bluuebunny/crossref_metadata_2025 huggingface dataset:
Short-term Impact of Assisted Deliveries
Authors: Rakza Thameur , Butruille Laura , Thirel Lucille , Houfflin-Debarge Veronique , Logier Régis , Storme Laurent , De Jonckheere Julien
Published: November 2017

Objectives:

Assisted deliveries (ADs) are used in current practice by obstetrical teams during labor when the fetus is likely to face difficulties. In this study, we hypothesized that pain related to instrumental delivery could impair autonomic nervous system (ANS) activity.

Materials and Methods:

We investigated infants born by spontaneous delivery (SD group, n=35) and those whose deliveries were assisted by vacuum, forceps, or both (AD group, n=35) between the second and fourth hours of life. Pain was evaluated using the Echelle de Douleur et d’Inconfort du Nouveau-Né/Neonatal Pain and Discomfort Scale (EDIN) behavioral pain scale. ANS activity was analyzed using the newborn infant parasympathetic evaluation (NIPE) index, a heart rate variability based index which is related to the autonomic activity mediated by the parasympathetic nervous system.

Results:

Neonates in the AD group presented higher EDIN scores than neonates born by spontaneous vaginal deliveries (SD group) (P<0.0001). In contrast, the NIPE index was significantly reduced in the AD group compared with the SD group (P=0.005). A significant inverse correlation was found between the NIPE index and the EDIN score (r=−0.287, P=0.016).

Discussion:

ADs (vacuum, forceps, or both) are associated with persistent pain after birth, unlike normal vaginal deliveries. Moreover ADs are associated with reduced NIPE. Taken together, our results suggest that pain related to instrumental delivery impairs the ANS activity.
The Middle Ear Muscle Reflex in Rat: Developing a Biomarker of Auditory Nerve Degeneration
Authors: Chertoff Mark E. , Martz Ashley , Sakumura Joey T. , Kamerer Aryn M. , Diaz Francisco
Published: November 2017

Objectives:

The long-term goal of this research is to determine whether the middle ear muscle reflex can be used to predict the number of healthy auditory nerve fibers in hearing-impaired ears. In this study, we develop a high-impedance source and an animal model of the middle ear muscle reflex and explore the influence of signal frequency and level on parameters of the reflex to determine an optimal signal to examine auditory nerve fiber survival.

Design:

A high-impedance source was developed using a hearing aid receiver attached to a 0.06 diameter 10.5-cm length tube. The impedance probe consisted of a microphone probe placed near the tip of a tube coupled to a sound source. The probe was calibrated by inserting it into a syringe of known volumes and impedances. The reflex in the anesthetized rat was measured with elicitor stimuli ranging from 3 to 16 kHz presented at levels ranging from 35 to 100 dB SPL to one ear while the reflex was measured in the opposite ear containing the probe and probe stimulus.

Results:

The amplitude of the reflex increased with elicitor level and was largest at 3 kHz. The lowest threshold was approximately 54 dB SPL for the 3-kHz stimulus. The rate of decay of the reflex was greatest at 16 kHz followed by 10 and 3 kHz. The rate of decay did not change significantly with elicitor signal level for 3 and 16 kHz, but decreased as the level of the 10-kHz elicitor increased. A negative feedback model accounts for the reflex decay by having the strength of feedback dependent on auditory nerve input. The rise time of the reflex varied with frequency and changed with level for the 10- and 16-kHz signals but not significantly for the 3-kHz signal. The latency of the reflex increased with a decrease in elicitor level, and the change in latency with level was largest for the 10-kHz stimulus.

Conclusions:

Because the amplitude of the reflex in rat was largest with an elicitor signal at 3 kHz, had the lowest threshold, and yielded the least amount of decay, this may be the ideal frequency to estimate auditory nerve survival in hearing-impaired ears.
OPTICAL COHERENCE TOMOGRAPHY 2
Authors: Cereda Matteo G. , Corvi Federico , Cozzi Mariano , Pellegrini Marco , Staurenghi Giovanni
Published: November 2017

Purpose:

To investigate the utility of new wide-field optical coherence tomography (OCT) device in the evaluation of mid and far retinal periphery and to show its feasibility and advantages in clinical practice.

Methods:

Consecutive patients underwent a complete ophthalmologic examination including standard OCT and new prototype OCT2 derived from Heidelberg Spectralis.

Results:

Thirty-one eyes of 31 patients were studied with a total of 44 lesions, including 18 retinal detachments, 15 retinal holes and tears, 9 retinoschisis, and 2 retinal tufts. Fourteen (32%) lesions were found in mid and 30 (68%) in far periphery with 9 (20%) lesions in the superior region, 10 (23%) in the superior temporal, 8 (18%) in the temporal, 4 (9%) in the inferior temporal, 7 (16%) in the inferior, 4 (9%) in the nasal, and 2 (5%) in the superior nasal. Among the lesions evaluated by OCT2, 10 (71%) in mid periphery and 11 (37%) in far periphery could be imaged by standard OCT.

