bluuebunny/crossref_metadata_2025 huggingface dataset:
Clusters of water governance problems and their effects on policy delivery
Authors: Kirschke Sabrina , Franke Christian , Newig Jens , Borchardt Dietrich
Published: March 2019

Public policy problems are increasingly being characterised as wicked or tame problems, assuming that this classification is also meaningful for attempts to effective problem-solving. But do distinct ‘wicked’ or ‘tame’ problems empirically exist? We investigate 37 water-related problems in Germany, based on interview-based data on problem wickedness and official data on policy delivery. Our analysis clearly reveals four clusters of water governance problems (system complexity, uncertainty, tame and wicked problems), based on variations of three factors of wickedness (goals, uncertainty and system complexity). These clusters of problems vary in their effects on different dimensions of policy delivery (goal formulation, stages and degrees of implementation of measures), with significant effects on goal formulation and the number of measures ‘in construction’. These empirical insights may contribute to a more systematic design of governance strategies for addressing water governance problems in practice.
NOTE ON THE NATURE OF THE CURRENT OF INJURY IN TISSUES
Authors: Osterhout W. J. V. , Harris E. S.
Published: March 2019

On page 48 to 54, Vol. 13, No. 1, September 20, 1929, through a mistake in printing the image of the string in Figs. 2, 6, 7, 9, 12, and 14 appears double. To obviate any misunderstanding it should be stated that in the original photograph the string was always single, as in Fig. 13.
THE PHOTOCHEMICAL NATURE OF THE PHOTOSENSORY PROCESS
Authors: Hecht Selig
Published: March 2019

On page 243, Vol. ii, No. 3, January 20, 1920, line 12 (counting each equation as a line) for a photochemical reaction read a reversible photochemical reaction.
Driven probe under harmonic confinement in a colloidal bath
Authors: Démery Vincent , Fodor Étienne
Published: March 2019

Colloids held by optical or magnetic tweezers have been used to explore the local rheological properties of a complex medium and to extract work from fluctuations with some appropriate protocols. However, a general theoretical understanding of the interplay between the confinement and the interaction with the environment is still lacking. Here, we explore the statistical properties of the position of a probe confined in a harmonic trap moving at constant velocity and interacting with a bath of colloidal particles maintained at a different temperature. Interactions among particles are accounted for by a systematic perturbation, whose range of validity is tested against direct simulations of the full dynamics. Overall, our results provide a way to predict the effect of the driving and the environment on the probe, and can potentially be used to investigate the properties of colloidal heat engines with many-body interactions.
Facelift Part I: History, Anatomy, and Clinical Assessment
Authors: Hashem Ahmed M , Couto Rafael A , Duraes Eliana F R , Çakmakoğlu Çagri , Swanson Marco , Surek Chris , Zins James E
Published: March 2019

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.
Response envelope analysis for quantitative evaluation of drug combinations
Authors: Du Di , Chang Chia-Hua , Wang Yumeng , Tong Pan , Chan Wai Kin , Chiu Yulun , Peng Bo , Tan Lin , Weinstein John N , Lorenzi Philip L
Published: March 2019

Motivation

The concept of synergy between two agents, over a century old, is important to the fields of biology, chemistry, pharmacology and medicine. A key step in drug combination analysis is the selection of an additivity model to identify combination effects including synergy, additivity and antagonism. Existing methods for identifying and interpreting those combination effects have limitations.

Results

We present here a computational framework, termed response envelope analysis (REA), that makes use of 3D response surfaces formed by generalized Loewe Additivity and Bliss Independence models of interaction to evaluate drug combination effects. Because the two models imply two extreme limits of drug interaction (mutually exclusive and mutually non-exclusive), a response envelope defined by them provides a quantitatively stringent additivity model for identifying combination effects without knowing the inhibition mechanism. As a demonstration, we apply REA to representative published data from large screens of anticancer and antibiotic combinations. We show that REA is more accurate than existing methods and provides more consistent results in the context of cross-experiment evaluation.

