypass time in the CABG group (169 vs. 147 min; p = 0.09). One month survival in the CABG group was significantly lower than the non-CABG group (75.0% vs. 94.1%; p = 0.014). No difference in the occurrence of ventricular arrhythmias was detected between the groups, nor was there a difference in the incidence or severity of right ventricular failure. Concomitant CABG surgery during LVAD implantation may carry significant perioperative mortality, and addition of CABG to LVAD surgery may be performed only in strictly selected cases.
Normothermic Regional Perfusion for Controlled Donation After Circulatory Death: A Technical Complication During Normothermic Regional Perfusion
Authors: Brogi Etrusca , Circelli Alessandro , Gamberini Emiliano , Russo Emanuele , Benni Marco , Pizzilli Giancinto , Agnoletti Vanni
Published: February 2019

Organ retrieved from donors after circulatory deaths (DCD) is vulnerable of the effects of warm ischemia with important consequence on graft survival and posttransplant outcome. Preservation techniques, such as normothermic regional perfusion (NRP), can be used to reduce the effects of the cardiac arrest and to generate a continuous flow to the organs, resulting in a better preservation of the organs for transplantation. However, technical complications may occur during NRP which can compromise the retrieve of donors’ organs. We present a case report of a technical complication arisen during an NRP for DCD. During the extracorporeal circuit, we observed a dramatical decrease in the blood flow with excessive negative inlet pressure. It was because of a later recognized venous cannula malposition. In fact, we did not perform the radiological control for wire position. As a consequence, our clinical practice was modified. Currently, a radiological control of the wire is performed before the insertion of the catheter. Even if the donation was accomplished successfully, we reckon that it is fundamental to describe the technical issue that may occur during perfusion technique in order to improve the safety and the effectiveness of these procedures.
Pulsatile Conduit Pressure Gradients in the HeartWare HVAD
Authors: Jain Pankaj , Shehab Sajad , Stevens Michael , Macdonald Peter , Jansz Paul , Hayward Christopher
Published: February 2019

We evaluated mean, peak, and instantaneous pressure gradients across the outflow conduit in a pulsatile mock circulation loop which incorporated Heartware HVADs for left ventricular (LV) and right ventricular (RV) support. Steady-state 50 Hz measurements of left ventricular assist device (LVAD) flow (Q) and pressures within the proximal and distal outflow conduit were obtained at varying pump speed, LV contractility, hematocrit (HCT), heart rate (HR), and conduit diameter and length. Experiments were conducted using polyvinyl chloride (PVC) tubing and results confirmed in HVAD Gelweave conduit. Conduit diameter was negatively and nonlinearly associated with mean and peak gradient in both the PVC and HVAD conduits. There were no significant differences between the PVC and HVAD conduits in terms of mean Q, systolic dQ/dt, mean conduit gradient, or peak gradient. Across the 10 mm HVAD conduit, mean gradient correlated linearly with mean Q, systolic dQ/dt, HCT, and conduit length (r
2 = 0.91), whereas peak gradient correlated with mean Q, systolic dQ/dt, and conduit length (r
2 = 0.93). A nonlinear model to determine instantaneous gradient was highly predictive (r
2 = 0.83) across a range of pump and circulatory conditions. In summary, hemodynamically significant pressure gradients are observed across the LVAD outflow conduit under physiologic conditions, which may result in diminished pump flow.
Cellular Dissociation Grading Based on the Parameters Tumor Budding and Cell Nest Size in Pretherapeutic Biopsy Specimens Allows for Prognostic Patient Stratification in Esophageal Squamous Cell Carcinoma Independent From Clinical Staging
Authors: Jesinghaus Moritz , Brühl Frido , Steiger Katja , Klare Peter , Reiser Marianne , Scheiter Alexander , Konukiewitz Björn , Kuhn Peer , Münch Stefan , Quante Michael , Schmid Roland M. , Wilhelm Dirk , Feith Markus , Friess Helmut , Combs Stephanie E. , Saur Dieter , Boxberg Melanie , Weichert Wilko
Published: February 2019