Conclusion:

The introduction of OCT2 into clinical practice may provide significant benefits for imaging peripheral retinal disorders. The application of OCT2 technology with 55° lens and scan length and angle modulation could improve our understanding of peripheral vitreoretinal disorders and facilitate their management.
Acquired Infection and Antimicrobial Utilization During Initial NICU Hospitalization in Infants With Congenital Diaphragmatic Hernia
Authors: Keene Sarah , Murthy Karna , Pallotto Eugenia , Brozanski Beverly , Gien Jason , Zaniletti Isabella , Hulbert Cheryl , Seabrook Ruth , Rintoul Natalie , Chicoine Louis , Porta Nicolas , Grover Theresa R.
Published: November 2017

Background:

In addition to substantial medical and surgical intervention, neonates with congenital diaphragmatic hernia often have concurrent concerns for acquired infection. However, few studies focus on infection and corresponding antimicrobial utilization in this population.

Methods:

The Children’s Hospital Neonatal Database was queried for congenital diaphragmatic hernia infants hospitalized from January 2010 to February 2016. Patient charts were linked to the Pediatric Health Information Systems database. Descriptive clinical data including delivery history, cultures sent, diagnosed infection, antimicrobial use and outcomes were reported.

Results:

A total of 1085 unique patients were identified after data linkages; 275 (25.3%) were born at <37 weeks’ gestation. Bacteremia at delivery (2/1085) and in the first 7 days of life (8/1085) was less common than later infection, but 976 patients (89.9%) were treated with antibiotics. Median number of days on antibiotics was 6 [3,11] for those without a documented infection and 21 [13,36] for those with positive cultures. Incidence of urinary tract infection, bacteremia and pneumonia increased significantly over time and was most common after 28 days. Antibiotic use, conversely, decreased over time (92% of infants in week 1 to 44% in week 4 and beyond).

Conclusions:

Although culture positivity increased with age, risk of these selected infections was relatively low for a population in neonatal intensive care unit. An important mismatch is observed between culture negativity and high rates of antibiotic utilization. These data identify opportunities for antibiotic stewardship quality improvement programs.
Treatment of Acute Otitis Media in the Pediatric Emergency Department
Authors: Rothman Sarah , Pitaro Jacob , Hackett Asher , Kozer Eran , Gavriel Haim , Muallem-Kalmovich Limor , Eviatar Ephraim , Marom Tal
Published: November 2017

Background:

Over-treatment of acute otitis media (AOM) with antibiotics is common, and poses a high burden on health-care systems.

Methods:

Records of children 6–36 months of age with AOM visiting a university-affiliated pediatric emergency department between 2014 and 2016 were reviewed for the treatment given: watchful waiting versus antibiotics. If antibiotics were prescribed, the type and duration were recorded. We evaluated appropriate and inappropriate treatment rates of eligible AOM cases, in respect to the local guidelines, which encourage watchful waiting in most mild–moderate cases.

Results:

Out of 1493 AOM visits, 863 (57.8%) were boys, with a median age of 14.9 months (interquartile range, 9–19). The overall pre-visit antibiotic rate was 24.1%, but among those children examined by a physician, this rate was 95.2%. Amoxicillin was the most common antibiotic, administered in 66.3% of the cases. Only 21 children (5.8%) had been treated with antibiotics for ≥7 days before their visit, and were considered as treatment failure. Antibiotic therapy upon discharge was recorded in 1394/1449 visits (96.2%), again with amoxicillin as the most common antibiotic therapy, in 80.8% of the cases. In these visits, the average duration of antibiotic treatment was 8.29 days. Appropriateness of treatment (watchful waiting or antibiotics) could be analyzed in 1134 visits; 20.9% were considered as inappropriate. Of them, 98.3% were prescribed with the wrong antibiotic type and duration.

Conclusions:

Adherence rate to the local guidelines treatment recommendations for uncomplicated AOM was high, as measured by whether appropriate treatment was given and type and duration of antibiotics.
Introduction of Routine HIV Birth Testing in the South African National Consolidated Guidelines
Authors: Moyo Faith , Haeri Mazanderani Ahmad , Barron Peter , Bhardwaj Sanjana , Goga Ameena Ebrahim , Pillay Yogan , Sherman Gayle G.
Published: November 2017

Background:

South Africa represents the first high-burden setting to introduce routine virologic testing at birth within its early infant diagnosis program, implemented in June 2015. National HIV birth testing coverage, intrauterine transmission rates and case rates for the first year since introduction of universal birth testing are reported.

Methods:

HIV polymerase chain reaction (PCR) test data from June 2015 to May 2016 were extracted from the National Health Laboratory Service’s central data repository by year, month, age, result and geographic location. Birth testing was defined as all HIV PCR tests performed at <7 days of life; coverage as the proportion of all HIV-exposed neonates born who were tested at birth; estimated intrauterine transmission rate as the percentage of HIV PCR positive tests in HIV-exposed neonates tested and case rates as the number of HIV PCR positive tests per 100,000 total live births.

Results:

Between June 2015 and May 2016, the South African national monthly birth testing coverage increased from 39% (8636 tests) to 93% (20,479 tests). During this period, the number of positive tests at birth increased from 114 to 234 per month, equating to a national intrauterine transmission rate of 1.1% and a birth case rate of 247 per 100,000 live births.

