bluuebunny/crossref_metadata_2025 huggingface dataset:
Routine podiatry assessment as a potential preventive tool for atrial fibrillation screening in diabetics
Authors: Petridou M , Matopoulou E , Kanellos I , Daios S , Patrikios I , Charalampous K , Lampropoulos K , Stefanou A , Skantzis P , Arkouli V , Papaioannou N , Papaioannou G , Kaiafa G , Savopoulos C , Papaioannou S
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Atrial fibrillation (AF) is a common heart arrhythmia predominantly in advanced age patients and in diabetic’s type II (DMPII). Even if the risk of stroke in AF in DMPII is relative high, 25% of AF patients remains undiagnosed and also cryptogenic AF is very common in the diabetic population. During a 12-month study project, podiatrists and podologists performed foot pulse-checks in their routine podiatry assessment, when encountering visual symptoms that suggest an underlying circulatory disorder in diabetics. This simple non-invasive method aims to increase screening and diagnosis of AF from allied health professionals, in order to reveal patients with previously undiagnosed AF and patients with cryptogenic Af, challenging the potential reduction of AF complications and mainly of stroke.

Purpose 

Early detection of AF in diabetics from allied health professionals during routine podiatry assessment. Revealing of previously undiagnosed AF contributes to stroke and other AF complications incidence reduction in the diabetics population.

Methods 

During a 12-month study, 2 podiatrists and 6 podologists performed foot pulse-checks on diabetics, during their annual foot screening appointments, since they have been trained from medical doctors to spot rhythm abnormalities during pulse palpation of the foot arteries. They have been also trained to confirm their pulse palpation evidence thought Doppler ultrasound wave assessments during evaluation of arterial blood supply (anterior-posterior tibial arteries and ramifications) of the diabetic foot. During the study 300 diabetics (mean age 60 years old, 180 males, 120 females) had their feet pulse-tested. Spss statistical software had been used. 

Results 

17% of diabetics during foot pulse-checks presents undiagnosed AF. There was no statistically significant difference (p < 0.05) between sex  (males and females AF screening percents were similar). 

Conclusion(s) 

Early detection and properly managed during AF screening reduces AF complications and specifically stroke incidence. Opportunistic podiatric detection of previously undiagnosed and cryptogenic AF from allied professionals is a non invasive, safe, fast and economic method with potential contributions in this direction. More studies must be designed in order to support the routine podiatry assessment, as a useful Screening diagnostic tool of AF for reducing cardiovascular complications incidence in diabetics but also in the general population.
Advanced practice providers should interpret 12-lead ECGs
Authors: Carey M
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Due to the rapid development of cardiac diagnostic modalities such as imaging techniques, device therapies, invasive procedures and cardiogenomics, many cardiology trainees lack personal interest in clinical electrocardiography (ECG) training. In addition, fewer and fewer practioners are mentoring trainees in this skill. Thus, most ECGs are read by non-cardiologists, including emergency, urgent care and family practice-physicians who do not necessarily have clinical ECG training. Purpose: The purpose of this proposal is to promote the training and certification of Advanced Practice Providers (APPs) to interpret 12-lead ECGs.  Rationale. By tradition, as health care tasks increase in complexity, many physician-based tasks are delegated to APPS, especially in the demanding hospital setting.  For example, nurses continuously monitor and interpret all bedside ECG arrhythmias and myocardial ischemia. The transition of cardiologist read 12-lead ECGs to APP read 12-lead ECG makes sense in light of the ubiquitous computerization of the ECG which provides high quality waveforms with sophisticated algorithms to help guide in decision making.  Despite significant improvements in cardiac technology, the 12-lead ECG remains the classic, non-invasive gold standard for the diagnosis of a myocardial infarction (MI) and it is expected to be interpreted within 10 minutes of chest pain onset. Conclusion: Cardiologists have moved on to utilize new technology for secondary and tertiary evaluations, 12-lead ECGs are the first line diagnostic tool in diagnosis of MI. By training and certifying APPs in ECG interpretation, higher quality, rapid initial diagnosis will be made without delays.
The SCN5A point mutation M1875T, associated with familial atrial fibrillation, causes a gain-of-function effect of the cardiac Nav1.5 channel in atrial cardiomyocytes
Authors: O"reilly M , Sommerfeld L , O"shea C , Broadway-Stringer S , Kabir S , Andaleeb S , Malinova A , Reyat J , Fortmueller L , Pavlovic D , Skryabin BV , Holmes A , Kirchhof P , Fabritz L
Published: May 2021

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Leducq Foundation

Background

The point mutation M1875T in the SCN5A gene, which encodes the pore-forming α-subunit of the cardiac voltage-gated Na+ channel Nav1.5, has been associated with familial atrial fibrillation (AF), but its effects on atrial cardiomyocyte electrophysiology is unclear.

Aim

To investigate the effect of the point mutation M1875T on atrial electrophysiological parameters.

Methods

In a novel heterozygous knock-in murine model (Scn5a-M1875T+/-), whole-cell patch clamp electrophysiology was used to investigate Na+ currents in left atrial (LA) cardiomyocytes isolated from hearts of young adult mice (10-16 weeks). LA microelectrode and optical mapping recordings were used to study action potential (AP) characteristics. Cardiac size and function were measured by transthoracic echocardiography. Atrial Scn5a gene and Nav1.5 protein expression were assessed by Rt-PCR and Western blot.