Initial treatment planning in esophageal squamous cell carcinoma mainly relies on clinical staging. Recently, a highly prognostic grading system based on the cellular dissociation parameters Tumor Budding and Cell Nest Size has been proposed for resected esophageal squamous cell carcinoma. To probe for the transferability and relevance of this established novel grading system in the pretreatment setting, we evaluated Tumor Budding/Cell Nest Size in pretherapeutic biopsies of either primarily resected (cohort 1, n=80) or neoadjuvantly treated (cohort 2, n=75) esophageal squamous cell carcinoma. Grading data were correlated with clinicopathologic and survival parameters. High Tumor Budding Activity and small Cell Nest Size in pretherapeutic biopsies were strongly associated with shortened overall survival, disease-free survival, and disease-specific survival in both cohorts. A modified histopathologic grading system incorporating both factors termed “Cellular Dissociation Grade” showed excellent prognostic demarcation between well (G1), moderately (G2), and poorly differentiated (G3) carcinomas in both scenarios (overall survival: cohort 1: P<0.001; cohort 2: P=0.009) and was predictive for a high pathologic tumor stage and the presence of nodal metastases in primarily resected patients. Multivariate analyses revealed the Cellular Dissociation Grade to be a predictor of poor outcome in the pretherapeutic setting independent of clinical stage (overall survival, disease-free survival, and disease-specific survival: P<0.001). Hazard ratio for disease-free survival was 3.19 for G2 and 5.66 for G3 carcinomas compared with G1 neoplasms. Our data not only prove the transferability of histopathologic grading based on Tumor Budding/Cell Nest Size to biopsy specimens in esophageal squamous cell carcinoma, but also demonstrate that the Cellular Dissociation Grade is a strong outcome predictor in this entity even in the pretreatment scenario. Therefore, we believe that this novel type of grading has the ability to serve as a powerful histology-based pretherapeutic biomarker, that might supplement clinical staging for choosing the most suitable therapy decision.
Atypical “Sclerosing” Osteoblastic Neoplasm
Authors: McHugh Kelsey E. , Reith John D. , Lucas David R. , Emory Cynthia L. , Mesko Nathan W. , Kilpatrick Scott E.
Published: February 2019

The existence of “aggressive” osteoblastoma (OB) or malignant transformation of OB is controversial. Over a few decades, we have encountered a group of “borderline” sclerosing osteoblastic lesions that are difficult to classify, tending toward local recurrence, especially following curettage. A search of the consultative and institutional files from 3 co-authors for atypical OB, malignant transformation of OB, well-differentiated osteosarcoma (OS), and OB-like OS diagnoses revealed 8 similar cases. There were 6 males and 2 females, ages 11 to 55 years (mean, 26 y). Three arose in metatarsals, 2 in the fibula, and 1 each in the humerus, tibia, and femur. Radiologically, most were expansile, lytic to sclerotic, with circumscribed and at least partially sclerotic borders. Pathologically, all displayed a predominant, sclerosing sheet-like neoplastic bone growth pattern, associated with minor components of conventional OB. No solid sheets of osteoblasts or permeation of surrounding bone were identified. Six cases were reviewed by >1 expert orthopedic pathologist, often with divergent opinions. Four were initially diagnosed as OB, 2 as low-grade OS, 1 as high-grade OS, and 1 as atypical sclerosing osteoblastic neoplasm. Clinical follow-up for 7 patients ranged from 12 to 138 months (mean, 71 mo). Four underwent curettage only; 2, curettage and en bloc resection with negative margins; 1, en bloc intralesional resection, and 1 amputation. 5 locally recurred, with 3 “reclassified” as OSs. One local recurrence was considered dedifferentiation. Whether these tumors represent low-grade OSs or aggressive forms of OB remains unclear. We recommend classifying these neoplasms as “atypical sclerosing osteoblastic neoplasm” and performing complete resection with negative margins.
State Health Officials: Backgrounds and Qualifications
Authors: Yeager Valerie A. , Menachemi Nir , Jacinto Corey M. , Chapple-McGruder Theresa , Danielson Elizabeth C. , Halverson Paul K.
Published: February 2019

Context:

State health officials (SHOs), the executive and administrative leaders of state public health, play a key role in policy development, must be versed in the relevant/current evidence, and provide expertise about health issues to the legislature and the governor.