Conclusions:

Universal birth testing for all HIV-exposed neonates is rapidly being achieved in South Africa, facilitating earlier detection of intrauterine infected neonates. However, the successful linkage into care of HIV-infected neonates and their treatment outcomes remain to be assessed.
Offering eConsult to Family Physicians With Patients on a Pain Clinic Wait List: An Outreach Exercise
Authors: Poulin Patricia A. , Romanow Heather C. , Cheng Jeannette , Liddy Clare , Keely Erin J. , Smyth Catherine E.
Published: November 2017

Wait times for many chronic pain programs in Canada range from 6 months to 2 years. This project sought to determine the interest of primary care providers (PCPs) in using an electronic consult system for patient(s) waiting for a pain consultation. This cross-sectional study was conducted at the pain clinic of a Canadian tertiary academic health sciences center. Participants were PCPs who had submitted a referral to this clinic. Referrals received between April 1, 2012, and March 31, 2014, were reviewed to determine their appropriateness for eConsult, and a letter providing information about eConsult and encouraging its use was sent to the referring PCP. Of the 585 referrals that were reviewed, 227 were appropriate for eConsult. Fifty-one (26%) of the 194 PCP responses received were positive. Technologies like eConsult may help address the growing demand for specialist advice. In addition to facilitating response to specific questions, the bidirectional nature of eConsult permits its use for educating PCPs about chronic pain treatment. Given that almost one third of responding PCPs indicated an interest in eConsult, its potential reach is vast. Additional study is needed to understand barriers to PCP acceptance and use of eConsult and the uptake of advice given.
Investigating Physicians' Views on Soft Signals in the Context of Their Peers' Performance
Authors: van den Goor Myra , Silkens Milou , Heineman Maas Jan , Lombarts Kiki
Published: November 2017

Background:

Physicians are responsible for delivering high quality of care. In cases of underperformance, hindsight knowledge indicates forewarning being potentially available in terms of concerns, signs, or signals. It is not known how the physicians involved perceive such signals.

Purpose:

To openly explore how physicians perceive soft signals and react on them.

Methods:

In-depth interviews with 12 hospital-based physicians from various specialties and institutions following the interpretative phenomenological analysis approach.

Results:

Physicians perceive soft signals as an observable deviation from a colleague's normal behavior, appearance, or communication. Once observed, they evaluate the signal by reflecting on it personally and/or by consulting others, resulting in either an active (i.e., speaking up) or passive (i.e., avoidance) reaction. Observer sensitivity, closeness to the peer, and cohesion of the physician group influence this observation–evaluation–reaction process.

Conclusions and Implications:

Physicians perceive soft signals as indicators of well-being and collegiality, not as concerns about performance or patient safety. They feel it is their responsibility to be sensitive to and deal with expressed signals. Creating a psychological safe culture could foster such an environment. Because a threat to physicians' well-being may indirectly affect their professional performance, soft signals require serious follow-up.
The Diagnostic Accuracy of Ultrasound in Detecting Distal Radius Fractures in a Pediatric Population
Authors: Ko Chae , Baird Matthew , Close Matthew , Cassas Kyle J.
Published: November 2017

Objective:

Sports ultrasound (US) is becoming popular in diagnosing musculoskeletal injuries. This study, also called the Pediatric Distal Radius Ultrasound Study (PeDRUS), compared the diagnostic accuracy of sports US with plain radiographs in possible distal radius buckle fractures in pediatric population.

Methods:

In this prospective observational study, patients (2-15 years) presenting to an outpatient orthopedic injury clinic with distal forearm injuries without deformity were recruited. Bedside ultrasonography was performed and interpreted by the investigators as positive or negative for fracture. Plain radiographs were then performed and interpreted by the same investigator. The radiographs were considered the definitive imaging study for this investigation.

Results:

Fifty-one patients were included with a mean age of 9.9 years. Fractures were diagnosed on both US and plain radiographs in 34 patients. Fractures were ruled out on both US and plain radiographs in 16 patients. There was only one case in which the US was interpreted differently than radiograph. For fractures of the distal radius in this population, the sensitivity was 97.1% [95% confidence interval (CI) = 89.2-97.1] and the specificity was 100% (95% CI = 82.5-100). The positive predictive value was 100% (95% CI = 91.8-100), whereas the negative predictive value was 94.1% (95% CI = 77.7-94.1). The positive likelihood ratio was infinite, suggesting utility in confirming a fracture. The negative likelihood ratio was 0.03 (95% CI = 0.03-0.13), suggesting that US has value in ruling out a fracture.

Conclusions:

Our study suggests that diagnostic sports US is sensitive and specific for detecting distal radius fractures in pediatric patients with nondeformed forearm injuries, demonstrating that US is an acceptable alternative to plain radiographs for evaluating fractures in a pediatric population.
Wake-up Call to Clinicians
Authors: Parekh Parth J. , Oldfield Edward C. , Johnson David A.
Published: November 2017

Sleep dysfunction is an epidemic affecting a large portion of the adult population. Recent studies have linked sleep dysfunction with an upregulation of proinflammatory cytokines (eg, tumor necrosis factor-α, interleukin-1 and interleukin-6), the implications of which can have a profound impact on a variety of gastrointestinal disease. In particular, sleep dysfunction seems to accelerate disease states characterized by inflammation (eg, gastroesophageal reflux disease, irritable bowel syndrome and functional dyspepsia, chronic liver disease, inflammatory bowel disease, and colorectal cancer). This article evaluates the complex interplay between sleep dysfunction and gastrointestinal health and disease.
Estimating Associations Between Medical Home Adoption, Utilization, and Quality
Authors: Martsolf Grant R. , Kandrack Ryan , Baird Matthew , Friedberg Mark W.
Published: November 2017

Background:

Methodological differences between evaluations of medical home adoption might complicate readers’ ability to draw conclusions across studies.