Availability and implementation

The open-source software package associated with REA is available at: https://github.com/4dsoftware/rea.

Supplementary information

Supplementary data are available at Bioinformatics online.
Extended-arch repair for acute type-A aortic dissection: perioperative and mid-term results
Authors: Fichadiya Akash , Gregory Alexander J , Kotha Vamshi K , Herget Eric J , Smith Holly N , Tai Elizabeth , Guo Ming , Mina Fady , Appoo Jehangir J
Published: March 2019

OBJECTIVES:

Extended-arch techniques offer the potential to comprehensively treat acute type-A aortic dissection (ATAAD), but add surgical complexity compared to the standard hemiarch technique. This study describes both perioperative and mid-term outcomes following the introduction of an extended-arch technique for ATAAD.

METHODS:

Ours is a retrospective single-centre observational study of 95 consecutive patients with ATAAD from 2011 to 2016. The decision to perform extended-arch or hemiarch repair was individualized based on clinical and radiological features. Extended-arch repair was defined as replacement of the ascending aorta and arch with reimplantation of head vessels with or without distal endovascular extension. Clinical follow-up was 100% complete. Cross-sectional double-oblique measurements were performed for aortic remodelling analysis.

RESULTS:

Extended-arch (n = 28) and hemiarch (n = 67) repair resulted in a in-hospital mortality of 10% (n = 3) and 10%, (n = 7), and permanent neurological deficit rate of 7% and 12%, respectively. At a mean imaging follow-up duration of 2.7 ± 1.5 years, false lumen thrombosis was achieved in 57% and 9% of patients undergoing extended-arch and hemiarch repair, respectively. Rate of growth in the proximal descending aorta was 0.7 ± 2.3 mm/year in the extended-arch group vs 2.7 ± 3.9 mm/year in the hemiarch group. At a mean clinical follow-up time of 3.0 ± 1.6 years, open surgical aortic reoperation was 0% in the extended-arch group and 22% in the hemiarch group.

CONCLUSIONS:

Extended-arch repair of ATAAD can be introduced in the acute setting without increase in perioperative mortality or morbidity. At mid-term follow-up, extended-arch for ATAAD improves aortic remodelling and reduces the need for open surgical reoperation.
First report of a hybrid robotic beating-heart quadruple totally endoscopic coronary artery bypass: toward complete revascularization
Authors: Kitahara Hiroto , Hirai Taishi , Nathan Sandeep , Balkhy Husam H
Published: March 2019

To the best of our knowledge, this is the first report describing robotic beating-heart quadruple all-arterial totally endoscopic coronary artery bypass combined with percutaneous coronary intervention attempting complete revascularization (residual SYNTAX score 0). A 66-year-old male with severe triple-vessel coronary artery disease underwent percutaneous coronary intervention for a sub-total occlusion of the right coronary artery as the initial component of a hybrid revascularization strategy. Subsequently, the left coronary system was revascularized via robotic beating-heart totally endoscopic coronary artery bypass with bilateral internal mammary artery grafts.
Are two internal thoracic grafts better than one? An analysis of 5301 cases
Authors: Pevni Dmitry , Mohr Rephael , Kramer Amir , Paz Yosef , Nesher Nachum , Ben-Gal Yanai
Published: March 2019

OBJECTIVES

Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique due to its greater complexity and the potentially increased risk of sternal infection. This observational study examined if BITA grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting in patients with multivessel coronary disease.

METHODS

Patients in our institution who underwent BITA grafting during 1996–2011 were compared to those who underwent SITA grafting during the same period. To adjust for differences in demographic and clinical characteristics, patients were matched by propensity score. The Cox model was used to identify predictors of decreased survival and the Kaplan–Meier analysis was performed, both for the entire cohort and for the matched cohort.