Objective:

To provide an empirical examination of SHO backgrounds and qualifications over time.

Design, Setting, and Participants:

Cross-sectional survey of current/former SHOs.

Main Outcome Measures:

State health official educational backgrounds; public health experience; previous employment setting.

Results:

Two-thirds of respondents (64.6%) reported having a medical degree, approximately half (48.3%) a formal public health degree, and almost one-quarter (21.8%) a management degree. The majority had governmental public health experience at some prior point in their career (70.0%). Almost two-thirds worked in governmental public health immediately before becoming an SHO. The proportion that was female increased significantly by decade from 5.6% in the 1970s/80s to 46.4% in the 2010s (P = .02).

Conclusions:

The main finding from this study shows that more than two-thirds of SHOs have had governmental public health experience at some point in their career. This is not a new trend as there were no statistical differences in public health experience by decade. More than half of the SHOs were appointed to the role directly from governmental public health, indicating that their public health experience is timely and likely germane to their appointment as SHO. Findings also indicate improvements in gender diversity among one of the most influential leadership roles in governmental public health whereas significant changes in racial and ethnic diversity were not identified. Women are increasingly being appointed as SHOs, indicating increasing gender diversity in this influential position. Given that governmental public health employees are predominantly women, there is still room for gender equity improvements in executive leadership roles. This is coupled with the need for further racial and ethnic diversity improvements as well.
Cost of Responding to the 2017 University of Washington Mumps Outbreak: A Prospective Analysis
Authors: Pike Jamison , Schwartz Sheryl , Kay Meagan , Perez-Osorio Ailyn , Marin Mona , Jenkins Mark , Routh Janell , Duchin Jeff , DeBolt Chas , Zhou Fangjun
Published: February 2019

Objectives:

To estimate costs of labor and materials by the University of Washington (UW) and state and local public health departments (PHDs) to respond to the February to June 2017 UW mumps outbreak, where 42 cases were identified among students (primarily sorority and fraternity members), staff, and associated community members.

Design:

We applied standard cost analysis methodology using a combined public health and university perspective to examine the cost of responding to the outbreak.

Setting:

UW's Seattle campus encompasses 703 acres with approximately 32 000 undergraduate students. Nearly 15% of the undergraduate population are members of fraternities or sororities. Housing for the fraternities and sororities is adjacent to the UW campus and consists of 50 houses.

Participants:

During the outbreak, customized costing tools based on relevant staff or faculty positions and activities were provided to the UW and Public Health–Seattle & King County, populated by each person participating in the outbreak response, and then collected and analyzed. Laboratory hours and material costs were collected from the Washington Department of Health and the Minnesota Department of Health.

Main Outcome Measure:

Labor and material costs provided by the UW and PHDs during the outbreak were collected and categorized by payer and activity.

Results:

Total costs to the UW and PHDs in responding to the outbreak were $282 762 ($6692 per case). Of these, the UW spent $160 064, while PHDs spent $122 098. Labor accounted for 77% of total outbreak costs, and UW response planning and coordination accounted for the largest amount of labor costs ($75 493) overall.

Conclusions:

Given the current university and public health department budget constraints, the response to the outbreak amounted to a significant use of resources. Labor was the largest driver of costs for the outbreak response; UW labor costs—related to campus response planning and coordination—dominated the total economic burden from public health and university perspectives.
Potential Effect of Vouchers on the Completion of Self-management Education Among Patients With Diabetes
Authors: Lyonnais Mary Jane , Bray Paul , Rafferty Ann P. , Winterbauer Nancy L. , Bell Ronny A.
Published: February 2019