Objectives:

To study whether associations between medical home adoption and patient care are affected by methodological choices.

Design, Setting, and Subjects:

Among 71 practices participating in the Pennsylvania Chronic Care Initiative (a medical home pilot), we estimated cross-sectional and longitudinal associations between 4 definitions of “medical home adoption” [National Committee on Quality Assurance (NCQA) recognition in year 3, Medical Home Index scores at baseline and 3, and within-practice changes in Medical Home Index scores between baseline and year 3] and utilization and quality.

Measurements:

Six utilization and 6 quality measures.

Results:

In cross-sectional analyses at year 3, NCQA recognition was associated with higher rates of nephropathy monitoring (7.23 percentage points; confidence interval, 0.45–14.02), breast cancer screening (7.48; 2.11–12.86), and colorectal cancer screening (8.43; 2.44–14.42). In longitudinal analyses, NCQA recognition was associated with increases in hospitalization rates (2.75 per 1000 patient-months; 0.52–4.98). In baseline cross-sectional analyses, higher Medical Home Index scores were associated with fewer ambulatory care-sensitive hospitalizations (−0.61 per 1000 patient per month; −1.11 to −0.11), all-cause emergency department visits (−6.80; −12.28 to −1.32), and ambulatory care-sensitive emergency department visits (−5.60; 10.32 to −0.88). There were no statistically significant associations between any other measure of medical home adoption and quality or utilization.

Conclusions:

The findings of medical home evaluations are sensitive to methodological choices. Meta-analyses, narrative reviews, and other syntheses of medical home studies should consider subdividing their findings by analytic approach.
The Role of Mental Health Disease in Potentially Preventable Hospitalizations
Authors: Medford-Davis Laura N. , Shah Rohan , Kennedy Danielle , Becker Emilie
Published: November 2017

Background:

Preventable hospitalizations are markers of potentially low-value care. Addressing the problem requires understanding their contributing factors.

Objective:

The objective of this study is to determine the correlation between specific mental health diseases and each potentially preventable hospitalization as defined by the Agency for Healthcare Research and Quality.

Design/Subjects:

The Texas Inpatient Public Use Data File, an administrative database of all Texas hospital admissions, identified 7,351,476 adult acute care hospitalizations between 2005 and 2008.

Measures:

A hierarchical multivariable logistic regression model clustered by admitting hospital adjusted for patient and hospital factors and admission date.

Results:

A total of 945,280 (12.9%) hospitalizations were potentially preventable, generating $6.3 billion in charges and 1.2 million hospital days per year. Mental health diseases [odds ratio (OR), 1.25; 95% confidence interval (CI), 1.22–1.27] and substance use disorders (OR, 1.13; 95% CI, 1.12–1.13) both increased odds that a hospitalization was potentially preventable. However, each mental health disease varied from increasing or decreasing the odds of potentially preventable hospitalization depending on which of the 12 preventable hospitalization diagnoses were examined. Older age (OR, 3.69; 95% CI, 3.66–3.72 for age above 75 years compared with 18–44 y), black race (OR 1.44; 95% CI, 1.43–1.45 compared to white), being uninsured (OR 1.52; 95% CI, 1.51–1.54) or dual-eligible for both Medicare and Medicaid (OR, 1.23; 95% CI, 1.22–1.24) compared with privately insured, and living in a low-income area (OR, 1.20; 95% CI, 1.17–1.23 for lowest income quartile compared with highest) were other patient factors associated with potentially preventable hospitalizations.

Conclusions:

Better coordination of preventative care for mental health disease may decrease potentially preventable hospitalizations.
Successful Nonmyeloablative Allogeneic Stem Cell Transplant in a Child With Emberger Syndrome and GATA2 Mutation
Authors: Rastogi Neha , Abraham Roshini S. , Chadha Ritu , Thakkar Dhwanee , Kohli Shruti , Nivargi Sagar , Prakash Yadav Satya
Published: November 2017

Emberger syndrome with underlying guanine-adenine-thymine-adenine 2 (GATA2) mutation is a rare disorder and very few successful nonmyeloablative allogeneic hematopoietic stem cell transplants (HSCTs) have been reported. We report a case of Emberger syndrome with GATA2 mutation in a 9-year-old girl who presented with congenital sensorineural deafness, warts, lymphedema, and Myelodysplastic syndrome. Her sister had died of a similar illness. She underwent a nonmyeloablative matched related donor peripheral blood HSCT with rabbit antithymoglobulin (5 mg/kg), fludarabine (160 mg/m2), cyclophophamide (29 mg/kg), and total body irradiation (2 Gray). Graft versus host disease prophylaxis consisted of tacrolimus and mycophenolate moefetil. She had neutrophil engraftment on day+15 and fully donor chimerism by day+30. She developed limited chronic skin graft versus host disease on tapering off immunosuppression. She is disease free on day+475. The review of literature showed a total of 28 patients with GATA2 mutation have undergone HSCT mostly nonmyeloablative and overall survival is 75%. Nonmyeloablatove HSCT is feasible and safe for the patients with GATA2 mutation.
Successful Treatment of a Very Late Isolated Relapse in an Adolescent With a PICALM-MLLT10 Positive T-lineage Acute Lymphoblastic Leukemia
Authors: Cannata Emanuela , Samperi Piera , Cimino Carla , Marino Silvia , Sullo Federica , Mirabile Elena , Di Cataldo Andrea , Russo Giovanna , Lo Nigro Luca
Published: November 2017

