bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Inhaled Nitric Oxide on Outcomes in Children With Acute Lung Injury: Propensity Matched Analysis From a Linked Database*
Authors: Gupta Punkaj , Richardson Troy , Hall Matthew , Bertoch David , Hebbar Kiran B. , Fortenberry James D. , Wetzel Randall C.
Published: May 2016

Objectives:

To evaluate the effect of inhaled nitric oxide on outcomes in children with acute lung injury.

Design:

Retrospective study with a secondary data analysis of linked data from two national databases. Propensity score matching was performed to adjust for potential confounding variables between patients who received at least 24 hours of inhaled nitric oxide (inhaled nitric oxide group) and those who did not receive inhaled nitric oxide (no inhaled nitric oxide group).

Setting:

Linked data from Virtual Pediatric Systems (LLC) database and Pediatric Health Information System.

Patients:

Patients less than 18 years old receiving mechanical ventilation for acute lung injury at nine participating hospitals were included (2009–2014).

Interventions:

None.

Measurements and Main Results:

A total of 20,106 patients from nine hospitals were included. Of these, 859 patients (4.3%) received inhaled nitric oxide for at least 24 hours during their hospital stay. Prior to matching, patients in the inhaled nitric oxide group were younger, with more comorbidities, greater severity of illness scores, higher prevalence of cardiopulmonary resuscitation, and greater resource utilization. Before matching, unadjusted outcomes, including mortality, were worse in the inhaled nitric oxide group (inhaled nitric oxide vs no inhaled nitric oxide; 25.7% vs 7.9%;p< 0.001; standardized mortality ratio, 2.6 [2.3–3.1] vs 1.1 [1.0–1.2];p< 0.001). Propensity score matching of 521 patient pairs revealed no difference in mortality in the two groups (22.3% vs 20.2%;p= 0.40; standardized mortality ratio, 2.5 [2.1–3.0] vs 2.3 [1.9–2.8];p= 0.53). However, the other outcomes such as ventilation free days (10.1 vs 13.6 d;p< 0.001), duration of mechanical ventilation (13.8 vs 10.1 d;p< 0.001), duration of ICU and hospital stay (15.5 vs 12.2 d;p< 0.001 and 28.0 vs 24.1 d;p< 0.001), and hospital costs ($150,569 vs $102,823;p< 0.001) were significantly worse in the inhaled nitric oxide group.

Conclusions:

This large observational study demonstrated that inhaled nitric oxide administration in children with acute lung injury was not associated with improved mortality. Rather, it was associated with increased hospital utilization and hospital costs.
Employment Outcomes After Critical Illness: An Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors Cohort*
Authors: Norman Brett C. , Jackson James C. , Graves John A. , Girard Timothy D. , Pandharipande Pratik P. , Brummel Nathan E. , Wang Li , Thompson Jennifer L. , Chandrasekhar Rameela , Ely E. Wesley
Published: May 2016

Objectives:

To characterize survivors’ employment status after critical illness and to determine if duration of delirium during hospitalization and residual cognitive function are each independently associated with decreased employment.

Design:

Prospective cohort investigation with baseline and in-hospital clinical data and follow-up at 3 and 12 months.

Setting:

Medical and surgical ICUs at two tertiary-care hospitals.

Patients:

Previously employed patients from the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors study who survived a critical illness due to respiratory failure or shock were evaluated for global cognition and employment status at 3- and 12-month follow-up.

Measurements and Main Results:

We used multivariable logistic regression to evaluate independent associations between employment at both 3 and 12 months and global cognitive function at the same time point, and delirium during the hospital stay. At 3-month follow-up, 113 of the total survival cohort of 448 (25%) were identified as being employed at study enrollment. Of these, 94 survived to 12-month follow-up. At 3- and 12-month follow-up, 62% and 49% had a decrease in employment, 57% and 49% of whom, respectively, were newly unemployed. After adjustment for physical health status, depressive symptoms, marital status, level of education, and severity of illness, we did not find significant predictors of employment status at 3 months, but better cognition at 12 months was marginally associated with lower odds of employment reduction at 12 months (odds ratio, 0.49; p = 0.07).

Conclusions:

Reduction in employment after critical illness was present in the majority of our ICU survivors, approximately half of which was new unemployment. Cognitive function at 12 months was a predictor of subsequent employment status. Further research is needed into the potential relationship between the impact of critical illness on cognitive function and employment status.
First-line treatment in advanced or metastatic disease: one size fits all or adapted to specific histiotypes?
Authors: Seddon Beatrice
Published: May 2016

Purpose of review

This article evaluates the supporting evidence for adapting choice of first-line chemotherapy to specific histological subtypes in advanced or metastatic soft tissue sarcoma (STS).

Recent findings

The evidence for the current standard of care for first-line chemotherapy in STS is reviewed. This is followed by an overview of the evidence for use of specific chemotherapy drugs in a number of specific STS histological subtypes. The more recent literature on newer drugs being used in the first-line setting in STS is then reviewed, and finally an assessment is made as to whether it is possible at this time to tailor first-line chemotherapy to histiotype.

The review shows that at present there is insufficient evidence to support the concept of adapting choice of first-line chemotherapy in advanced or metastatic STS to specific histiotypes.
Molecular subtypes of gastrointestinal stromal tumor requiring specific treatments
Authors: Pogorzelski Michael , Falkenhorst Johanna , Bauer Sebastian
Published: May 2016

Purpose of review

This article reviews and discusses the current literature on how molecular subtyping of gastrointestinal stromal tumor (GIST) impacts decision-making in clinical practice.