Diabetes is a significant public health problem in eastern North Carolina, and completion of formal diabetes self-management education (DSME) is low. To seek methods to increase DSME completion, patients with diabetes in an eastern North Carolina regional health care system who had not completed DSME (n = 58) were surveyed during wellness visits to examine attitudes toward the use of vouchers (eg, coupons that purchase healthy food, exercise classes, gym memberships). There was an extremely low awareness (19%) of and referral (5%) to DSME. Most respondents (77%) said they would or might be more likely to complete DSME if they received a voucher at the end. Vouchers for healthy food venues such as farmers' markets were most preferred, and 6 months or less was found to be an acceptable time frame to use the voucher. This study offers some evidence for DSME providers to explore vouchers as one approach to increase program completion.
Effect of Mature Adipocyte-Derived Dedifferentiated Fat Cells on Formation of Basement Membrane after Cultured Epithelial Autograft on Artificial Dermis
Authors: Soejima Kazutaka , Kashimura Tsutomu , Kazama Tomohiko , Matsumoto Taro , Nakazawa Hiroaki
Published: February 2019

Background:

Artificial dermis is an important option for preparing full-thickness wounds for cultured epithelial autografting. Long-term fragility after cultured epithelial autografting remains a problem, probably because of the lack of basement membrane proteins. The authors hypothesized that treating artificial dermis with mesenchymal stem cells would promote basement membrane protein production. The authors tested this using dedifferentiated fat cells in a porcine experimental model.

Methods:

This study used four male crossbred (Landrace, Large White, and Duroc) swine. Cultured epithelium and dedifferentiated fat cells were prepared from skin and subcutaneous fat tissue harvested from the cervical region. Full-thickness open dorsal wounds were created and treated with artificial dermis to prepare a graft bed for cultured epithelial autograft. Two groups were established: the control group (artificial dermis treated with 0.5 ml of normal saline solution applied to the wounds) and the dedifferentiated fat group (artificial dermis treated with 0.5 × 105dedifferentiated fat cells suspended in 0.5 ml of normal saline solution sprayed onto the wounds). On postoperative day 10, the prepared cultured epithelium was grafted onto the generated dermis-like tissue. Fourteen days later, tissue specimens were harvested and evaluated histologically.

Results:

Light microscopy of hematoxylin and eosin–stained sections revealed the beginning of rete ridge formation in the dedifferentiated fat group. Synthesis of both collagen IV and laminin-5 was significantly enhanced in the dedifferentiated fat group. Transmission electron microscopy revealed a nearly mature basement membrane, including anchoring fibrils in the dedifferentiated fat group.

Conclusion:

Combined use of artificial dermis and dedifferentiated fat cells promotes post–cultured epithelial autograft production and deposition of basement membrane proteins at the dermal-epidermal junction and basement membrane development, including anchoring fibrils.
Predictive Factors of Duration of Continuous Renal Replacement Therapy in Acute Kidney Injury Survivors
Authors: Baek Seung Don , Kang Jae-Young , Shin Seulgi , Park Hyang-Sook , Kim Mi-Soon , Kim So Mi , Lee Eun Kyoung , Chang Jai Won
Published: February 2019

The factors influencing continuous renal replacement therapy (CRRT) duration for critically ill patients with acute kidney injury (AKI) are unclear. Therefore, we investigated the clinical factors that could influence the duration of CRRT for AKI survivors. In this retrospective observational study, the medical records of all hospital survivors who required CRRT for AKI in intensive care units were analyzed. The CRRT duration (median, 6 days) was categorized as short-duration CRRT (≤ 6 days, n = 65) and long-duration CRRT (> 6 days, n = 59), according to the median CRRT duration. A urine output of less than 0.5 mL/kg/h (adjusted odds ratio [OR], 3.4; P = 0.010), mechanical ventilation use (adjusted OR, 7.9; P = 0.001), and extracorporeal membrane oxygenation (ECMO) use (adjusted OR, 6.5; P = 0.010) were independent predictors of long-duration CRRT, whereas serum creatinine and neutrophil gelatinase-associated lipocalin were not significant predictors. A clinical model demonstrated a good discriminatory ability to predict long-duration CRRT (area under the curve, 0.84; 95% confidence interval, 0.76–0.90). The urine output immediately before CRRT initiation and factors associated with disease severity significantly affected the duration of CRRT. Simultaneously considering the urine output, mechanical ventilation use, and ECMO use predicted CRRT duration in AKI survivors.
Mechanical Circulatory Support in Refractory Vasodilatory Septic Shock: a Randomized Controlled Porcine Study
Authors: Chvojka Jiri , Martinkova Vendula , Benes Jan , Valesova Lenka , Danihel Vojech , Nalos Lukas , Matejovic Martin
Published: February 2019