Results

The Na+ current was increased in cardiomyocytes isolated from Scn5a-M1875T+/- LA (wildtype (WT) -22.7 ± 0.9 pA/pF (N = 14, n = 115); Scn5a-M1875T+/- -28.3 ± 1.1 pA/pF (N = 15, n = 117)). Scn5a-M1875T+/- intact isolated superfused LA had an elevated AP amplitude (100 ms pacing cycle length (PCL): WT 86.4 ± 0.9 mV (N = 8, n = 24); Scn5a-M1875T+/- 91.2 ± 0.7 mV (N = 8, n = 25)) and a faster peak upstroke velocity (100 ms PCL: WT 127.98 ± 3.28 mV/ms; Scn5a-M1875T+/- 142.80 ± 3.98 mV/ms). AP duration (APD) was not different apart from a small APD shortening at slow rates. Echocardiography revealed no difference in size and function at the age of investigation. Atrial Scn5a gene and Nav1.5 protein expression were comparable. When challenged with flecainide (1 µM), Scn5a-M1875T+/- LA showed less conduction slowing than WT (100 ms PCL: WT -10.43 ± 1.27 cm/s (N = 12); Scn5a-M1875T+/- -6.10 ± 1.34 cm/s (N = 12)).  5 µM flecainide caused significant increase in WT refractoriness (7/12 atria lost 1:1 capture at PCL ≤ 120 ms) compared to Scn5a-M1875T+/- (1/12).

Conclusion(s): SCN5A point mutation M1875T increases the Na+ current in atrial cardiomyocytes and intact atria, leading to a faster AP upstroke and an attenuated response to flecainide. Abstract Figure 1: Current-Voltage relationship
Determination of dominant loop in dual loop atrial tachycardia with direct graph mapping: an alternative for entrainment mapping?
Authors: Lowie L , Van Nieuwenhuyse E , Sanchez J , Panfilov A , Knecht S , Duytschaever M , Vandersickel N
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Entrainment mapping (EM) is an important tool to determine the mechanism of complex reentrant atrial tachycardias (ATs), mostly to distinguish dominant from bystander reentrant loops. However, entrainment maneuvers are challenging, time consuming and risk to end the tachycardia. 

Purpose

Recently, we developed a novel method Directed Graph Mapping (DGM), using concepts of network theory, allowing to automatically determine AT reentry loops from the local activation times (LAT) of any clinical mapping system. DGM showed good performance: it correctly finds ablation target (100 % success rate) on simple AT cases and could automatically determine reentry loops confirmed by the expert electrophysiologist with EM in complex AT cases. Out of 32 single loop cases, 62.5 % was identified correctly with automated DGM and out of 6 true double loop cases, 83.3 %. Lower performance for single reentry complex cases compared to EM was mainly because DGM could not distinguish the dominant loop from additional bystander loops found by DGM. Hence, the purpose of this work was to develop additional algorithms which in case of multiple found DGM loops could automatically find the dominant loop and compare it with the results of EM.

Methods

We performed multiple  simulations of various types of double loop reentry on a patient specific model of the left atrium. Based on a clinical case, double loops were simulated around a scar at the anterior wall (localized reentry) and the mitral valve (MV). LAT maps were determined similar as in the clinic. By varying the size of the scar in multiple steps, we obtained a transition from a regime of a dominant loop around the scar (small scar), to a true double loop and further to a regime of a dominant loop around the MV (large scar). We developed a novel DGM algorithm to determine the dominant loop from the region of collision (ROC) found from the vector field of the wavefront graph.  

The developed method was also tested on 8 clinical cases of double loop ATs with EM measurements.

Results

Our algorithm found the location of the ROC and determined the correct dominant loop in 100% of the simulated data. 

We tested this on 8 clinical cases of AT, and accuracy of the method was 75 %.

Conclusions

Determining the ROC in case of multiple loops in AT could correctly determine the dominant versus bystander loop, leading to the correct ablation target, without the need for further EM.
CaMKII as a therapeutic target in catecholaminergic polymorphic ventricular tachycardia type 1
Authors: Sadredini M , Manotheepan R , Haugsten Hansen M , Frisk M , Louch WE , Lehnart SE , Anderson ME , Sjaastad I , Stokke MK
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Background

In catecholaminergic polymorphic ventricular tachycardia type 1 (CPVT1) adrenergic activation of the cardiac ryanodine receptor (RyR2) causes spontaneous calcium release and triggers arrhythmias. Calcium/calmodulin-dependent protein kinase II (CaMKII) can contribute to such arrhythmogenic calcium release and has been proposed as a therapeutic target in CPVT1. To predict the efficacy and safety of this strategy, it is necessary to know whether the mechanism for CaMKII activation is important for its arrhythmogenic effects, and if inhibition has proarrhythmic effects. We tested (1) if oxidation of CaMKII contributes to spontaneous calcium release in CPVT1 and (2) if inhibition of CaMKII in this condition can induce calcium alternans.