RESULTS

SITA patients were older than BITA patients, included more females, and were more likely to have chronic obstructive lung disease, an ejection fraction <30%, diabetes, renal insufficiency, peripheral vascular disease and emergency and repeat operations. Three-vessel and left main diseases were more common among BITA patients, and operative mortality was reduced (2.1% vs 3.6% for SITA, P = 0.002). Sternal infection and stroke rates were similar for the groups. Ten-year Kaplan–Meier survival of BITA patients was better (71.2% vs 56.8%, respectively, P < 0.001). BITA grafting was found to be a predictor of better survival in the analysis of the matched cohort (P < 0.001).

CONCLUSIONS

Our results support the routine use of BITA grafting in patients who undergo myocardial revascularization.
Klotho: An Elephant in Aging Research
Authors: Cheikhi Amin , Barchowsky Aaron , Sahu Amrita , Shinde Sunita N , Pius Abish , Clemens Zachary J , Li Hua , Kennedy Charles A , Hoeck Joerg D , Franti Michael , Ambrosio Fabrisia
Published: March 2019

The year 2017 marked the 20th anniversary of the first publication describing Klotho. This single protein was and is remarkable in that its absence in mice conferred an accelerated aging, or progeroid, phenotype with a dramatically shortened life span. On the other hand, genetic overexpression extended both health span and life span by an impressive 30%. Not only has Klotho deficiency been linked to a number of debilitating age-related illnesses but many subsequent reports have lent credence to the idea that Klotho can compress the period of morbidity and extend the life span of both model organisms and humans. This suggests that Klotho functions as an integrator of organ systems, making it both a promising tool for advancing our understanding of the biology of aging and an intriguing target for interventional studies. In this review, we highlight advances in our understanding of Klotho as well as key challenges that have somewhat limited our view, and thus translational potential, of this potent protein.
Short-Term Increases in Aphid Dispersal From Defensive Dropping Do Not Necessarily Affect Long-Term Biological Control by Parasitoids
Authors: La-Spina Michelangelo , Jandricic Sarah E , Buitenhuis Rose
Published: March 2019

Foxglove aphid (Aulacorthum solani (Kaltenbach) (Hemiptera: Aphididae)) is one of the principal aphid pests of greenhouse ornamental crops in North America. Biological control of foxglove aphid mostly relies on the use of Aphidius ervi Haliday (Hymenoptera: Braconidae). However, studies indicate that A. ervi may not be adapted to search for A. solani, and that in response to parasitoid attack aphids can drop and/or disperse, which may aggravate an infestation. Our goal was to further describe the searching behavior of A. ervi in the presence of foxglove aphids, the corresponding defensive behavior of foxglove aphid and the short- and medium-term effects on both pest dispersal and control by A. ervi. Behavioral observations were done on top and bottom leaves infested with foxglove aphid and a high release rate of A. ervi. Parasitoids tended to land on top leaves; however, more aphids were parasitized on bottom leaves, leading to equal numbers of parasitoid attacks in both locations. Most aphids dropped off the plant in the presence of a parasitoid. In large cage experiments, aphids were allowed to distribute naturally and A. ervi was released. The parasitoid still caused a high rate of aphid dropping. However, only a few aphids were able to successfully reach new plants, and most of these mummified over time. Our studies confirm that parasitoid-induced dispersal of foxglove aphid in greenhouse crops does occur, but also suggests this should not necessarily be a barrier to adoption of biological control, as A. ervi controls the aphids over time.
Searching for the 380 GHz H2O emission from the high-z lensed quasi-stellar object MG J0414+0534
Authors: Kuo Cheng-Yu , Suyu Sherry H , Impellizzeri Violette , Braatz James A
Published: March 2019