T-lineage ALL is an aggressive disease that needs to be treated with intensive treatment schedules. A late relapse rarely occurs and a clear choice for second-line treatment is on debate. We report on a young adult with a very late isolated extramedullary relapse of PICALM-MLLT10 positive T-ALL, successfully treated with a chemotherapy-based and radiotherapy-based pediatric protocol. We demonstrate that relapse can occur in T-ALL although a SR-MRD behavior treated with a high-risk protocol; specific molecular diagnostic aberrations, as PICALM-MLLT10, are still conserved at very late relapse; a second-line treatment based on pediatric protocol can be effective.
Steroid-induced Hypertension During Induction Chemotherapy for Acute Lymphoblastic Leukemia in US Children’s Hospitals
Authors: Bakk Ian , Koch Terah , Stanek Joseph , O’Brien Sarah H. , Reed Suzanne
Published: November 2017

Childhood acute lymphoblastic leukemia achieves excellent cure rates in part due to induction chemotherapy including high dose corticosteroids. Hypertension (HTN) is a known complication of corticosteroids, but incidence and risk factors for steroid-induced HTN are poorly understood. We sought to describe these using a large pediatric health database. Of the 5578 unique patients receiving induction chemotherapy, 14.7% received anti-HTN medications during their initial hospital admission. We found that age below 1 year, obesity, secondary diabetes mellitus, and abnormal glucose were associated with developing steroid-induced HTN. We also found that ICD-9 codes had poor sensitivity for detecting treatment of HTN, suggesting underreporting by physicians.
Understanding Disease Biology and Informing the Management of Pancreas Cancer With Preclinical Model Systems
Authors: Whittle Martin C. , Hingorani Sunil R.
Published: November 2017

Recent advances in cytotoxic therapies for pancreatic ductal adenocarcinoma (PDA) are overshadowed by stalled clinical progress of more targeted strategies, the vast majority of which have failed in clinical trials. Inability to translate preclinical promise into clinical efficacy derives, in part, from imperfect disease modeling and mismatches between preclinical and clinical study design and execution. Into these gaps fall our patients who enter the clinical trial landscape expectantly and bear the brunt of its inadequacies. If improving patient survival is paramount, then it must be acknowledged that the failure of a phase III trial represents a larger failure of all of the work that preceded it. Repeated failures suggest a need to reappraise the current preclinical-to-clinical apparatus. Exceptional models of PDA are now available to researchers, and the first steps toward a new era of success can begin with improved selection and application of these systems. We discuss the key features of the major preclinical platforms for PDA and propose a paradigm for rigorous interrogation of prospective therapies.
Diagnosis and Detection of Pancreatic Cancer
Authors: Chu Linda C. , Goggins Michael G. , Fishman Elliot K.
Published: November 2017

Computed tomography is the first-line imaging modality for suspected pancreatic cancer. Magnetic resonance cholangiopancreatography is a second-line modality for suspected pancreatic cancer and is usually reserved for equivocal cases. Both computed tomography and MR are highly sensitive in the detection of pancreatic cancer, with up to 96% and 93.5% sensitivity, respectively. Computed tomography is superior to MR in the assessment of tumor resectability, with accuracy rates of up to 86.8% and 78.9%, respectively. Close attention to secondary signs of pancreatic cancer, such as pancreatic duct dilatation, abrupt pancreatic duct caliber change, and parenchymal atrophy, are critical in the diagnosis of pancreatic cancer. Emerging techniques such as radiomics and molecular imaging have the potential of identifying malignant precursors and lead to earlier disease diagnosis. The results of these promising techniques need to be validated in larger clinical studies.
Clinical Management
Authors: White Rebekah R. , Lowy Andrew M.
Published: November 2017

Despite the identification of more active systemic therapy combinations for pancreatic cancer, cures remain elusive and feasible only in patients with localized, operable disease. When examining outcome data from phase III adjuvant trials conducted during the past decade, the survival for patients with localized disease has improved, likely owing to a combination of factors including more active adjuvant therapy and improved surgical and perioperative care. Perhaps the greatest recent change in the care of patients with localized pancreatic cancer has been the extension of surgery to tumors previously thought to be inoperable because of involvement of major blood vessels. These so-called “borderline resectable pancreatic cancers” have now been objectively defined, and their management is being studied in randomized trials. This has been made feasible by the availability of more active systemic therapy combinations that are increasingly being used in the neoadjuvant setting. Given the increasing activity of systemic regimens, the challenges in delivering such therapy in the postoperative setting, and the numerous novel agents in late stages of clinical development, it is reasonable to hypothesize that the neoadjuvant setting may eventually become the standard of care for patients with resectable disease.
Ablative Radiotherapy Doses for Locally Advanced
Authors: Crane Christopher H. , O’Reilly Eileen M.
Published: November 2017