Recent findings

Genotyping has not yet been used for prognostication of localized GIST. Recent findings indicate that mutations in platelet-derived growth factor receptor alpha (PDGFRA) and stem cell growth factor receptor (KIT) exon 11 duplication mutations are associated with a favorable prognosis. Subgroup analyses of randomized trials provide first evidence on how genotyping predicts clinical benefit in the adjuvant setting. In the palliative setting, genotyping should be performed for dose selection but may also be relevant in patients who are intolerant to imatinib. For patients whose tumors harbor the notoriously resistant D842V PDGFRA mutations, novel inhibitors have entered clinical trials, which may end the therapeutic deadlock. Several novel targets have been identified that are currently being investigated in GIST, including inhibitors against fibroblast growth factor receptor, hepatocyte growth factor receptor, mitogen-activated protein, and phosphoinositide 3-kinase. Preliminary clinical data suggest that predictive markers will be needed to define sensitive molecular subgroups.

Genotyping should be an integral part of clinical management of GIST as it aids in prognostication, prediction of efficacy, and selection of drugs and dosing. Genotyping reduces the risk of both unnecessary adjuvant treatment as well as undertreatment and overtreatment in the palliative setting.
Metastatic Lung Lesions as a Preferred Resection Site for Immunotherapy With Tumor Infiltrating Lymphocytes
Authors: Ben-Avi Ronny , Itzhaki Orit , Simansky David , Zippel Dov , Markel Gal , Ben Nun Alon , Schachter Jacob , Besser Michal J.
Published: May 2016

Adoptive cell therapy with tumor infiltrating lymphocytes (TIL) yields 50% response rates in metastatic melanoma and shows promising clinical results in other solid tumors. Autologous TIL cultures are isolated from resected tumor tissue, expanded ex vivo to large numbers and reinfused to the preconditioned patient. In this prospective study, we validate the origin of the tumor biopsy and its effect on T-cell function and clinical response. One hundred forty-four patients underwent surgery and 79 patients were treated with TIL adoptive cell therapy. Cultures from lung tissue were compared with other origins. The success rate of establishing TIL culture from lung tissue was significantly higher compared with nonlung tissue (94% vs. 72%, respectively, P≤0.003). Lung-derived TIL cultures gave rise to higher cell numbers (P≤0.011) and exhibited increased in vitro antitumor reactivity. The average fold expansion for lung-derived TIL during a rapid expansion procedure was 1349±557 compared with 1061±473 for nonlung TIL (P≤0.038). Patients treated with TIL cultures of lung origin (compared with nonlung) had prolonged median overall survival (29 vs. 9.5 mo; P≤0.065). Given the remarkable advancement in minimally invasive thoracic surgery and the results of this study, we suggest efforts should be taken to resect lung metastasis rather than other sites to generate TIL cultures for clinical use.
Latent Profiles of Externalizing Psychopathology and Their Relation to Children's Aggression and Social Behavior
Authors: Andrade Brendan F. , Wade Mark
Published: May 2016

Objective:

This study identified profiles of clinic-referred children with disruptive behavior and determined the association between identified profiles and children's aggression, peer problems, and prosocial skills.

Method:

Parents and teachers of 208 children (163 boys) aged 6 to 12 years (M
age = 8.80, SD = 1.75) completed measures to assess children's callous-unemotional (CU) traits, inattentive-impulsive-overactive (IO) and oppositional-defiant (OD) behavior, aggression, and social behaviors. Latent class analysis was used to identify the profiles, and the pseudoclass draw method to test the equality of means for each of the aggression and social behavioral outcomes across the latent classes.

Results:

Five profiles were identified: (1) Low (35.6% of children), with relatively low levels of CU traits and IO and OD behavior; (2) Low-Moderate (30.8%), with low-moderate levels of CU traits, low IO and moderate OD behavior; (3) Moderate (21.6%), with moderate levels of CU traits and IO and moderate-high OD behavior; (4) Moderate-High (7.2%), with moderate-high levels of CU traits, high IO and moderate-high OD behavior; and (5) High (4.8%), with high levels of CU traits, IO and OD behavior.

Conclusion:

Children categorized into profiles showed important differences in level of aggression and social behavior. The overlap between CU traits, IO, and OD behavior add to understanding of child psychopathology that influences behavior and clinical outcomes.
Predictive Factors in the Outcome of Surgical Repair of Abdominal Rectus Diastasis
Authors: Strigård Karin , Clay Leonard , Stark Birgit , Gunnarsson Ulf
Published: May 2016

Background:

The aim of this study was to define the indicators predicting improved abdominal wall function after surgical repair of abdominal rectus diastasis (ARD). Preoperative subjective assessment quantified by the validated Ventral Hernia Pain Questionnaire (VHPQ) was related to relative postoperative functional improvement in abdominal muscle strength.

Methods:

Fifty-seven patients undergoing surgery for ARD completed the VHPQ before surgery. Preoperative pain assessment results were compared with the relative improvement in muscle strength measured with the BioDex system 4.