We report the results of our search for the 380 GHz H2O line emissions from the quadruply lensed quasi-stellar object (QSO) MG J0104+0534 at z = 2.639 with the Atacama Large Millimeter/submillimeter Array. Our observation shows a tentative detection of the 380 GHz line from the lensed QSO, and the line spectrum shows a broad spectral distribution that has a velocity width of ∼290 km s−1 and a peak flux of ∼0.8 mJy. The integrated intensity map of the H2O line shows lensed emissions at the A1 and A2 component of the QSO, with the A2 component slightly resolved. The integrated line flux ratio between the A1 and A2 components shows an unexpected difference from the continuum flux ratio. Based on our gravitational lens modeling, assuming our tentative detection is real, this flux ratio anomaly would suggest that the 380 GHz line emissions come from two or three spatially displaced locations in the QSO, with the dominant one located at the position of the continuum emission from the QSO, and the other one(s) displaced from the continuum by ∼1.5 kpc on the source plane.
Factors Influencing Neonatal Practice in a Rural Community in Kano (Northern), Nigeria
Authors: Farouk Zubaida Ladan , Slusher Tina M , Danzomo Abba Ahmed , Slusher Ida L
Published: March 2019

Nigeria has the highest number of neonatal and under-five deaths in Africa. Socio-cultural determinants play an important role in disease burden in low-middle income countries.

This study aimed to describe knowledge, attitudes and neonatal care practice among household caregivers in a rural community in Nigeria, specifically uvulectomy, female genital mutilation (FGM), failure to routinely immunize and unsafe cord care. Further, relationships between demographic characteristics and knowledge, attitudes and neonatal care practices among caregivers were analyzed.

The study design was descriptive correlational and cross-sectional. Consented caregivers (N = 298) were enrolled and interviewed using a structured questionnaire.

Data were collected on demographic characteristics of the study participants and practice of uvulectomy, FGM, immunization and cord care.

Statistically significant correlations were found between the practice of uvulectomy, FGM and failure to immunize based on occupation (p = 0.0202, p = 0.0290, p = 0.0071) and educational level (p =< 0.0001, p =< 0.0001, p =< 0.0001), with variations by ethnicity.

Intense, preventative health measures and maternal education to eliminate harmful care practices are essential to influence outcomes.
Augmented and Virtual Reality Instrument Tracking for Minimally Invasive Spine Surgery
Authors: Burström Gustav , Nachabe Rami , Persson Oscar , Edström Erik , Elmi Terander Adrian
Published: March 2019

Study Design.

Cadaveric animal laboratory study.

Objective.

To evaluate the feasibility and accuracy of pedicle cannulation using an augmented reality surgical navigation (ARSN) system with automatic instrument tracking, yielding feedback of instrument position in relation to deep anatomy.

Summary of Background Data.

Minimally invasive spine surgery (MISS) has the possibility of reducing surgical exposure resulting in shorter hospital stays, lower blood loss and infection rates compared with open surgery but the drawback of limiting visual feedback to the surgeon regarding deep anatomy. MISS is mainly performed using image-guided 2D fluoroscopy, thus exposing the staff to ionizing radiation.

Methods.

A hybrid operating room (OR) equipped with a robotic C-arm with integrated optical cameras for augmented reality instrument navigation was used. In two pig cadavers, cone beam computed tomography (CBCT) scans were performed, a 3D model generated, and pedicle screw insertions were planned. Seventy-eight insertions were performed. Technical accuracy was assessed on post-insertion CBCTs by measuring the distance between the navigated device and the corresponding pre-planned path as well as the angular deviations. Drilling and hammering into the pedicle were also compared. Navigation time was measured. An independent reviewer assessed a simulated clinical accuracy according to Gertzbein.

Results.

The technical accuracy was 1.7 ± 1.0 mm at the bone entry point and 2.0 ± 1.3 mm at the device tip. The angular deviation was 1.7 ± 1.7° in the axial and 1.6 ± 1.2° in the sagittal plane. Navigation time per insertion was 195 ± 93 seconds. There was no difference in accuracy between hammering and drilling into the pedicle. The clinical accuracy was 97.4% to 100% depending on the screw size considered for placement. No ionizing radiation was used during navigation.