Standard palliative doses of radiation for locally advanced unresectable pancreatic cancer have had minimal to no impact on survival. Randomized trials evaluating these palliative doses have not shown a significant survival benefit with the use of radiation as consolidation after chemotherapy. Results from nonrandomized studies of 3- to 5-fraction low-dose stereotactic radiation (SBRT) have likewise had a minimal impact, but with less toxicity and a shorter treatment time. Doses of SBRT have been reduced to half the level that is necessary (biological equivalent dose, BED of 53 Gy) to achieve tumor ablation in the treatment of other solid tumors (100 Gy BED) to protect the gastrointestinal (GI) tract. The survival benefit of these palliative options is modest. In contrast, ablative doses of radiation (100 Gy BED) can be delivered using the same SBRT technique in 15 to 25 fractions. In addition to precision tumor targeting and solutions for respiratory motion as with SBRT, the delivery of ablative doses takes advantage of heterogeneous dosing, increased fractionation, which allows higher doses to be given, as well as adaptive planning to address day-to-day GI tract motion in selected cases. These higher doses have resulted in encouraging long-term survival results in multiple studies. In this review, we discuss the critical concepts and components of techniques that can be used to deliver ablative radiotherapy doses for patients with pancreatic tumors: fractionation, intentional dose heterogeneity, respiratory gating, image guidance, and adaptive planning.
A tonic heat test stimulus yields a larger and more reliable conditioned pain modulation effect compared to a phasic heat test stimulus
Authors: Lie Marie Udnesseter , Matre Dagfinn , Hansson Per , Stubhaug Audun , Zwart John-Anker , Nilsen Kristian Bernhard
Published: November 2017

Introduction:

The interest in conditioned pain modulation (CPM) as a clinical tool for measuring endogenously induced analgesia is increasing. There is, however, large variation in the CPM methodology, hindering comparison of results across studies. Research comparing different CPM protocols is needed in order to obtain a standardized test paradigm.

Objectives:

The aim of the study was to assess whether a protocol with phasic heat stimuli as test-stimulus is preferable to a protocol with tonic heat stimulus as test-stimulus.

Methods:

In this experimental crossover study, we compared 2 CPM protocols with different test-stimulus; one with tonic test-stimulus (constant heat stimulus of 120-second duration) and one with phasic test-stimuli (3 heat stimulations of 5 seconds duration separated by 10 seconds). Conditioning stimulus was a 7°C water bath in parallel with the test-stimulus. Twenty-four healthy volunteers were assessed on 2 occasions with minimum 1 week apart. Differences in the magnitude and test–retest reliability of the CPM effect in the 2 protocols were investigated with repeated-measures analysis of variance and by relative and absolute reliability indices.

Results:

The protocol with tonic test-stimulus induced a significantly larger CPM effect compared to the protocol with phasic test-stimuli (P < 0.001). Fair and good relative reliability was found with the phasic and tonic test-stimuli, respectively. Absolute reliability indices showed large intraindividual variability from session to session in both protocols.

Conclusion:

The present study shows that a CPM protocol with a tonic test-stimulus is preferable to a protocol with phasic test-stimuli. However, we emphasize that one should be cautious to use the CPM effect as biomarker or in clinical decision making on an individual level due to large intraindividual variability.
Long-Term Patient-Reported Outcomes following Free Flap Lower Extremity Reconstruction for Traumatic Injuries
Authors: Egeler Sabine A. , de Jong Tim , Luijsterburg Antonius J. M. , Mureau Marc A. M.
Published: November 2017

Background:

Reconstruction of severe lower extremity injuries using free flaps has become a reliable approach. Knowledge of long-term surgical outcomes, limb function, and quality of life is limited.

Methods:

Two hundred thirty-nine patients undergoing a free flap reconstruction of an open lower extremity fracture between 1993 and 2014 were divided into three groups and studied, as follows: group 1, early free flap reconstruction within 6 weeks; group 2, delayed reconstruction after 6 weeks; and group 3, delayed reconstruction with osteomyelitis. Patient-reported outcomes were assessed with the 36-Item Short-Form Health Survey and the Lower Extremity Functional Scale. Independent variables predicting outcomes were identified using multivariate analyses.

Results:

Patients in group 3 significantly more often experienced delayed union. Questionnaires were completed by 108 patients (mean follow-up, 9.7 years). The 36-Item Short-Form Health Survey physical component scores were significantly lower in all three groups compared with Dutch norms, as was the mental health score in group 3. There were no significant differences in quality of life and lower limb function among the three groups. Chronic pain was an independent predictor for decreased quality of life and limb function in groups 1 and 2, as was delayed union for decreased limb function in group 3.

Conclusions:

After free flap reconstruction of severe lower extremity injuries, all patient groups showed significantly lower quality of life compared to the Dutch population; however, there were no significant differences between the groups. Predictors for poorer quality of life and limb function were chronic pain and delayed union.
Inconsistency in Automated Reports of Scientific Productivity and Impact in Academic Plastic Surgery
Authors: Plana Natalie M. , Massie Jonathan P. , Bekisz Jonathan M. , Fryml Elise M. , Spore Stuart , Diaz-Siso J. Rodrigo , Flores Roberto L.
Published: November 2017

Background:

Currently, no consensus metric for measuring academic productivity within plastic surgery exists. The h-index is widely used, as it captures both the quantity and quality of an individual’s contribution. However, discrepancies in online reporting make accurate h-index calculation challenging. This study highlights inconsistencies within plastic surgery by assessing differences in reporting of the h-index and other measures of academic productivity across online scientific databases.