Results:

There was a correlation between the relative improvement in muscle strength measured by the BioDex System 4 for flexion at 30 degrees (P = 0.046) and 60 degrees per second (P = 0.004) and the preoperative question, “Do you find it painful to sit for more than 30 minutes?” There was also a correlation between BioDex improvement for flexion at 30 degrees (P = 0.022) and for isometric work load (P = 0.038) and the preoperative question, “Has abdominal pain limited your ability to perform sports activities?” The VHPQ responses also formed a pattern with a fairly good correlation between other BioDex modalities (with the exception of extension at 60 degrees per second) and the response to the question regarding complaints when performing sports. Postoperative visual analog scale ratings of abdominal wall stability correlated to the questions regarding complaints when sitting (P = 0.040) and standing (P = 0.047). No other correlation was seen.

Conclusion:

VHPQ ratings concerning pain while being seated for more than 30 minutes and pain limiting the ability to perform sports are promising indicators in the identification of patients likely to benefit from surgical correction of their ARD.
Improving Antimicrobial Regimens for the Treatment of Breast Tissue Expander-Related Infections
Authors: Viola George M. , Baumann Donald P. , Mohan Kriti , Selber Jesse , Garvey Patrick , Reece Gregory , Raad Issam I. , Rolston Kenneth V. , Crosby Melissa A.
Published: May 2016

Background:

Infectious complications in tissue expander (TE) breast reconstruction can be devastating and costly. Therefore, to optimize care, we examined patient’s demographics, microbiology of TE infections, and the efficacy of empiric antimicrobial regimens and thereafter generated an algorithm for the treatment of these complex infections.

Methods:

We retrospectively reviewed all patients who underwent TE breast reconstruction between 2003 and 2012 and analyzed those patients who developed a “definite” device-related infection leading to TE explantation and had a positive intraoperative culture.

Results:

A total of 3,082 patients underwent immediate breast reconstruction with TE. Of these, 378 patients (12.3%) developed an infection, 189 (6.1%) eventually proceed with explantation, and 118 (3.8%) had a positive intraoperative culture. Gram-positive organisms caused 73% of infections, and Gram-negative organisms caused 27% of infections. Narrow-spectrum empiric antimicrobials with predominantly Gram-positive coverage were deemed appropriate in only 62% of cases, and those with Gram-negative coverage were appropriate in 46%. Broad-spectrum antimicrobials were used in 47% of cases, mainly recommended by infectious disease specialists, and were considered appropriate in >90% of the occasions.

Conclusions:

Current empiric antibiotic regimens do not cover the vast spectrum of organisms causing TE infections. To increase the salvage rate of an infected TE, at the first sign of infection, in addition to benefiting with an infectious diseases consultation, empiric coverage with broad-spectrum antibiotics active against biofilm-embedded organisms should be administered.
The Vermilionectomy and the Subsequent Lower Lip Reconstruction Were Introduced by Victor von Bruns and not by von Langenbeck or von Esmarch as Reported Previously
Authors: Roldán J. Camilo , Teschke Marcus , Feinendegen Dominik L.
Published: May 2016

Vermilionectomy is an established procedure for the management of precancerous lesions of the lip and is often performed simultaneously with a lower lip resection for the treatment of a malignancy. The literature suggests that Dieffenbach or von Langenbeck or von Esmarch was the first to introduce this procedure. A systematic review of the German literature from the 19th century revealed that it was von Bruns who performed the vermilionectomy for the management of lip malignancies for the first time.
Vermilion Reconstruction with Genital Mucosa
Authors: Müller-Richter Urs D.A. , Weyandt Gerhard H. , Woeckel Achim , Kübler Alexander C.
Published: May 2016

Functional and aesthetical reconstruction, especially of the upper lip after ablative tumor surgery, can be very challenging. The skin of the lip might be sufficiently reconstructed by transpositional flaps from the nasolabial or facial area. Large defects of the lip mucosa, including the vestibule, are even more challenging due to the fact that flaps from the inner lining of the oral cavity often lead to functional impairments. We present a case of multiple vermilion and skin resections of the upper lip. At the last step, we had to resect even the whole vermilion mucosa, including parts of the oral mucosa of the vestibule, leaving a bare orbicularis oris muscle. To reconstruct the mucosal layer, we used a mucosal graft from the labia minora and placed it on the compromised lip and the former transpositional flaps for the reconstructed skin of the upper lip with very good functional and aesthetic results.
CHRONICALLY PROGRESSIVE SARCOID GRANULOMA IN AN ASYMPTOMATIC PATIENT
Authors: Stefater James A. , Gragoudas Evangelos S.
Published: May 2016

Purpose:

To report 18 years of follow-up of a patient with atypical ocular sarcoidosis.

Methods:

The patient was observed in clinic and with photography for over 18 years.

Results:

One patient with a history of dermal melanoma and atypical ocular sarcoidosis.

Discussion:

Several features presented in this case are exceedingly atypical including lack of any intraocular inflammation over 18 years of yearly observation, the preservation of excellent vision despite the choroidal disease, and lack of systemic symptoms. This case suggests a disconnect between ocular sarcoidosis and intraocular inflammation, and supports clinical observation as a prudent method in patients with extensive choroidal disease and good vision.
EPIRETINAL MEMBRANE FORMATION AFTER INTRAVITREAL AUTOLOGOUS STEM CELL IMPLANTATION IN A RETINITIS PIGMENTOSA PATIENT
Authors: Kim Ju Young , You Yong Sung , Kim Soon Hyun , Kwon Oh Woong
Published: May 2016

Methods:

A retrospective case report of a retinitis pigmentosa patient who underwent vitrectomy for epiretinal membrane after intravitreal autologous stem cell implantation.