Conclusion.

ARSN with instrument tracking for MISS is feasible, accurate, and radiation-free during navigation.

Level of Evidence: 3
Risk Factors for Compromised Surgical Resection: A Nationwide Propensity Score-Matched Study on Laparoscopic and Open Resection for Colonic Cancer
Authors: Vogelsang Rasmus P. , Klein Mads F. , Gögenur Ismail
Published: March 2019

BACKGROUND:

High-quality surgical resection of colonic cancer, including dissection along the embryologic mesocolic plane, translates into improved long-term oncological outcomes.

OBJECTIVE:

This study aimed to identify risk factors for compromised specimen quality and to evaluate the specimen quality of patients undergoing laparoscopic and open resection for colonic cancer.

DESIGN:

This is a retrospective observational study.

SETTINGS:

This database study is based on the prospective national Danish Colorectal Cancer Database including patients undergoing intended curative elective colonic cancer surgery from January 1, 2010 through December 2013.

PATIENTS:

A total of 5143 patients (1602 open resections; 3541 laparoscopic resections) with colonic cancer were included.

MAIN OUTCOME MEASURES:

Risk factors for poor resection quality were identified through uni- and multivariate logistic regression analysis. The surgical approach was assessed by propensity score-matched regression analysis. Poor resection quality was defined as resections in the muscularis plane accompanied by R0 resection, or resections in any resection plane accompanied by R1 resection.

RESULTS:

Overall, 4415 (85.8%) of the resections were considered good and 728 (14.2%) were considered poor. After multivariate analysis, neoadjuvant oncological treatment, advanced tumor stage (T3-4), advancing N stage (N1-2), open tumor perforation, and open surgery significantly increased the risk of poor resection quality. In a propensity score-matched sample (n = 1508 matched pairs), matched for age, sex, ASA score, BMI, neoadjuvant treatment, tumor stage, and tumor location, open resection was still associated with a higher risk of poor resection quality compared with laparoscopic resection (OR, 1.4; 95% CI, 1.1–1.8; p = 0.002).

LIMITATIONS:

Retrospective design was a limitation of this study.

CONCLUSIONS:

In this nationwide propensity score-matched database study, laparoscopic resection was associated with a higher probability of good resection quality compared with open resection for colonic cancer. Risk factors for compromised specimen quality were neoadjuvant oncological treatment, locally advanced tumor stage (T3-4), advanced N stage (N1-2), open tumor perforation, and open surgery. See Video Abstract at http://links.lww.com/DCR/A830.
Diagnosis and Management of Lynch Syndrome
Authors: Hajirawala Luv , Barton Jeffrey S.
Published: March 2019

Case Summary:

A 56-year-old man with a history of hypertension and hyperlipidemia was referred by gastroenterology for bleeding per rectum. Because of a family history of colon cancer, he had several prior colonoscopies, most recently 3 years ago, without evidence of pathology. His mother was diagnosed with colon cancer in her mid-40s. His current colonoscopy demonstrated a 2.4 × 1.5 cm cecal adenocarcinoma. Staging workup revealed no evidence of metastatic disease. Because of the patient’s family history, the specimen was further evaluated and found to have high microsatellite instability (MSI-H). The patient was referred to a genetic counselor and found to have a germline pathogenic variant in MSH6 on gene panel testing. The patient did not have a family history of any extracolonic malignancies.