Methods:

Plastic surgery faculty at institutions with Accreditation Council for Graduate Medical Education–accredited residency programs were identified and searched across four databases: Web of Science, Scopus, Google Scholar, and the National Library of Medicine (PubMed). The total number of publications, citations, and h-index were recorded for each author and analyzed using a Mann-Whitney test.

Results:

Seven hundred twenty-two faculty members were included in this study. Reporting of publications was highest in Google Scholar and lowest in Web of Science. Because of incomplete information (PubMed) and underuse (Google Scholar), h-index could be assessed only between Web of Science and Scopus, where the average discrepancy in citations and h-index was 722 and 7.0 per author, respectively. Discrepancies were more significant among faculty members holding a Ph.D. degree, higher academic rank, or belonging to the male gender.

Conclusions:

Inconsistencies between online scientific databases profoundly affect plastic surgeons. Given the importance placed on metrics such as the h-index, it is imperative that the plastic surgery community push for solutions that ensure more reliable, transparent, and cohesive reporting of academic productivity.
Quantification of the Effect of Shuttling on Computed Tomography Perfusion Parameters by Investigation of Aortic Inputs on Different Table Positions From Shuttle-Mode Scans of Lung and Liver Tumors
Authors: Ghosh Payel , Chandler Adam G. , Hobbs Brian P. , Sun Jia , Rong John , Hong David , Subbiah Vivek , Janku Filip , Naing Aung , Hwu Wen-Jen , Ng Chaan S.
Published: November 2017

Objectives

The aim of this study was to quantify the effect of shuttling on computed tomography perfusion (CTp) parameters derived from shuttle-mode body CT images using aortic inputs from different table positions.

Methods

Axial shuttle-mode CT scans were acquired from 6 patients (10 phases, 2 nonoverlapping table positions 1.4 seconds apart) after contrast agent administration. Artifacts resulting from the shuttling motion were corrected with nonrigid registration before computing CTp maps from 4 aortic levels chosen from the most superior and inferior slices of each table position scan. The effect of shuttling on CTp parameters was estimated by mean differences in mappings obtained from aortic inputs in different table positions. Shuttling effect was also quantified using 95% limits of agreement of CTp parameter differences within-table and between-table aortic positions from the interaortic mean CTp values.

Results

Blood flow, permeability surface, and hepatic arterial fraction differences were insignificant (P > 0.05) for both within-table and between-table comparisons. The 95% limits of agreement for within-table blood volume (BV) value deviations obtained from lung tumor regions were less than 4.7% (P = 0.18) compared with less than 12.2% (P = 0.003) for between-table BV value deviations. The 95% limits of agreement of within-table deviations for liver tumor regions were less than 1.9% (P = 0.55) for BV and less than 3.2% (P = 0.23) for mean transit time, whereas between-table BV and mean transit time deviations were less than 11.7% (P < 0.01) and less than 14.6% (P < 0.01), respectively. Values for normal liver tissue regions were concordant.

Conclusions

Computed tomography perfusion parameters acquired from aortic levels within-table positions generally yielded higher agreement than mappings obtained from aortic levels between-table positions indicating differences due to shuttling effect.
Comparing Fourth Generation Statistical Iterative Reconstruction Technique to Standard Filtered Back Projection in Pediatric Head Computed Tomography Examinations
Authors: Thomas Anna Kalathil , Southard Richard , Curran John , Augustyn Robyn
Published: November 2017

Objective

Although advanced statistical iterative reconstruction (IR) techniques are valued in pediatric computed tomography (CT) imaging, there is little published data on how these techniques affect image quality and radiation dose in the pediatric population. This is particularly true in the context of pediatric head CT examinations. This study analyzed the differences in image quality and several standard metrics of radiation dose on multidetector pediatric head CT examinations performed using standard filtered back projection (FBP) with reconstructions using iDose4, a fourth-generation statistical iterative reconstruction technique.

Materials and Methods

Using a retrospective review of 282 pediatric head CT examinations, we compared how iDose4 fared against FBP for effects on several standard metrics of radiation dose and qualitative and quantitative assessment of image quality.

Results

Our assessment revealed that examinations obtained using low-dose protocols reconstructed using iDose4, when compared with standard-dose examinations reconstructed using FBP, resulted in significant radiation dose reduction while performing equally or better in quantitative image quality parameters. For most qualitative image quality parameters, the iDose4 group demonstrated equal performance to standard filtered back technique with a few notable exceptions. In the parameter of image sharpness in the 1.5 to 7 year olds, iDose4 fared better than FBP. However, FBP outperformed iDose4 in the qualitative parameters of decreased image graininess/noise in patients older than 13 years, improved image sharpness in patients aged between 7 and 13 years, and improved visibility of small parts for those aged 7 to 13 years.