Results:

A 71-year-old female RP patient came to our clinic for ophthalmic evaluation after intravitreal autologous stem cell injection. Four months ago, she underwent intravitreal autologous stem cell injection for both eyes at another hospital. New thick epiretinal membrane (ERM) with extensive macular pucker was found on her left eye. She underwent pars plana vitrectomy and membranectomy. After biopsy, many CD34-positive stem cells were detected in ERM specimen.

Conclusion:

This is the first report of ERM formation following intravitreal autologous stem cells injection. CD34-positive stem cells were detected in a human eye at 4 months after injection. Further studies are needed to determine how stem cells caused ERM and how long they would stay in the eye.
A SECOND CASE OF BILATERAL RHEGMATOGENOUS RETINAL DETACHMENTS REPAIRED WITH SIMULTANEOUS BILATERAL PNEUMATIC RETINOPEXY
Authors: Rubin Uriel , De Jager Cornelis , Zakour Moayed , Gonder J. Thomas
Published: May 2016

Background/Purpose:

To present a case of a patient with simultaneous bilateral retinal detachments treated successfully with bilateral pneumatic retinopexy.

Study design:

Case report.

Results:

This is a case of an otherwise healthy 49-year-old woman with no remarkable ocular history that presented with simultaneous phakic superior bilateral rhegmatogenous retinal detachments. Treatment on the day of presentation included laser retinopexy of the inferior lattice degeneration in the left eye and bilateral intravitreal injection of 0.4 cc of 100% C3F8 gas preceded by topical anesthesia. After 48 hours, both retinas were completely reattached, and bilateral laser retinopexy was performed to the superior tears.

Discussion:

After a review of the literature, the authors could find only two reported cases of simultaneous bilateral retinal detachments treated successfully with pneumatic retinopexy. This is not only a cost-effective procedure but also allows treatment when there is no immediate operating room availability or a when a quick referral for surgery is not possible.
Tear Function and Ocular Surface Alterations After Accelerated Corneal Collagen Cross-Linking in Progressive Keratoconus
Authors: Kalkan Akçay Emine , Kilicarslan Aydan , Uysal Betul Seher , Hondur Gozde , Kosekahya Pinar , Altinkaynak Hasan , Cagil Nurullah
Published: May 2016

Objective:

To investigate the alterations in the ocular surface and tear film parameters 3 months after accelerated corneal collagen cross-linking (A-CXL) in progressive keratoconus (KC) patients.

Methods:

Twenty-six patients (33 eyes total) with progressive KC were enrolled in this study. All patients were subjected to ophthalmic surface examination, such as OSDI (ocular surface disease index) scoring, the osmolarity tear test, Schirmer test, tear film breakup time (TBUT) analysis, rose bengal (RB) and fluorescein (Fl) ocular surface staining, and conjunctival impression cytology (IC) analysis, respectively. These tests were performed at baseline and 3 months after A-CXL. Nelson's grading system was used to evaluate the cell morphology and goblet cell density.

Results:

No statistically significant differences in the levels of tear osmolarity, TBUT, Schirmer test, OSDI scoring, and Fl and RB staining between pretreatment and 3 months postoperatively were observed (all P values >0.05). A statistically significant increase in superior (P=0.005) and temporal (P=0.006) IC grading was seen at the postoperative third month compared to pretreatment.

Conclusions:

Only metaplastic changes and a reduction in the density of the goblet cells were seen in conjunctival IC, which is probably because of the toxicity of ultraviolet-A 3 months after A-CXL. However, these results do not lead to deterioration in TBUT. In this study, A-CXL has no adverse effect on ocular surface and tear function, which are important for visual quality.
Unilateral Alacrima as a Presenting Symptom of Nasopharyngeal Carcinoma
Authors: Ko Audrey C. , Satterfield Kellie R. , Lee Bradford W. , Alameddine Ramzi M. , Korn Bobby S. , Kikkawa Don O.
Published: May 2016

Advanced nasopharyngeal carcinoma may present to oculoplastic surgeons and ophthalmologists as epiphora or medial canthus swelling. In contrast, the authors describe an uncommon initial presentation of alacrima in a 30-year-old female with nasopharyngeal carcinoma without invasion of the nasolacrimal sac, duct, or lacrimal gland. The diagnosis was delayed due an initial misdiagnosis of dry eye. Nasopharyngeal carcinoma should be included in the differential for diminished tear production, especially if it presents asymmetrically.
Patient phenotyping in clinical trials of chronic pain treatments: IMMPACT recommendations
Authors: Edwards Robert R. , Dworkin Robert H. , Turk Dennis C. , Angst Martin S. , Dionne Raymond , Freeman Roy , Hansson Per , Haroutounian Simon , Arendt-Nielsen Lars , Attal Nadine , Baron Ralf , Brell Joanna , Bujanover Shay , Burke Laurie B. , Carr Daniel , Chappell Amy S. , Cowan Penney , Etropolski Mila , Fillingim Roger B. , Gewandter Jennifer S. , Katz Nathaniel P. , Kopecky Ernest A. , Markman John D. , Nomikos George , Porter Linda , Rappaport Bob A. , Rice Andrew S.C. , Scavone Joseph M. , Scholz Joachim , Simon Lee S. , Smith Shannon M. , Tobias Jeffrey , Tockarshewsky Tina , Veasley Christine , Versavel Mark , Wasan Ajay D. , Wen Warren , Yarnitsky David
Published: May 2016