The patient underwent an uncomplicated laparoscopic total abdominal colectomy with ileorectal anastomosis, which revealed a T2N0Mx adenocarcinoma with abundant peritumoral lymphocytes. He was discharged on postoperative day 2, and recuperated appropriately from surgery. Follow-up surveillance proctoscopy showed no evidence of disease. His sole offspring, a 25-year-old man, was negative for a pathogenic variant in MSH6 and had no polyps on colonoscopy. His siblings did demonstrate a pathogenic variant in MSH6 and are currently opting for annual surveillance colonoscopy.
Multiplanar Assembly Mammaplasty Based on the Divine Proportion
Authors: Pereira Filho Osvaldo , BIns Ely Jorge , Lee Kuang Hee , Paulo Elizabeth Machado , Granemann Alfredo Spautz
Published: March 2019

Background:

The study sought to plan mastopexy and breast reduction according to the principle of the divine proportion, represented by the letter phi, via the convergent assembly of multiple layers to create the new breast. This strategy is based on the constancy of the submammary fold and the orientation of the vertex of a V-shaped triangle opening at approximately 60° at the umbilicus, with each branch opening in the direction of the acromioclavicular joint.

Methods:

The strategy was prospectively investigated in 265 patients (n = 530 breasts). The mean patient age was 36 years. The follow-up ranged from 6 months to 3 years.

Results:

A total of 220 patients (83%) received a good score (1–4) according to Strasser grading. Complications were few, but included delayed healing with minimal scar ulceration in 19 patients (7%), asymmetry in 16 (6%), and partial nipple necrosis in 4 (1.5%).

Conclusions:

This approach adds precision to mammaplasty, reduces the laxity in the axillary region, promotes bulk in the upper pole, and eases nipple–areola complex elevation.
Five Financial Pearls for Medical Students, Residents, and Young Surgeons
Authors: Poppler Louis H. , Sharma Ketan , Buck Donald W. , Myckatyn Terence M.
Published: March 2019

Background:

Finances impact every aspect of our daily lives. Despite this, they are rarely discussed in medical school or surgical training. Consequently, more than half the medical students we interview report no formal teaching about personal finance. The purpose of this article was to present 5 topics every graduating medical student, resident, and young surgeon should understand to start the path to financial independence.

Methods:

We synthesized recommendations and data from several books on financial literacy, blogs on the topic, and the personal experiences of the 4 authors.

Results:

The following 5 topics were identified as critical for young surgeons: learn about and manage your own finances, consider the financial implications of your career choices, make a plan to pay off your student loans, make a budget and stick to it, and think carefully before buying property. Central to these 5 lessons is the idea that starting to invest and save early is essential to taking advantage of interest and capital gains. We also demonstrate pay and cost differences in 5 regions of the country and outline the 2 main pathways one can take to repaying their student loans.

Conclusions:

Financial literacy is an important aspect of being an effective surgeon. With minimal effort, you can take these 5 steps now toward financial freedom. Doing so will improve your sense of control over your financial life and decrease anxiety about the unknown.
Extended L-Framework: An Innovative Technique for Reconstruction of Low Nasal Dorsum by Autogenous Costal Cartilage Graft
Authors: Aboul Wafa Ahmed Mabrouk
Published: March 2019

Background:

Congenital, iatrogenic, and traumatic etiologies can produce a deficient nasal dorsum requiring dorsal augmentation. Traditional techniques for dorsal augmentation as onlay dorsal graft, cantilever graft, or conventional L-framework usually have less stability and produce a rigid lobule if the single unit framework extends to the tip. Because of abundant volume and relative ease of harvest and carving, the autogenous rib cartilage has been considered the graft of choice for dorsal nasal augmentation when structural support is necessary and sufficient septal cartilage is not available.

Methods:

Eighteen patients with congenital, iatrogenic, and posttraumatic low nasal dorsum were reconstructed with the extended L-cartilage framework over the past 3 years with an average postoperative follow-up of 15 months. The framework was reconstructed from 3 carved cartilaginous pieces. If needed, columellar strut, spreader, and tip grafts were also provided.

Results:

All the 18 patients were generally satisfied with the cosmetic and functional outcomes at around 1-year follow-up. The nasal projection and dorsal aesthetic lines were pleasing and maintained over a prolonged postoperative follow-up period. There was free natural movement of the lobular part of the nose. No major complications were encountered.