Methods

Mice with the CPVT1-causative mutation RyR2-R2474S (RyR2-RS) were crossed with mice with the CaMKII M281/282V (MMVV) mutation that prevents CaMKII M281/282 oxidation, to create double mutants (RyR2-RSxMMVV). Telemetric ECG surveillance was used to study in vivo arrhythmias following an adrenergic challenge by i.p. administration of the beta-adrenoceptor agonist isoprenaline. Confocal line-scan imaging and whole-cell calcium imaging were used to study arrhythmogenic calcium release in isolated left ventricular cardiomyocytes during stimulation with isoprenaline.

Results

As expected, RyR2-RS mice exhibited more arrhythmic events and spontaneous calcium release (i.e. calcium sparks and calcium waves) compared to wild-type mice. Treatment of RyR2-RS cardiomyocytes with either the CaMKII inhibitor KN-93 or the antioxidant n-acetyl-cysteine reduced spontaneous calcium release (i.e. calcium sparks and calcium waves, for KN-93 and n-acetyl-cysteine, respectively). Interestingly, CaMKII inhibition by KN-93 also increased both incidence and degree of arrhythmogenic calcium alternans in RyR2-RS cardiomyocytes. This adverse effect was a result of prolonged refractoriness of calcium release. Furthermore, to test whether the protective effect of antioxidant treatment in RyR2-RS was mediated via CaMKII oxidation, we compared arrhythmias and spontaneous calcium release (i.e. calcium waves) in RyR2-RSxMMVV with RyR2-RS. However, these two genotypes did not differ in either incidence or severity of arrhythmias, and showed similar degree of spontaneous calcium release.

Conclusions

Inhibition of CaMKII protects against spontaneous calcium release in CPVT1, and is a promising therapeutic strategy. However, the fact that such inhibition also induces calcium alternans needs further exploration. Antioxidative agents also attenuate arrhythmogenic calcium release in CPVT1 cardiomyocytes, but this effect does not seem to involve the M281/282 CaMKII oxidation site. Future studies should explore other oxidation sites.
Is selective late sodium current inhibition different from class I/B antiarrhythmic action? Comparison of the effects of GS967 to mexiletine in canine ventricular myocardium
Authors: Horvath B , Khan MN , Hezso T , Dienes C , Kovacs Z , Kiss D , Prorok J , Arpadffy-Lovas T , Varga R , Fujii E , Topal L , Kistamas K , Varro A , Virag L
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): National Research, Development and Innovation Office New National Excellence Programme

Enhancement of the late Na+ current (INa,late) increases arrhythmia propensity in the heart, while suppression of the current is antiarrhythmic. GS-458967 (GS) is an agent considered to be a selective blocker of INa,late. In the present study, effects of GS967 on INa,late, on L-type calcium current (ICaL), and on action potential (AP) morphology were studied in canine ventricular myocytes by using conventional voltage clamp, action potential voltage clamp and sharp microelectrode techniques. These effects of GS were compared to tetrodotoxin (TTX) and to the class I/B antiarrhythmic compound mexiletine.

GS (1 μM), mexiletine (40 μM) and TTX (10 μM) dissected largely similarly shaped inward currents under action potential voltage clamp conditions. In case of GS and mexiletine, the amplitude and integral of this inward current was significantly smaller when measured in the presence of 1 μM nisoldipine, while no difference was observed in case of TTX. Under conventional voltage clamp conditions, INa,late was significantly reduced by 1 μM GS and 40 μM mexiletine (about 79% and 63% reduction of current integrals, respectively). The integral of ICa,L was moderately but significantly decreased by both drugs (reduction of 9% and 14%, respectively). These changes were associated with a faster inactivation of ICa,L.

Drug effects on early Na+ current (INa,early) were assessed by analyzing the maximal rate of depolarization (V + max) in multicellular preparations. Both GS and mexiletine showed fast onset and offset kinetics: 110 ms and 289 ms offset time constants, respectively, as determined from V + max measurements in right ventricular papillary muscles, while the onset kinetics was characterized by 5.3 AP and 2.6 AP lengths, respectively, at 2.5 Hz.

Effects on beat-to-beat variability of AP duration (APD) was studied in isolated myocytes. Short-term variability was significantly decreased by both GS and mexiletine (average reduction of 42% and 24%, respectively) while they caused similar shortening of the APD.

The electrophysiological effects of GS are similar to those of mexiletine, but with a somewhat faster offset kinetics of V + max block. However, since GS reduced V+ max and INa,late in the same concentration, the currently accepted view that GS that selectively blocks INa,late has to be questioned and it is suggested that GS should be classified as a class I/B (or I/B + IV) antiarrhythmic agent.
How does the level of pulmonary venous isolation compare between pulsed field ablation and thermal energy ablation (radiofrequency, cryo, or laser)?
Authors: Kawamura Iwanari , Neuzil Petr , Shivamurthy Poojita , Kuroki Kenji , Lam Jeff , Musikantow Daniel , Chu Edward , Turagam Mohit K , Minami Kentro , Funasako Moritoshi , Petru Jan , Choudry Subbarao , Miller Marc A , Langan Marie-Noelle , Whang William , Dukkipati Srinivas R , Koruth Jacob S , Reddy Vivek Y
Published: May 2021

Aims

We studied the extent/area of electrical pulmonary vein isolation (PVI) after either pulsed field ablation (PFA) using a pentaspline catheter or thermal ablation technologies.