There is tremendous interpatient variability in the response to analgesic therapy (even for efficacious treatments), which can be the source of great frustration in clinical practice. This has led to calls for “precision medicine” or personalized pain therapeutics (ie, empirically based algorithms that determine the optimal treatments, or treatment combinations, for individual patients) that would presumably improve both the clinical care of patients with pain and the success rates for putative analgesic drugs in phase 2 and 3 clinical trials. However, before implementing this approach, the characteristics of individual patients or subgroups of patients that increase or decrease the response to a specific treatment need to be identified. The challenge is to identify the measurable phenotypic characteristics of patients that are most predictive of individual variation in analgesic treatment outcomes, and the measurement tools that are best suited to evaluate these characteristics. In this article, we present evidence on the most promising of these phenotypic characteristics for use in future research, including psychosocial factors, symptom characteristics, sleep patterns, responses to noxious stimulation, endogenous pain-modulatory processes, and response to pharmacologic challenge. We provide evidence-based recommendations for core phenotyping domains and recommend measures of each domain.
Increased fronto-hippocampal connectivity in the Prrxl1 knockout mouse model of congenital hypoalgesia
Authors: Monteiro Clara , Cardoso-Cruz Helder , Matos Mariana , Dourado Margarida , Lima Deolinda , Galhardo Vasco
Published: May 2016

Despite the large number of studies addressing how prolonged painful stimulation affects brain functioning, there are only a handful of studies aimed at uncovering if persistent conditions of reduced pain perception would also result in brain plasticity. Permanent hypoalgesia induced by neonatal injection of capsaicin or carrageenan has already been shown to affect learning and memory and to induce alterations in brain gene expression. In this study, we used the Prrxl1

−/−
model of congenital mild hypoalgesia to conduct a detailed study of the neurophysiological and behavioral consequences of reduced pain experience. Prrxl1 knockout animals are characterized by selective depletion of small diameter primary afferents and abnormal development of the superficial dorsal laminae of the spinal cord, resulting in diminished pain perception but normal tactile and motor behaviour. Behavioral testing of Prrxl1

−/−
mice revealed that these animals have reduced anxiety levels, enhanced memory performance, and improved fear extinction. Neurophysiological recordings from awake behaving Prrxl1

−/−
mice show enhanced altered fronto-hippocampal connectivity in the theta- and gamma-bands. Importantly, although inflammatory pain by Complete Freund Adjuvant injection caused a decrease in fronto-hippocampal connectivity in the wild-type animals, Prrxl1

−/−
mice maintained the baseline levels. The onset of inflammatory pain also reverted the differences in forebrain expression of stress- and monoamine-related genes in Prrxl1

−/−
mice. Altogether our results suggest that congenital hypoalgesia may have an effect on brain plasticity that is the inverse of what is usually observed in animal models of chronic pain.
Facilitating Nurses' Engagement in Hospital Quality Improvement: The New Jersey Hospital Association's Implementation of Transforming Care at the Bedside
Authors: Pearson Marjorie L. , Needleman Jack , Beckman Robin , Han Bing
Published: May 2016

Transforming Care at the Bedside (TCAB) is a program designed by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement to engage frontline staff in change processes to improve the work environment and patient care on nursing units. Originally designed and piloted in a small number of hospitals, TCAB is being disseminated through large-scale quality improvement (QI) collaboratives facilitated by professional organizations, such the New Jersey Hospital Association's Institute for Quality and Patient Safety (NJHA). This article presents the results of an evaluation of the NJHA dissemination effort. The evaluation team used an observational mixed-method evaluation design and multiple data sources to assess implementation of TCAB by nursing units in these facilities. The results show that most of the participating units successfully implemented the TCAB improvement processes. Nursing teamwork and three nursing-sensitive outcomes improved significantly over the course of TCAB, and TCAB unit managers attributed important improvements to their unit's participation. These findings suggest that TCAB is a viable mechanism for engaging frontline nursing staff in valuable QI activities. Other hospitals interested in furthering the culture and capacity for QI among frontline nursing unit staff should consider a TCAB collaborative for achieving these goals.
Attitudes and Beliefs Regarding the Utility of Robotically Assisted Gynecologic Surgery Among Practicing Gynecologists
Authors: Wright Jason D. , Raglan Greta B. , Schulkin Jay , Fialkow Michael F.
Published: May 2016