Conclusions

We conclude that iDose4 is effective at allowing significant radiation dose reduction while maintaining or, rarely, even improving quantitative image quality compared with FBP in the setting of pediatric head CT examinations. However, for certain qualitative image quality parameters in older-aged children, the use of iDose4 resulted in a poorer performance compared with FBP.
Artifactual Appearance of Thrombosis on Using Metal Artifact Reduction Software Reconstruction in Computed Tomographic Angiography
Authors: Thomas Richard , Aghayev Ayaz , Steigner Michael L.
Published: November 2017

The authors attempted to use metal artifact reduction software in 2 computed tomographic angiogram studies to decrease beam hardening. Although the beam hardening artifacts were reduced in the postprocessed images, there was an artifactual appearance of thrombosis in the adjacent arteries in the first case and in the inflow cannula of a left ventricular assist device in the second case. Comparison of the reconstructed images with the original images is therefore essential to avoid a misdiagnosis.
Intrahepatic Mass-Forming Cholangiocarcinoma: Relationship Between Computed Tomography Characteristics and Histological Subtypes
Authors: Nam Ju Gang , Lee Jeong Min , Joo Ijin , Ahn Su Joa , Park Jin Young , Lee Kyoung Bun , Han Joon Koo
Published: November 2017

Objective

The aim of this study was to determine the value of multi–detector row computed tomography (MDCT) in differentiating the small-duct (SD) and large-duct (LD) types of intrahepatic mass-forming cholangiocarcinomas (IMCCs) and predicting patient prognosis.

Methods

The 4-phase MDCT image findings of 82 patients with surgically confirmed IMCCs (60 SD-type and 22 LD-type IMCCs) were compared between 2 types using univariate and multivariate analyses. Overall survival rates for 78 patients with available information were compared using the Kaplan-Meier method.

Results

Arterial hyperenhancement, round or lobulated contour, and lack of bile duct encasement were significant MDCT features suggesting the SD type, and lymph node enlargement was significantly associated with the LD type (all P's < 0.05). The presence of those 3 SD-type-suggestive features (MDCT-suggested SD type) demonstrated high specificity (90.9% [20/22]) in differentiating the SD type. Patients of MDCT-suggested SD type without lymph node enlargement (n = 24) demonstrated significantly better overall survival than other groups.

Conclusions

Preoperative MDCT features of IMCCs can help differentiate the SD and LD types and predict patient prognosis.
Incidental Cardiac Findings in Non–Electrocardiogram-gated Thoracic Computed Tomography of Intensive Care Unit Patients: Assessment of Prevalence and Underreporting
Authors: Kuetting Daniel , Müller Andreas , Feisst Andreas , Luetkens Julian , Dabir Darius , Schild Hans H. , Thomas Daniel
Published: November 2017

Purpose:

Cardiac findings frequently remain unreported on non–electrocardiogram (ECG)-gated computed tomography (CT). Although the clinical relevance of such findings may be limited in a general patient population, they may have significant impact in intensive care patients. Thus, the purpose of this study was to evaluate the prevalence, underreporting, and clinical relevance of incidental cardiac findings in intensive care unit (ICU) patients.

Materials and Methods:

Non–ECG-gated chest CT examinations of ICU patients were retrospectively analyzed for incidental cardiac findings. The findings were classified into 3 categories (A to C): category A findings, which carry potential for risk to life; category B findings, which have a potential for significant morbidity; category C findings, which have a possible effect on prognosis.

Results:

A total of 500 patients who underwent non–ECG-gated thoracic CT examinations were included. Of the 500 patients, 403 presented with 1443 cardiac findings. Of all cardiac findings, 37% were described in the initial written report. Sixty category A findings were detected, of which 48% were not mentioned in the report. Six hundred forty category B findings were detected, of which 77% were not described in the report. The remaining 743 findings were classified as category C, 55% of which were not reported in the report.

Conclusions:

The prevalence as well as the rate of underreporting of incidental cardiac findings in non–ECG-gated chest CT of ICU patients is very high. The results of this study underscore the importance of dedicated training for assessment of cardiac structures and conditions, which may be detected on non–ECG-gated chest CT.
Sinai Abbreviated Geriatric Evaluation
Authors: Katlic Mark R. , Coleman JoAnn , Khan Kamran , Wozniak Susan E. , Abraham Joseph H.
Published: November 2017

Objective:

To develop and validate a simple geriatric screening tool that performs as well as more complex assessments

Background:

Many tools that predict treatment risk in older adults are impractical for routine clinical use.

Methods:

We prospectively conducted comprehensive preoperative evaluations on 1025 patients age ≥75 years who presented to Sinai Hospital of Baltimore for major elective surgery, then retrospectively reviewed patients’ medical records for occurrence of postoperative outcomes. Using logistic regression modeling and receiver operating characteristic curve analysis we selected the best combination of simple tests, labeling this the Sinai Abbreviated Geriatric Evaluation (SAGE). The performance of the SAGE was then compared with 3 standard tools in its power to predict postoperative outcomes.

Results:

The SAGE is a statistically significant predictor of postoperative outcomes. Each unit decrease in SAGE score was significantly associated with a 51% (95% CI 1.30–1.77) increase in odds of a complication, a 2-fold increase in odds of postoperative delirium (95% CI 1.65–2.66), a 27% increase in odds of length of hospital stay >2 days (95% CI 1.10–1.47), a 54% increase in odds of a hospital readmission within 30 days (95% CI 1.25–2.88), and a 38% increase in odds of an unanticipated discharge to higher-level care (95% CI 1.18–1.61). We estimated the receiver operating characteristic curve area under the curve (AUC) for the SAGE of 0.69, 0.77, 0.73, 0.66, and 0.78 for the above outcomes, respectively. The SAGE performed as well in predicting postoperative outcomes as Fried's frailty phenotype, Charlson Comorbidity Index, and American Society of Anesthesiologists Physical Status Class (ASA).

Conclusion:

The SAGE performs as well as other geriatric evaluations that require equipment or memorization.