Methods and results

In a clinical trial (NCT03714178), paroxysmal atrial fibrillation (PAF) patients underwent PVI with a multi-electrode pentaspline PFA catheter using a biphasic waveform, and after 75 days, detailed voltage maps were created during protocol-specified remapping studies. Comparative voltage mapping data were retrospectively collected from consecutive PAF patients who (i) underwent PVI using thermal energy, (ii) underwent reablation for recurrence, and (iii) had durably isolated PVs. The left and right PV antral isolation areas and non-ablated posterior wall were quantified. There were 20 patients with durable PVI in the PFA cohort, and 39 in the thermal ablation cohort [29 radiofrequency ablation (RFA), 6 cryoballoon, and 4 visually guided laser balloon]. Pulsed field ablation patients were younger with shorter follow-up. Left atrial diameter and ventricular systolic function were preserved in both cohorts. There was no significant difference between the PFA and thermal ablation cohorts in either the left- and right-sided PV isolation areas, or the non-ablated posterior wall area. The right superior PV isolation area was smaller with PFA than RFA, but this disappeared after propensity score matching. Notch-like normal voltage areas were seen at the posterior aspect of the carina in the balloon sub-cohort, but not the PFA or RFA cohorts.

Conclusion

Catheter-based PVI with the pentaspline PFA catheter creates chronic PV antral isolation areas as encompassing as thermal energy ablation.
The bound executive: Emergency powers during the pandemic
Authors: Ginsburg Tom , Versteeg Mila
Published: May 2021

Emergency governance, we are often told, is executive governance. Only the executive has the information, decisiveness, and speed to respond to crises, and so the executive is not capable of being effectively constrained by other branches. Ordinary checks and balances, then, are believed to effectively disappear during a crisis. Referring to the classic theorist of emergency rule, conventional accounts describe crisis governance as “Schmittian” and “post-Madisonian,” characterized by an unbound executive that faces few, if any, legal constraints. This article interrogates these propositions using evidence from how countries responded to the 2020 global pandemic during the critical first few months. It presents data from an original and global survey of over one hundred countries to evaluate the nature of emergency powers during the pandemic. This article finds that, contrary to the conventional wisdom, courts, legislatures, and subnational governments have played important roles in constraining national executives. Courts have insisted on procedural integrity of invocations of emergency, engaged in substantive review of rights restrictions, and in some cases demanded that government take affirmative steps to combat the COVID-19 virus and its effects. Legislatures have played a role in providing oversight and, in many cases, in producing new legislation that responds to the current crisis. Subnational governments, too, have pushed back against central authorities, engaging in valuable checks and balances that shaped the response. Taken together, these findings suggest that, during COVID, emergency governance has been closer to the Madisonian ideal of strong checks and balances than to Schmittian accounts of an unbound executive. This article considers the implications of these findings for theories of emergency governance, arguing that the conventional theories are based on one particular type of crisis—a national security crisis—and therefore their insights may be ill-suited to other kinds of emergencies, such as a pandemic.
Cellular Activation, Differentiation, and Proliferation Influence the Dynamics of Genetically Intact Proviruses Over Time
Authors: Horsburgh Bethany A , Hiener Bonnie , Fisher Katie , Lee Eunok , Morgan Hannah , Eden John-Sebastian , von Stockenstrom Susanne , Odevall Lina , Milush Jeffrey M , Hoh Rebecca , Fromentin Rémi , Chomont Nicolas , Hecht Frederick M , Schlub Timothy E , Deeks Steven G , Palmer Sarah
Published: May 2021

Human immunodeficiency virus (HIV) persists in cells despite antiretroviral therapy; however, the influence of cellular mechanisms such as activation, differentiation, and proliferation upon the distribution of proviruses over time is unclear. To address this, we used full-length sequencing to examine proviruses within memory CD4+ T-cell subsets longitudinally in 8 participants. Over time, the odds of identifying a provirus increased in effector and decreased in transitional memory cells. In all subsets, more activated (HLA-DR–expressing) cells contained a higher frequency of intact provirus, as did more differentiated cells such as transitional and effector memory subsets. The proportion of genetically identical proviruses increased over time, indicating that cellular proliferation was maintaining the persistent reservoir; however, the number of genetically identical proviral clusters in each subset was stable. As such, key biological processes of activation, differentiation, and proliferation influence the dynamics of the HIV reservoir and must be considered during the development of any immune intervention.
A mutant equipped with a regenerated disulphide for the missing His loop of a serine protease zymogen in the horseshoe crab coagulation cascade
Authors: Yamashita Keisuke , Takeshita Naoki , Arita Aina , Shibata Toshio , Kobayashi Yuki , Kawabata Shun-ichiro
Published: May 2021