While use of robotic-assisted surgery has increased rapidly, little is known about the attitudes and beliefs of practicing gynecologists regarding the utility of the technology. We surveyed a large sample of gynecologists to examine their attitudes and beliefs about the benefits, utility, and factors driving use of robotic-assisted gynecologic surgery. A 51-item survey was mailed to 600 fellows or junior fellows of the American College of Obstetricians and Gynecologists. The survey included questions on use of robotic surgery, decision-making, and beliefs regarding the technology. Responses were stratified based on whether the respondent used robotic surgery or not. A total of 310 responses were received including 27.8% who used robotic surgery in their practices. Hysterectomy was the most commonly performed procedure. Opinions about the use and effectiveness of robotic procedures varied based on whether an individual was a robot user. Eighty-two percentage of robot users and 21% of nonrobot users believed robotic surgery provided benefits over laparoscopic (p < .0001). Among both groups, the ability to increase access to minimally invasive surgery and marketing were believed to be the greatest drivers of use of robotic surgery. Attitudes and beliefs about the effectiveness of robotic gynecologic surgery are highly variable among clinicians.
Developing, Implementing, and Evaluating a Nurse-Driven Rapid Reversal Protocol for Patients With Traumatic Intracerebral Hemorrhage in the Presence of Preinjury Warfarin
Authors: Blackmore Abigail R. , Caputo Lisa M. , Bourg Pamela W. , Mains Charles W.
Published: May 2016

Warfarin-related traumatic intracerebral hemorrhage (ICH) is often fatal, yet timely evaluation and treatment can improve outcomes. Our study describes the process of developing and implementing a protocol to guide the care of patients with traumatic brain injury (TBI) on preinjury warfarin developed by nurses across several service lines at our Level I trauma center over a 6-month period. Further, we evaluated its efficacy by examining records of adult patients with TBI on preinjury warfarin admitted 1 year before and after protocol implementation. Efficacy was defined as activation rates, receipt and time to head computed tomography (CT) scan and international normalization ratio (INR), and receipt and time to fresh frozen plasma (FFP) administration in patients with ICH with an INR more than 1.5, as per protocol. A subset analysis examined patients with and without an ICH. Outcomes were compared using univariate analyses. One hundred seventy-eight patients were included in the study; 90 (50.6%) were admitted before and 88 (49.4%) after implementation. After implementation, there were improvements in activation rates (34.4% vs. 65.9%; p < .001), the frequency of head CT scans (55.6% vs. 83.0%; p < .001), time to INR (24.0 min vs. 15.0 min; p < .05), and, for patients with ICH with an INR 1.5 or more, decreased time to FFP (157.0 vs. 90.5; p < .05). In conclusion, our protocol led to a more efficient process of care for patients with TBI on warfarin. We believe the implementation process, managed by a dedicated group of nurses across several service lines, substantially contributed to the success of the protocol.
Being-in-the-World of the Trauma Patient: A Heideggerian Perspective
Authors: Ekeh Assumpta
Published: May 2016

In his analysis of the human existence, Martin Heidegger's central focus was on teasing out the complexities intrinsic in man. He employed interrelated elements that he created to explain man's inseparability from the world. For Heidegger, a human being is never isolated but embedded completely in the world. This reality, which entails experiencing undesirable life situations, such as traumatic injuries, is viewed as an inherent part of being in the world. The trauma patient, just as any other individual in the world, is not spared of the vagaries of life at any given point in time. When the unexpected and unpleasant event happens, Heidegger suggests that life should be accepted and experienced as it is. Preoccupation with what life was prior to the unfortunate incident should be shunned. Being in the present promotes healing and positions the patient to accept the future, which leads to the road to full recovery. Personal motivation, good support systems, as well as, processes of care available in the practice environment will advance this expected goal.
Diagnostic performance of T lymphocyte subpopulations in assessment of liver fibrosis stages in hepatitis C virus patients: simple noninvasive score
Authors: Toson El-Shatat A. , Shiha Gamal E. , El-Mezayen Hatem A. , El-Sharkawy Aml M.
Published: May 2016

Background/aims

Evaluation of liver fibrosis in patients infected with hepatitis C virus is highly useful for the diagnosis of the disease as well as therapeutic decision. Our aim was to develop and validate a simple noninvasive score for liver fibrosis staging in chronic hepatitis C (CHC) patients and compare its performance against three published simple noninvasive indexes.

Materials and methods

CHC patients were divided into two groups: an estimated group (n=70) and a validated group (n=52). Liver fibrosis was tested in biopsies using the Metavair score system. CD4+ and CD8+ count/percentage were assayed by fluorescence-activated cell sorting analysis.

Results

The multivariate discriminant analysis selects a function on the basis of absolute values of five biochemical markers: immune fibrosis index (IFI); score=3.07+3.06×CD4+/CD8++0.02×α-fetoprotein (U/l)−0.07×alanine aminotransferase ratio−0.005×platelet count (109/l)−1.4×albumin (g/dl). The IFI score produced areas under curve of 0.949, 0.947, and 0.806 for differentiation of all patient categories [significant fibrosis (F2–F4), advanced fibrosis (F3–F4), and cirrhosis (F4)].

Conclusion

The IFI score, a novel noninvasive test, can be used easily for the prediction of liver fibrosis stage in CHC patients. Our score was more efficient than aspartate aminotransferase to platelet ratio index, fibrosis index, and fibroQ and more suitable for use in Egyptian hepatitis C virus patients.
Commence, continue, withhold or terminate?: a systematic review of decision-making in out-of-hospital cardiac arrest
Authors: Anderson Natalie E. , Gott Merryn , Slark Julia
Published: May 2016