Conclusions:

Consistent, reproducible results were achieved with using the extended L-framework in primary and secondary rhinoplasty and in posttraumatic dorsal nasal deformities as well. This technique has different advantages over the conventional techniques as the extended framework is more anatomical, preserves pliability of the lobule, maintains stability without any means of fixation, and offers good control of aesthetic needs.
The Shame–Blame Game: Is It Still Necessary? A National Survey of Shame-based Teaching Practice in Canadian Plastic Surgery Programs
Authors: Boehm Kaitlin S. , McGuire Connor , Boudreau Colton , Jenkins Danielle , Samargandi Osama A. , Al-Youha Sarah , Tang David
Published: March 2019

Background:

As understanding of poor physician mental health and burnout strengthens, it is becoming important to identify factors that detract from wellbeing. Shame-based learning (SBL) is detrimental to psychological health and can contribute to burnout, substance abuse and suicide. This study endeavoured to quantify the unknown prevalence and effects of SBL in Canadian plastic surgery programs.

Methods:

An electronic survey was sent to all attending surgeons and trainee (residents and fellows) members of the Canadian Society of Plastic Surgeons. SBL was assessed using a validated questionnaire. Data was analyzed using descriptive statistics and thematic analysis.

Results:

98 responses (14.7%) comprising of 63 attending surgeons and 36 trainees were received. The majority of attending surgeons (78 percent) and trainees (67%) have been shamed. Fourteen percent of trainees and 9% of attending surgeons felt that SBL is necessary. The most common event provoking shaming for trainees was wrong answers (56%) and for attending surgeons was disagreement in clinical care (21%). For both groups, shamers were in positions of authority. The most common effect of SBL in trainees was a loss of self-confidence (53%), compared to no negative effect in attending surgeons (49 percent). Thirty-nine percent of trainees dealt with shaming events with support from fellow trainees (39 percent), while attending surgeons kept it to themselves (40 percent).

Conclusion:

SBL is present in Canadian plastic surgery residency programs and has numerous detrimental effects. To foster better mental health, residency programs should identify ongoing SBL and make efforts to transition to healthier feedback strategies.
The Lipo-Body Lift: Operative Technique
Authors: Bertheuil Nicolas , Chaput Benoit , Bergeat Damien , Morvan Christophe , Mocquard Camille , Watier Eric
Published: March 2019

Bariatric surgery induces massive weight loss, which results in global and complex skin deformities. Lower body lift procedure has become the gold standard for lower trunk reconstruction. The authors describe in this video the lipo-body lift technique in detail. The video is divided into 4 parts: part 1, indications and preoperative markings; part 2, posterior contouring; part 3, anterior contouring; and part 4, preoperative and postoperative results. Patient selection and technical key points of the technique are discussed. The lipo-body lift method is an important component of reconstructive strategies and should be widely offered to patients who experienced massive weight loss.
RECLASSIFICATION OF FUNDUS AUTOFLUORESCENCE PATTERNS SURROUNDING GEOGRAPHIC ATROPHY BASED ON PROGRESSION RATE
Authors: Shen Liangbo L. , Liu Feimei , Nardini Holly Grossetta , Del Priore Lucian V.
Published: March 2019

Purpose:

To reclassify fundus autofluorescence (FAF) patterns around geographic atrophy (GA) based on GA progression rates.

Methods:

MEDLINE, EMBASE, Cochrane Library, Clinicaltrials.gov, and PubMed were searched for studies reporting GA progression rates among different FAF patterns, such as “None,” “Focal,” “Banded,” “Patchy,” “Diffuse Nontrickling,” and “Diffuse Trickling.” The GA radius growth rate among different FAF patterns was compared, and a GA growth function for each group was derived. To account for the patients' different entry times, a horizontal translation factor was introduced to shift each data subset from “time after enrollment” to “duration of GA.”