The lipopolysaccharide (LPS)-triggered coagulation cascade in horseshoe crabs is composed of three zymogens belonging to the trypsinogen family: prochelicerase C, prochelicerase B (proB) and the proclotting enzyme (proCE). Trypsinogen-family members contain three conserved disulphides located around the active site. While it is known that proB evolutionarily lost one of the disulphides, the His-loop disulphide, the roles of the missing His-loop disulphide in proB remain unknown. Here, we prepared a proB mutant, named proB-murasame, equipped with a regenerated His-loop disulphide. The activation rate by upstream α-chelicerase C for proB-murasame was indistinguishable from that for wild-type (WT) proB. The resulting protease chelicerase B-murasame exhibited an 8-fold higher kcat value for downstream proCE than WT chelicerase B, whereas the Km value of chelicerase B-murasame was equivalent to that of WT chelicerase B. WT serpins-1, -2 and -3, identified as scavengers for the cascade, had no reactivity against WT chelicerase B, whereas chelicerase B-murasame was inhibited by WT serpin-2, suggesting that WT chelicerae B may trigger as-yet-unsolved phenomena after performing its duty in the cascade. The reconstituted LPS-triggered cascade containing proB-murasame exhibited ∼5-fold higher CE production than that containing WT proB. ProB-murasame might be used as a high value-adding reagent for LPS detection.
Hospital staff perspectives: medication reconciliation responsibility and barriers at a tertiary teaching hospital in Jordan
Authors: Ibrahim Seliman M , Abu Hamour Khawla , Mahfouz Farah Abu , Abdel Jalil Mariam H , Hammad Eman A
Published: May 2021

Objectives

To explore hospital staff perspective on the responsibility and barriers to medicine reconciliation (MedRec) at a leading internationally renowned teaching hospital in Jordan.

Methods

A cross-sectional study using a self-completed questionnaire was conducted at Jordan University Hospital (JUH). The target sample was members of the health team caring for patients across various locations and settings. A convenient sample of physicians, pharmacists and nurses was targeted. Those were approached at various days, shifts, locations to scop various views and practices across JUH.

Key findings

Two hundred questionnaires were included in the analysis, of which 41 (20.5%) completed by physicians, 23 (11.5%) by pharmacists and 136 (68.0%) by nurses. For most steps, physicians were seen as the prim responsible health providers. Nurse perceived their role to come second. Whilst pharmacists perceived limited or no role of nurses in a number of steps. The main barriers reported are heavy workload 158 (79%), followed by lack of time 152 (76%) and communication between health care providers 140 (70%). Pharmacists highlighted lack of knowledge, clarity and training as leading barriers too.

Conclusions

Physicians are perceived as the leading provider responsible for all MedRec steps. MedRec as a process involve overlapping functions with various skill-based steps. A number of steps allocated potentially to nurses or pharmacists, particularly comparing different sources of information, constructing medication lists or written summaries upon discharge. Barriers to MedRec might be overcome by interdisciplinary discussions and mapping MedRec process clearly.
In the Middle of What? A Fresh Analysis of the Language Attested in the Judaeo-Arabic Commentary on Pirqê ’Āvō

T

(The Sayings of the Fathers), Middle Arabic and Implications for the Study of Arabic Linguistic History
Authors: Stokes Phillip W
Published: May 2021

While recent scholarship on Middle Arabic recognizes a spectrum of varieties from which authors might draw in their compositions, there is still a tendency to place the ends of the spectrum of linguistic features which any Middle Arabic author might employ as dialectal on the one hand and a homogeneous Classical Arabic on the other. In this paper, I challenge the contours of this spectrum by contextualizing the language of a thirteenth-century Judaeo-Arabic text from Egypt—the ‘Commentary on the Sayings of the Fathers’—within previously and contemporarily attested literary and performative traditions, drawing especially on Quranic reading traditions, as well as vocalized Judaeo-Arabic and Christian texts. I highlight important parallels between these traditions and features attested in this text. I conclude that to properly understand the linguistic choices that authors made, we must avoid anachronisms about the range of linguistic variation available to composers, and assumptions about the prestige associated with those variants.
Predictivity of International Hip Dysplasia Institute classification in Pavlik harness treatment and correlation with Graf ultrasonographic classification
Authors: Bozkurt Celal , Bekin Sarikaya Pelin Zeynep , Kaptan Ahmet Yigit , Eren Toygun Kagan , Sarikaya Baran
Published: May 2021

Hip ultrasonography applied according to Graf’s criteria is frequently used in early diagnosis and monitoring of developmental dysplasia of the hip (DDH). Recently, the International Hip Dysplasia Institute (IHDI) classification has been proposed to be a prognostic indicator for patients with walking-age DDH. The purpose of this study is to evaluate the reliability of IHDI classification in the follow-up of patients with DDH diagnosed by ultrasonography scanning. A total of 69 hips of 38 patients (10 men, 28 women; mean age 59.9 ± 19.8 days, range 29–90 days) were diagnosed with DDH younger than 90 days of age. The AP pelvis radiographs of the patients who were diagnosed with DDH by ultrasound and classified according to the Graf method were evaluated and classified according to IHDI classification. A total of 52 hips were treated successfully with Pavlik harness treatment, 15 hips underwent closed reduction and pelvipedal casting (PPC) and 2 hips underwent open reduction and PPC after failed Pavlik harness treatment. Increasing IHDI grades correlated with the failure of Pavlik harness treatment (P = 0.001). Graf classification was not found to be predictive of successful Pavlik harness treatment (P = 0.482). There was no significant correlation between the IHDI classification and the Graf classification (Kappa = 0.079 ± 0.102, P = 0.402). The IHDI method is reliable in predicting the success of Pavlik harness treatment in patients diagnosed with DDH using the Graf method.
Preoperative Radiographic Evaluation of Thoracic Flexibility and Compensation for Adult Spinal Deformity Surgery. How to Select Optimal Upper Instrumented Vertebra to Prevent Proximal Junctional Kyphosis
Authors: Ohba Tetsuro , Koji Fujita , Koyama Kensuke , Oba Hiroki , Oda Kotaro , Tanaka Nobuki , Haro Hirotaka
Published: May 2021