When faced with an out-of-hospital cardiac arrest patient, prehospital and emergency resuscitation providers have to decide when to commence, continue, withhold or terminate resuscitation efforts. Such decisions may be made difficult by incomplete information, clinical, resourcing or scene challenges and ethical dilemmas. This systematic integrative review identifies all research papers examining resuscitation providers’ perspectives on resuscitation decision-making for out-of-hospital cardiac arrest patients. A total of 14 studies fulfilled the inclusion criteria: nine quantitative, four qualitative and one mixed-methods design. Five themes were identified, describing factors informing resuscitation provider decision-making: the arrest event; patient characteristics; the resuscitation scene; resuscitation provider perspectives; and medicolegal concerns. Established prognostic factors are generally considered important, but there is a lack of resuscitation provider consensus on other factors, indicating that decision-making is influenced by the perspective of resuscitation providers themselves. Resuscitation decision-making research typically draws conclusions from evaluation of cardiac arrest registry data or clinical notes, but these may not capture all salient factors. Future research should explore resuscitation provider perspectives to better understand these important decisions and the clinical, ethical, emotional and cognitive demands placed on resuscitation providers.
A Randomized, Placebo-Controlled Clinical Trial of Efficacy and Safety: Modafinil in the Treatment of Fatigue in Patients With Primary Biliary Cirrhosis
Authors: Silveira Marina G. , Gossard Andrea A. , Stahler Alisha C. , Jorgensen Roberta A. , Petz Janice L. , Ali Ahmad H. , Lindor Keith D.
Published: May 2016

Background and Aims:

Fatigue is a common symptom of primary biliary cirrhosis (PBC), and is associated with an impaired quality of life.

Study Question:

No studies have assessed the use of modafinil in fatigue related to PBC in a controlled manner.

Study Design, Measures, and Outcomes:

A randomized, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of modafinil for the treatment of fatigue in PBC. Forty patients were randomized to modafinil (n = 20) or placebo (n = 20) for 12 weeks. A verbal report of fatigue for at least 6 months was required for enrollment. Modafinil was administered at 100 mg by mouth once daily; a change by 50 mg every 2 weeks (maximum: 200 mg once daily) was allowed, depending on the subject's response to treatment. The primary outcome was defined as a ≥50% improvement in fatigue severity [quantified by the Fisk Fatigue Impact Scale (FFIS)] after 12 weeks of treatment, compared with baseline values.

Results:

Thirty-three PBC patients completed the study. After 12 weeks of therapy, only 5 patients had a ≥50% reduction in FFIS scores: 3 patients (17.6%) in the modafinil arm and 2 (12.5%) in the placebo arm (P = 1.00). Change in median FFIS score was not statistically different between patients in the 2 treatment groups (P = 0.36). Modafinil was associated with minimal adverse events (headaches, diarrhea, and rash).

Conclusions:

In patients with PBC who have fatigue, treatment with modafinil for 12 weeks was safe and fairly well tolerated; however, it did not result in beneficial effects on fatigue compared with patients treated with placebo (CONSORT Table 1). ClinicalTrials.gov identifier NCT00943176.
Diabetes Increases Morbidities of Colonic Diverticular Disease and Colonic Diverticular Hemorrhage: A Systematic Review and Meta-Analysis
Authors: Lin Xiaoti , Li Jingjing , Ying Mingang , Wei Fengqin , Xie Xiaoming
Published: May 2016

Colonic diverticular disease (CDD) and colonic diverticular hemorrhage (CDH) are the most common disorders in hospital admissions and outpatient health clinic visits. However, risk factors of CDD and CDH are complicated and need to be discussed. Diabetes mellitus (DM) has been related with CDD and CDH, but the associations remain ambiguous. Therefore, we performed a literature search for studies involving the associations among DM, morbidity of CDD, and incidence of CDH. Relative risks or odds ratios with their corresponding 95% confidence intervals (CIs) were combined and weighted to produce summary effect size. Sensitivity analysis and subgroup analysis were further performed. We selected 17 studies that involved a total of 8212 patients with diabetes, 381,579 controls without diabetes. We found that patients with DM had approximately 1.201 times higher CDD morbidity in prospective studies (95% CI, 1.135–1.270) with no significant heterogeneity (Q = 0.42, P = 0.519, I
2 = 0%). DM was associated with a 52.8% increase in risk of CDH (95% CI, 14%–104%); we did not find significant heterogeneity among these studies (Q = 12.94, P = 0.114, I
2 = 38.2%). This meta-analysis confirms that DM is an important risk factor for morbidities of CDD and CDH.
Deceleration and Acceleration Capacities in Risk Stratification for Arrhythmias in Patients With Chronic Obstructive Pulmonary Disease
Authors: Buzea Catalin A. , Dan Gheorghe A. , Dan Anca R. , Delcea Caterina , Balea Marius I. , Gologanu Daniela , Popescu Raluca A. , Dobranici Mihaela
Published: May 2016

Background:

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk for both supraventricular and ventricular arrhythmias. Autonomic dysregulation may be responsible for the development of arrhythmias in these patients, and its analysis could be useful for identifying those at high risk for arrhythmias.

Study Question:

Our purpose is to analyze the role of acceleration capacity (AC) and deceleration capacity (DC), novel markers of the autonomic balance, as potential arrhythmic risk predictors in patients with COPD.

Study Design:

We prospectively included 47 patients diagnosed with COPD, and a control group of 64 age-matched subjects without COPD. AC and DC values were obtained using 24-hour Holter monitoring. The arrhythmias were isolated premature atrial complexes, supraventricular tachycardias, isolated premature ventricular beats (PVC), and combined ventricular arrhythmias consisting in ventricular tachycardias or more than 10 PVC per hour.