As controversy persists regarding the benefits of mechanical circulatory support in septic shock with a predominantly vasoplegic phenotype, preclinical studies may provide a useful alternative to fill the actual knowledge gap. Here, we investigated the physiologic responses to venoarterial extracorporeal membrane oxygenation therapy (VA-ECMO) in a clinically relevant porcine peritonitis-induced model of refractory vasodilatory septic shock. In 12 anesthetized, mechanically ventilated, and instrumented domestic pigs, septic shock was induced by intraperitoneally inoculating autologous feces. After reaching the threshold for refractory vasodilatory shock (norepinephrine dose ≥1 μg/kg/min), the pigs were randomized into the conservative treatment group (control) or the VA-ECMO group (target flow 100 mL/kg/min). The time to develop refractory vasodilatory shock was similar in both groups (18.8 h in the ECMO group, 18.1 h in the control group). There was no difference between the groups in terms of time to death measured from the point of reaching the predefined vasopressor threshold (7.1 h for the ECMO group, 7.9 h for the control group). The initiation of ECMO resulted in a markedly increased fluid and vasopressor support. Although treatment with ECMO compromised neither renal nor carotid blood flow initially, both progressively decreased later during the experiment. The pattern of sepsis-induced multiorgan injury, alterations in energy metabolism, and the systemic inflammatory response were remarkably similar between both groups. In conclusion, the application of VA-ECMO in this model of peritonitis-induced refractory vasodilatory septic shock aggravated hemodynamic deterioration. Our findings contribute to increasing equipoise with respect to the clinical utility of VA-ECMO in refractory vasodilatory shock.
Desire for Continued Pessary Use Among Women of Hispanic and Non-Hispanic Ethnic Backgrounds for Pelvic Floor Disorders
Authors: Gupta Ankita , Cox Carol , Dunivan Gena C. , Gaskins Jeremy T. , Rogers Rebecca G. , Iglesia Cheryl B. , Meriwether Kate V.
Published: February 2019

Objective

This study aimed to describe the association between patient ethnicity/race and desire to continue using a pessary for the treatment of pelvic floor disorders.

Methods

We performed a secondary analysis of a randomized trial among women presenting for pessary fitting. The primary outcome was the desire to continue using a pessary at 3 months. Bacterial vaginosis by Nugent score and vaginal symptoms (discharge, itching, pain, sores) were also evaluated. Logistic or multiple linear regression was performed with correction for body mass index, education level, parity, Charlson Comorbidity Index, and randomization to TrimoSan gel.

Results

One hundred fourteen women (41 Hispanic and 73 non-Hispanic) were eligible for this analysis. Women self-identified as white (65/114; 57%), Hispanic (41/114, 36%), Asian (3/114; 2.6%), Native American (4/114; 3.5%), and “other” (1/114, 0.9%) race, with no self-identified African American women (0/114) meeting the inclusion criteria. No significant difference in desire to continue pessary use was found between Hispanic and non-Hispanic women (58.5% vs 63%; P = 0.69; corrected odds ratio [cOR], 1.11; 95% confidence interval [CI], 0.43–2.90) or across races (P = 0.89). Hispanic women had significantly higher risk of bacterial vaginosis (34% vs 16%; P = 0.04; cOR, 2.91; 95% CI, 1.01–8.39), higher Nugent scores (5.4 ± 2.3 vs 4.3 ± 2.3; P = 0.02; corrected coefficient, 1.10; 95% CI, 0.10–2.10), and more vaginal pain (17.1% vs 2.8%; P = 0.01; cOR, 9.14; 95% CI, 1.37–61.17) at 3 months.