Study Design.

Retrospective study of a cohort of consecutive patients.

Objective.

The aim of this study was to clarify the usefulness and value of the difference in thoracic kyphosis (ΔTK) angle in various positions by imaging the patient standing, prone, and supine to evaluate TK flexibility and compensation, and to establish optimal radiography to determine an appropriate thoracic level for upper instrumented vertebra (UIV) because a strategy to select an appropriate level to avoid proximal junctional kyphosis (PJK) remains elusive.

Summary of Background Data.

Postoperative reciprocal progression of TK is a significant risk factor for PJK. However, how to predict and prevent postoperative reciprocal progression of TK remains unclear. We hypothesized that preoperative evaluation of both TK flexibility and compensation is essential to predict PJK and determine the UIV level.

Methods.

We included 144 consecutive patients with adult spinal deformity (ASD), ≥2 years’ follow-up, and UIV Th9–11 in this retrospective cohort study. TK was measured from images with patients standing, prone, and supine. Supine ΔTK was calculated as standing TK– supine TK. Prone ΔTK was calculated as standing TK – prone TK. Receiver-operating characteristic (ROC) curves were analyzed to determine the thresholds of supine ΔTK and prone ΔTK for PJK occurrence.

Results.

PJK was observed in 64 of 144 (44%) patients 2 years postoperatively. Prone and supine ΔTKs were significantly larger in patients with PJK. A significant positive correlation between prone ΔTK and supine ΔTK was observed. When data from patients with and without PJK were plotted separately, a significantly higher proportion of patients with PJK had large prone and supine ΔTKs. The cutoff values of prone and supine ΔTKs for PJK risk were determined using ROC curve analysis.

Conclusion.

Because of their significantly high risk for PJK, in patients with ASD and prone ΔTK >11.5° and supine ΔTK >18.5°, the upper-thoracic spine should be considered for UIV.

Level of Evidence: 3
The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion
Authors: Chapman Emily K. , Doctor Tahera , Gal Jonathan S. , Shuman William H. , Neifert Sean N. , Martini Michael L. , McNeill Ian T. , Rothrock Robert J. , Schupper Alexander J. , Caridi John M.
Published: May 2021

Study Design.

Retrospective cohort study.

Objective.

To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF).

Summary of Background Data.

Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified.

Methods.

Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type.

Results.

Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906–$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9–6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37–8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00–24.02, P < 0.0001).

Conclusion.

Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.

Level of Evidence: 3
Mixed Reality Assisted Percutaneous Scaphoid Fixation: A Proposed New Surgical Technique
Authors: Gregory Thomas , Hurst Simon A. , Moslemi Aymane
Published: May 2021

The success of percutaneous fixation of non or minimally displaced scaphoid waist fractures is reliant on optimal placement of the screw. This can be challenging for surgeons to achieve, potentially involving a large volume of intraoperative imaging, and surgical time. Mixed reality (MR) is a new technology that allows the projection of holographic imagery within the surgeon’s field of vision intraoperatively. This imagery can include surgical planning data and 3D reconstructions of a patient’s anatomy that can be used in order to aid the surgeon in achieving accuracy. We describe a technique for how this novel technology might be used in the future to fix scaphoid fractures—MR assisted percutaneous scaphoid fixation. This is done using cadaveric modeling. MR assisted percutaneous scaphoid fixation may have the potential to aid surgeons in achieving an optimal guidewire placement with the ability to reduce surgical time and radiation exposure.
Adult-Onset Still’s Disease Presenting as Macrophage-Activation Syndrome With Critical Illness in the Third Trimester of Pregnancy: A Case Report
Authors: Peters Andrew T. , Prickett Michelle H.
Published: May 2021

BACKGROUND:

We report a case of a young woman with adult-onset Still’s disease presenting as macrophage-activation syndrome complicated by shock and respiratory failure during the third trimester of pregnancy.

CASE SUMMARY:

A previously healthy 26-year-old woman at 35 weeks of gestation presented with 1 week of constitutional symptoms and was found to be febrile, tachycardic, and hypotensive. She delivered a healthy neonate by cesarean section. Following delivery, she had worsening hypotension and fevers despite fluid resuscitation and antibiotics, and developed progressive hypoxemia requiring up to 60% Fio
2, with bilateral upper-lobe predominant opacities on chest CT. She also had laboratory derangements including anemia, thrombocytopenia, low fibrinogen, elevated ferritin, and abnormal liver chemistries. After extensive testing to exclude infections, hemolysis, and other pertinent disorders, the development of polyarthralgias and a characteristic rash fulfilled criteria for adult-onset Still’s disease complicated by macrophage-activation syndrome. Her condition improved with immunosuppressive therapy.