Results:

Supraventricular arrhythmias and isolated PVC were more frequent in the COPD group. The DC was significantly lower (3.10 vs. 5.60, P < 0.0001) and AC higher (−4.60 vs. −6.60, P = 0.002) in patients with COPD. DC was identified as a predictor of arrhythmic events with an area under the curve (AUC) for premature atrial complexes >70/d of 0.72 (0.56–0.87, P = 0.013), for supraventricular tachycardias 0.76 (0.62–0.90, P = 0.002), and for combined ventricular arrhythmias 0.69 (0.54–0.82, P = 0.025). AC was predictor only for combined ventricular arrhythmias with an AUC of 0.74 (0.58–0.85, P = 0.002).

Conclusions:

Patients with COPD associate a significant autonomic imbalance and a higher incidence of arrhythmias. DC could be a strong predictor for supraventricular and ventricular arrhythmias in patients with COPD with no clinically apparent cardiac disease. AC could be useful alongside with DC regarding the risk for ventricular arrhythmias, but seems to have lesser value as a predictor for supraventricular arrhythmias.
Update in the management of the middle vault in rhinoplasty
Authors: Fedok Fred G.
Published: May 2016

Purpose of review

The middle vault of the nose continues to be a topic of interest among surgeons interested in aesthetic and functional rhinoplasty. The purpose of this review is to present currently accepted concepts regarding the significance of the middle vault of the nose in rhinoplasty and to review the more frequently advocated methods to be used in the correction of deficiencies.

Recent findings

Spreader grafts may be at least as effective as flaring sutures in improving the airway. Studies have shown an improvement in quality of life and nasal breathing with the use of autospreader flaps. The correlation between acoustic rhinometry and clinical symptoms of nasal obstruction, however, has fallen short of providing clear diagnostic value.

The diagnosis of middle vault collapse and nasal valve obstruction remains largely clinical. The patient's reported symptoms of nasal obstruction are diagnostically considered along with the findings of clinical examination, including the findings of a modified Cottle maneuver.

The use of spreader grafts and autospreader flaps has been popularized to correct problems in the middle vault of the nose and will be presented in detail in this manuscript.
The future of screening, brief intervention and referral to treatment in adolescent primary care: research directions and dissemination challenges
Authors: D'Souza-Li Lilia , Harris Sion Kim
Published: May 2016

Purpose of review

Screening, brief intervention and referral to treatment (SBIRT) offers a practical, integrated model for addressing substance use in primary care settings. This review provides an update of the research on SBIRT for adolescents in primary care, examines current dissemination challenges and suggests future research directions.

Recent findings

A number of brief screening tools for adolescents have been developed and tested relative to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) substance use disorders. Computerized previsit screening promotes standardization and is a more time-efficient alternative to provider interview. The adolescent brief intervention literature is growing, particularly with respect to technology-based tools, but is still limited, with evidence greatest for alcohol, and for motivational enhancement therapy interventions. Increasing SBIRT implementation in pediatric primary care remains a challenge. Using nonphysician behavioral health providers to deliver SBIRT, and embedding a screener and decision support tool in electronic medical record systems are strategies being investigated to promote SBIRT implementation.

Substance use begins in adolescence, and pediatric SBIRT could help to achieve a population-level reduction of substance use-related harms. With a growing number of available tools, adolescent SBIRT effectiveness and feasibility are increasing, but more studies are needed to grow its evidence base, and elucidate strategies to increase implementation.
Helicobacter pylori‐Clarithromycin Resistance in Symptomatic Pediatric Patients in a High Prevalence Country
Authors: Serrano Carolina A. , Leon Miguel A. , Palma Camila , Vera Macarena , Hernandez Caroll , Harris Paul R.
Published: May 2016

Introduction:

Failure to eradicate Helicobacter pylori despite antibiotic treatment is generally attributed to increasing clarithromycin resistance conferred by point mutations in the 23S‐rRNA gene or metronidazole resistance attributed to rdxA gene (HP0954) deletion in patients. Scarce data for pediatric population are available from developing countries.

Objectives:

The aim of the present study was to determine the presence of A2142G/C and A2143G mutations in the 23S‐rRNA gene and/or rdxA gene (HP0954) deletion in a group of symptomatic H pylori–infected children recruited from an area with high infection rate and risk of gastric cancer.

Patients and Methods:

We recruited 118 patients referred for upper endoscopy for gastrointestinal symptoms. The presence of H pylori was determined by urease test and histological staining. The rdxA gene (HP0954) deletion, and 2142G/C and A2143G mutations were determined by polymerase chain reaction–restriction fragment length polymorphism. A subgroup of infected patients received a 14‐day regimen of omeprazole, amoxicillin, and clarithromycin. The effectiveness of this regime was determined by stool antigen determination 8 weeks after treatment.

Results:

About 21% of the analyzed infected patients showed mutation in the 23S‐rRNA gene, with the A2143G transition as the more frequent mutation, and 2% of the patients showed rdxA gene (HP0954) deletion. After treatment, 25% of the patients continued to harbor the bacteria; of these, 67% carried the A2143G mutation.

Conclusions:

H pylori–infected pediatric patients from Chile show high prevalence of the mutation responsible for clarithromycin resistance. The failure to eradicate H pylori can be attributed to the presence of the A2143G mutation.