Conclusions

Despite increased vaginal pain and vaginal microbiome disturbances in Hispanic women using a pessary, no significant differences in the desire to continue using the pessary existed.
Anatomical Outcomes Based on Suturing Technique During Vaginal Mesh Attachment in Robotic Sacrocolpopexy
Authors: Bazzi Ali A. , Osmundsen Blake C. , Hagglund Karen H. , Aslam Muhammad Faisal
Published: February 2019

Objectives

In this study, we assessed the difference in anatomical outcomes using the barbed, self-anchoring, delayed absorbable suture when compared with the traditional knot-tying interrupted suture technique during vaginal mesh attachment in robotic sacrocolpopexy. In addition, we compared the rates of mesh erosion with the 2 techniques.

Methods

This is a retrospective cohort study of 131 women who underwent minimally invasive robotic sacrocolpopexy at 2 sites. There were 65 subjects at site 1 (barbed, self-anchoring, delayed absorbable suture) and 66 from site 2 (traditional knot-tying technique). The primary outcome was anatomical success (measured by all Pelvic Organ Prolapse Quantification System points <0 postsurgery) in the barbed suture technique at site 1 compared with the traditional knot-tying technique at site 2. The secondary outcome was mesh erosion rates at these sites.

Results

In the barbed suture group, performed at site 1, 98% (n = 59/60) had postoperative success at the 3-month follow-up period compared with 62% (n = 40/65) in the traditional knot-tying group at site 2 during the 12-month postoperative follow-up (P < 0.0001). During this time period, 2% (n = 1) in the barbed suture group and 8% (n = 5) in the traditional knot-tying group experienced sacrocolpopexy mesh erosion (P = 0.208).

Conclusions

Our results indicate that the barbed, self-anchoring, delayed absorbable suture is associated with less anatomical failures compared with traditional knot tying. The use of barbed suture is a safe technique and can be adopted in place of the traditional knot-tying technique. We also found less mesh erosion in the barbed suture group.
The Quality of Health Information Available on the Internet for Patients With Fecal Incontinence
Authors: Kadam-Halani Priyanka K. , Lee Daniel D. , Sammel Mary D. , Arya Lily A. , Andy Uduak U.
Published: February 2019

Objective

The aim of this study was to assess the quality of information available through the Internet for a variety of search terms for fecal incontinence (FI).

Methods

Using the Google search engine, searches were performed for 4 terms: “bowel control problem,” “accidental bowel leakage,” “fecal incontinence,” and “leaking stool.” The DISCERN quality analysis tool and JAMA benchmark criteria were implemented by 2 independent reviewers to evaluate the first 20 search results for each term. To determine if 1 term provided higher-quality information, mean DISCERN and JAMA criteria scores as well as Web site category were compared using analysis of variance and Pearson χ2 tests.

Results

Mean DISCERN scores for all terms fell in the middle range of possible scores. DISCERN questions addressing risks of treatment options, effects of treatment on quality of life, and gaps in knowledge/differences in expert opinion had the lowest scores across all search terms (range of scores, 1.1–1.7/5). JAMA criteria on authorship and attribution were most frequently missing on average in 48 of 80 and 42 of 80 Web sites, respectively. There were significant differences in mean DISCERN scores among the terms, with “fecal incontinence” yielding the highest mean score. The term “accidental bowel leakage” yielded the highest number of marketing Web sites, whereas “leaking stool” had the highest proportion of social Web sites.

Conclusions

The quality of available information about FI on the Internet is variable, and key components are often missing. The term “fecal incontinence” yielded the highest quality information of all search terms.
Willingness of Women With Pelvic Floor Disorders to Use Mobile Technology to Communicate With Their Health Care Providers
Authors: Lee Daniel D. , Arya Lily A. , Andy Uduak U. , Sammel Mary D. , Harvie Heidi S.
Published: February 2019

Objectives

The aim of this study was to assess willingness of women with pelvic floor disorders to adopt nontraditional mobile communication methods with health care providers.

Methods

This is a cross-sectional study of women with pelvic floor disorders. Women completed a survey regarding what technology they owned, how they utilized it, and their willingness to use technology to communicate with providers.