CONCLUSION:

To our knowledge, this is the first report of new-onset adult-onset Still’s disease during the third trimester of pregnancy, which presented as macrophage-activation syndrome. In the context of late pregnancy, macrophage-activation syndrome can mimic or raise concern for hemolysis, elevated liver enzymes, and low platelet syndrome and other peripartum disorders. Furthermore, the characteristic articular symptoms of adult-onset Still’s disease may be mild and/or delayed, and pulmonary involvement with severe hypoxemia can occur. Clinicians should consider this diagnosis when evaluating a pregnant patient with unexplained fever and multiorgan dysfunction.
Evolution of Nursing Workload Indicators Since the Implementation of the Electronic Health Record at a Tertiary Hospital in Spain
Authors: Martín-Méndez María E. , García-Díaz Vanesa , Zurrón-Madera Paula , Fernández-Feito Ana , Jimeno-Demuth Franz , Lana Alberto
Published: May 2021

Nurses can be overwhelmed by the growing need for documentation derived from the implantation of electronic health records. The objective was to describe the evolution of nursing workload since the implementation of the EHR. We performed a longitudinal study of global workload indicators over a 5-year period at a referral hospital in Spain since introduction of the EHR (2014). Clinical activity records of each nurse were monitored using audit logs of their accesses to EHRs. During the study period, the number of EHR sessions, the number of EHR sessions in which a nursing order was changed, and the time needed to complete each session significantly increased. The number of mouse clicks and keystrokes and the time required to complete each nursing order decreased. Documentation of the following nursing tasks increased: administration of medication, peripheral vascular catheters, urinary catheters, pressure ulcers, nursing assessment forms, and pre-surgical verification. In conclusion, since the implementation of the EHR, an increase in the workload of nursing professionals—estimated through indirect indicators—has been observed due to greater documentation.
Risk Factors for Relapse after Intentional Discontinuation of Immune Checkpoint Inhibitors in Melanoma Patients
Authors: Persa Oana D. , Schatton Kerstin , Rübben Albert , Berking Carola , Erdmann Michael , Schlaak Max , Mauch Cornelia , Steeb Theresa
Published: May 2021

Immune checkpoint inhibitors (ICIs) have tremendously changed the therapeutic landscape of melanoma since they are associated with a durable response, allowing for intentional discontinuation of therapy after complete or partial remission. However, a subset of patients develops a relapse after cessation of ICI treatment and may not respond to reinduction of ICIs. The aim of the present study was to identify risk factors for relapse after intentional discontinuation of ICI therapy. Patients with intentional discontinuation of ICI therapy for metastatic or unresectable melanoma from 5 German university hospitals were analyzed retrospectively. Clinicopathologic and follow-up data of 87 patients were collected and analyzed by univariate and multivariate Cox proportional-hazards models. The following parameters were associated with relapse after cessation of ICI treatment in the univariate Cox regression analysis: concurrent radiotherapy and ICI, best overall response, and presence of brain metastases. Duration of treatment, type of primary tumor, body mass index, programmed-death ligand 1 expression, and lactate dehydrogenase levels did not significantly influence the risk for relapse. In the multivariate analysis, partial remission [hazard ratio 4.217 (95% confidence interval: 1.424−12.49), P=0.009] and stable disease [3.327 (1.204−9.19), P=0.02] were associated with a significant decrease in progression-free survival compared with complete remission. Concurrent radiotherapy and ICI [3.619 (1.288−10.168), P=0.015] are additional independent risk factors for decreased progression-free survival upon ICI discontinuation, whereas the presence of brain metastasis did not reach statistical significance on multivariate analysis.
An Executive Summary of the Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure
Authors: Dias Konrad J. , Shoemaker Michael J. , Lefebvre Kristin M. , Heick John D. , Collins Sean M.
Published: May 2021

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular and Pulmonary Section of APTA, published a clinical practice guideline (CPG) in January 2020 in the Physical Therapy journal to assist physical therapists in their clinical decision-making when treating patients with heart failure (HF). The purpose of this executive summary is to briefly describe the major themes of the CPG and provide current recommendations for evidence-based interventions in the management of patients with HF. A summary table of the 9 key action statements along with clinical algorithms guides the physical therapist in appropriate clinical decision-making.
Reporting and grading of complications after mid-urethral sling surgeries: Could the “Clavien-Dindo Classification” be adopted?
Authors: El-Hefnawy Ahmed S. , Wadie Bassem S.
Published: May 2021

Background:

To construct a modified model for reporting and grading of postoperative complications after the mid-urethral sling (MUS) procedure based on the Clavien-Dindo classification. In addition, complications of three different types of MUS were compared.