Results

Overall mobile technology ownership was high; however, older women were significantly less likely to own a smartphone (75%) compared with younger (100%) and middle-aged women (98%; P < 0.01). On univariable analysis, factors significantly associated with willingness to use mobile technology were age (P < 0.01) and education status (P < 0.01). A relationship between travel distance to the clinic and willingness to adopt various mobile technologies was not noted. On multivariable analysis, after controlling for education and travel distance to clinic, older women remained significantly less likely to express willingness to use various technologies: video-conference technology (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95–0.99), text messaging (OR, 0.94; 95% CI, 0.91–0.97), Internet-based patient portal (OR, 0.96; 95% CI, 0.94–0.98), and e-mail (OR, 0.94; 95% CI, 0.91–0.98). However, almost 50% of older women and greater than 65% of middle-aged women expressed willingness to adopt technologies for health care communication.

Conclusions

Age-related differences exist in the ownership, utilization, and willingness to communicate with medical providers through mobile technology. However, the majority of women across all age-groups, irrespective of travel distance, are willing to adopt alternative mobile technologies to communicate with their health care providers.
Considering Low Health Literacy: How Do the Pelvic Floor Distress Inventory—Short Form 20 and Pelvic Floor Impact Questionnaire—Short Form 7 Measure Up?
Authors: Spencer Jordan , Hadden Kristie , Brown Heidi , Oliphant Sallie S.
Published: February 2019

Objective

The objective of this study was to evaluate the readability and understandability of 2 commonly used pelvic floor disorder questionnaires, Pelvic Floor Distress Inventory—Short Form 20 (PFDI-20) and Pelvic Floor Impact Questionnaire—Short Form 7 (PFIQ-7), in a low health literacy patient population.

Methods

Flesh-Kincaid, SMOG, Fry, and FORCAST readability assessment tools were used to assign US grade levels to each questionnaire (PFDI-20, PFIQ-7). Two health literacy experts used PEMAT and ELF-Q tools to determine understandability, organization, content, and quality of each form. A focus group of women with low health literacy used Stop Light Coding and a facilitator-prompted discussion to further evaluate understandability and critique the forms.

Results

The PFIQ-7 required higher reading ability compared with PFDI-20 (ninth to 11th vs sixth to eighth mean grade level equivalents). Expert and focus group reviews identified concerns regarding purpose, formatting, and word choice in both forms. Focus group participants recommended assistance with questionnaire completion from clinical staff and gave mean overall ratings of 5.4 (0–10/worst to best) for PFDI-20 and 8.0 for PFIQ-7.

Conclusions

Knowledge of potential barriers to understanding and completion may improve utilization of and accuracy of patient responses to PFDI-20 and PFIQ-7 in women with low health literacy.
Obstetrical Anal Sphincter Injuries and the Need for Adequate Care
Authors: Elliot Victoria , Yaskina Maryna , Schulz Jane
Published: February 2019

Background

An estimated 4% to 6.6% of women delivering vaginally sustain obstetrical anal sphincter injuries (OASI). Despite this, a gap exists in the provision of postpartum care to women globally. Given the negative impact of OASI, action is needed, and multidisciplinary perineal clinics can help. Consequently, such a clinic was established in 2011 at the Royal Alexandra Hospital (RAH), a tertiary care center in Edmonton, Alberta.

Objective

This study assesses the state of perineal clinics specializing in OASI internationally and locally by investigating the literature for descriptions of specialized perineal clinics for women with OASI, describing the RAH perineal clinic, and assessing the prevalence of OASI at the RAH in the context of the clinic.

Methods

A search of peer-reviewed literature was conducted on Medline and observations and interviews of RAH perineal clinic staff were conducted, as was a medical chart review.

Results

Articles describing only 10 perineal clinics specializing in OASI were found, with varying structures. The multidisciplinary RAH clinic, like one other clinic, has a strong physiotherapy focus, with education and Pilates classes and one-on-one appointments offered by pelvic floor physiotherapists. In 2016, of the 326 (6.9%) vaginal deliveries that resulted in OASI at the RAH, only 66.0% (215) were referred to the clinic.