Materials and methods:

A PubMed search for postoperative complication after MUS was carried out for the period between January 1990 and July 2018. Reported complications were stratified in a plate form designed in accordance with grades of the Clavien-Dindo classification. Then, the proposed model was applied on reported complications in 160 females who underwent three different procedures of MUS (transvaginal tape [TVT], transobturator tape [TOT], and autologous fascial sling) with a minimum follow-up of 24 months.

Results:

The mean ± SD age at time of surgery was 46 ± 7 years. TVT was carried out in 75 (47%) patients, TOT in 40 (25%), and fascial sling in 45 (28%). The total number of complications was 62 in 43 (26.8%) patients. The vast majority of complications were Grade I and Grade II 19 (12%) and 21 (13%) out of 160 patients, respectively. Transient postoperative voiding difficulty (Grade II) and de novo urgency (Grade II) were the most prevalent complications in the fascial sling method (15.4% for each), whereas transient thigh pain (Grade II) was the most frequently reported complication after TOT (10%). Life-threatening vascular injury (Grade IV-a) was a serious complication in TVT cases.

Conclusions:

Postoperative complications of the MUS could be graded according to Clavien's classification. The vast majority of complications were Graded I or II. TVT can cause serious life-threatening complications.
Outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control: a trusted tool (SKIMS experience)
Authors: Khawaja Abdul Rouf , Ali Shayesta , Dar Yasir , Rouf Malik Abdul , Sofi Khalid , Malik Sajad , Bhat Arif Hamid , Wani Mohd Saleem
Published: May 2021

Background:

Nephron sparing surgery is a well-established surgical procedure for patients with small/bilateral renal masses. During the procedure, hilar control can be achieved by using bulldog clamps individually on the renal vessels, the renal artery alone without clamping the vein, or a laparoscopic Satinsky clamp for en bloc hilar clamping. In our series, we described the outcome of laparoscopic nephron sparing surgery using a Satinsky clamp for hilar control.

Materials and methods:

All eligible cases with confirmed diagnosis of a renal mass were advised of nephron sparing surgery. The short-term outcomes were evaluated by warm ischemia time (using a Satinsky clamp especially when CT renal angiography was not available), average blood loss, and length of postoperative hospital stay. The oncological outcome was evaluated by noting the surgical margins of histopathological specimen, local recurrence, and distant metastasis.

Results:

Of 30 cases 20 were male. The mean age was 54.25 years. On preoperative evaluation, 24 cases were T1a stage and the rest were 6 T1b stage. Four tumors were located in the upper pole, 4 in the posterior midpole, and 22 in the lower pole. Twenty-six patients had a low complexity score on RENAL scoring (ie, 4–6) and 4 patients a medium complexity score (ie, 7–9). Three patients were converted to open partial nephrectomy because of technical difficulty in intracorporeal suturing and difficulty in achieving hemostasis. Among these 3 patients, 2 patients had posterior base tumors and 1 had a lower polar tumor. Average blood loss was 350 ml, warm ischemia time was 28.46 minutes, and postoperative stay was 4.55 days. Of 30 specimens for histopathology, 23 (76%) were clear cell renal cell carcinoma (RCC), 4 (13%) were papillary RCC, 1 (3.3%) was chromophobe RCC, whereas 2 (6.6%) were benign (oncocytoma). Margins were free of tumors in all the patients with no recurrence in 2 years of follow-up.

Conclusion:

Laparoscopic partial nephrectomy by using a Satinsky clamp as a tool for en bloc hilar clamping in the proper axis at the hilum takes care of multiple vessels irrespective of size and number, particularly when renal angiography is not available. This technique of en bloc hilar clamping is quite useful especially in developing countries where robotic facilities are not available. The Satinsky clamp decreases blood loss and intraoperative time.
Self-development Tools Utilized by Plastic Surgeons: A Survey of ASPS Members
Authors: Gonzalez Santiago R. , Blumenauer Brian J. , Yuen James C. , Golinko Michael S.
Published: May 2021

Background:

The plastic surgery literature is devoid of research on the topic of professional development tools that may be used to enhance performance as a plastic surgeon. After an extensive review of the medical literature, we selected the most frequently referenced professional development tools utilized by plastic surgeons, which included the following: goal setting, positive visualization, scheduled practice, critically analyzing mistakes, professional development conferences, involvement in sports, motivational videos, podcasts & audiobooks, daily morning routines, self-development books, and advice from mentors.

Methods:

A 10-question survey was sent to 2542 members of the American Society of Plastic Surgeons (ASPS). The algorithm used to select ASPS members to survey was based on member demographics that would best reflect the views of the entire active society membership. Responses were compared based on demographic factors such as type of practice, gender, and age.

Results:

A total of 286/2542 (11.25%) ASPS members participated in the survey. Analyzing mistakes (96.3%), goal setting (88.51%), and advice from mentors (85.2%) were most commonly attributed to self-development. Respondents in an academic practice favored conferences and advice from mentors. Participants in a solo practice favored self-help books and morning routines. No statistical differences were observed based on training background.

Conclusions:

ASPS members attribute their professional development to setting measurable goals, carefully analyzing surgical mistakes, and guidance from mentors. This information opens the door for continued analysis of professional development within plastic surgery as well as supplement training practices at the resident and post-graduate level.