Conclusions

Multidisciplinary perineal clinics are needed globally. Despite the creation of the perineal clinic at the RAH, women continue to lack specialized care after OASI. It is crucial that healthcare professionals specializing in OASI share their experiences to establish best practices and create new, and improve existing, perineal clinics.
Predictive Factors of Postdischarge Narcotic Use After Female Pelvic Reconstructive Surgery
Authors: Ramaseshan Aparna S. , Tunitsky-Bitton Elena , O’Sullivan David M. , Reagan Krista M. L. , Steinberg Adam C.
Published: February 2019

Objective

The aim of the study was to evaluate the association of patient factors, amount of in-hospital postoperative narcotics, and pain scores on postdischarge narcotic use (PDNU).

Methods

This is a secondary analysis of a randomized controlled trial comparing a postoperative usual-care regimen with multimodal pain regimen after pelvic reconstructive surgery. This analysis evaluated patients in the multimodal arm. Postdischarge narcotic use (as mg oral morphine equivalents, MME, calculated from narcotic tablets remaining) was assessed postoperative days 7 to 10. Brief Pain Inventory (BPI) surveys were collected preoperatively and at postoperative day 1. Patient factors were evaluated using univariate and multivariate analysis. Correlations examined the relationships between PDNU and postoperative in-hospital narcotic use and BPI scores.

Results

Sixty-eight patients randomized to the multimodal pain regimen arm had median (interquartile range) PDNU of 22.5 (0–159.4) MME. After excluding postdischarge narcotic nonusers (34.8%), the median PDNU was 127.5 (22.5–180.0) MME. The median PDNU was 172.5 (150.0–180.0) MME after abdominal reconstructive surgery (n = 7), 82.5 (28.1–180.0) MME after laparoscopic reconstructive surgery (n = 22), and 37.5 (13.1–181.2) MME after vaginal reconstructive surgery (n = 14). A linear correlation was noted between the amount of postoperative narcotics used in-hospital and the amount needed postdischarge after abdominal (r = 0.588, P = 0.057), laparoscopic (r = 0.439, P = 0.019), and vaginal (r = 0.455, P = 0.017) reconstructive surgeries. The BPI scores on postoperative day 1 for “average” pain (r = 0.388, P = 0.002) and “now” pain (r = 0.490, P < 0.001), and on postoperative week 1 for “average” pain (r = 0.383, P = 0.002) and “now” pain (r = 0.389, P = 0.002) correlated with PDNU.

Conclusions

Amount of postoperative in-hospital use of narcotic medications and BPI scores can be valuable predictors of PDNU in patients undergoing pelvic reconstructive surgery.
A 3-Dimensional Anatomical Education Model in Postpartum Perineal Laceration Care: A Pre-Post Intervention Study
Authors: Koury Hannah , Corral Janet , Bastow Brittney D. , Sheeder Jeanelle , Muffly Tyler M.
Published: February 2019

Objective

The aim of this study was to investigate the effects of postpartum patients introduction to and interaction with a virtual 3-dimensional (3D) pelvic model on the self-care, knowledge, and anxiety parameters.

Methods

The model was designed from computed tomography data displaying the involvement of the levator ani in a fourth-degree perineal laceration. This 3D model was used to educate postpartum day 1 patients at the bedside. Patient data were collected using a pre and post questionnaire assessing knowledge, anxiety, and confidence in perineal wound self-care.

Results

Thirty-six patients were enrolled with a median age of 28.5 years (interquartile range, 31, 21.75 years) and a median parity of 1 (interquartile range, 2, 1). Patient use of the tool significantly decreased patient anxiety regarding perineal lacerations (P < 0.01) and significantly increased patient knowledge on what part of their vagina was lacerated during vaginal delivery (P < 0.01).

Conclusions

Reviewing a 3D model of perineal lacerations with patients on postpartum day 1 is associated with less anxiety and increased knowledge of pelvic floor anatomy. These pilot data represent a preliminary investigation into the relations between 3D model of perineal lacerations and a range of patient outcomes.