Results:

Seven studies with 496 eyes were included. Based on GA radius growth rates, the six FAF patterns were clustered into four groups with a high correlation coefficient within each group: Group 1, None, 0.061 mm/year (r2 = 0.996), Group 2, Focal, 0.105 mm/year (r2 = 0.987), Group 3, Banded, Patchy, and Diffuse Nontrickling, 0.149 mm/year (r2 = 0.993), and Group 4, “Diffuse Trickling, 0.245 mm/year (r2 = 0.997).

Conclusion:

This meta-analysis suggested that the six FAF patterns can be coalesced into four groups based on lesion progression rates. Simplification of the reclassified FAF patterns may shed light on the GA natural history and assist in the design of clinical trials.
Open-Source Three-Dimensional Printable Infant Clubfoot Brace
Authors: Savonen Benjamin , Gershenson John , Bow Jennifer K. , Pearce Joshua M.
Published: March 2019

Introduction

Open-source, self-replicating rapid prototypers (RepRaps) have radically reduced the costs of three-dimensional (3D) printing while expanding its access. Three-dimensional printing's model of distributed manufacturing can produce medical technologies at significantly reduced costs. We investigate this potential by evaluating the viability of an open-source 3D printable infant clubfoot brace.

Materials and Methods

Starting with a list of key features present in currently available clubfoot braces, a 3D-printed clubfoot brace was developed in free and open-source CAD software (FreeCAD) to enable future customization. Polylactic acid, a biodegradable and recyclable bioplastic, was selected among the various commercial 3D printable materials based on strength and cost.

Results

The results show that the open-source clubfoot brace matches or surpasses the physical features and mechanical degrees of freedom of all commercial- and nonprofit-developed brace designs while substantially reducing the costs of the braces to hospitals and families.

Conclusions

The 3D-printed brace has the features of commercially available braces while significantly reducing the cost, making this clubfoot brace particularly appropriate for use in developing countries. In addition, the results indicated that this model of distributed manufacturing of medical technology is technically and economically appropriate through much of the Global South.
Development and Implementation of a Pediatric Trauma Survivors Network Program
Authors: Scannell Brian P. , Wally Meghan K. , Flores Eileen , Levy Jessica , Waddell Megan , Seymour Rachel B.
Published: March 2019

The Trauma Survivors Network (TSN) was developed as a program of the American Trauma Society (ATS) to support recovery for adult trauma patients. However, the children of adult trauma patients, families of pediatric trauma patients, and pediatric trauma patients previously had scarce resources. Our institution, in collaboration with the ATS, sought to expand the TSN to support pediatric trauma patients, caregivers, and family members. We aimed to determine whether the TSN could be transferred to the pediatric population. Focus groups identified psychosocial needs of younger survivors, children of adult survivors, and caregivers. A Pediatric TSN Coordinator was hired, Pediatric TSN Peer Visitors were recruited and trained, and Pediatric TSN Activity Hour was implemented for pediatric patients and families. Since implementation 1 year ago, 26 peer visitors have been trained and have conducted approximately 200 visitations. In total, 93 patients and family members have attended Pediatric TSN Activity Hour. TSN services can be adapted to address psychosocial needs of pediatric trauma survivors, families, and children of trauma survivors. When possible, sharing resources between an existing adult TSN program and a pediatric program is valuable to facilitate expansion. TSN complements and strengthens the care offered at our institution by providing patient-centered and family-centered care services for the entire family at various stages of development. The implementation of this program might be different at sites without an existing adult TSN with established resources and support. This article describes the development and implementation of the program; we did not assess outcomes.
Trauma Nurse Leads in a Level I Trauma Center: Roles, Responsibilities, and Trauma Performance Improvement Outcomes
Authors: Polovitch Samantha , Muertos Keely , Burns Alison , Czerwinski Adam , Flemmer Kathryn , Rabon Summer
Published: March 2019

Grand Strand Medical Center is a 325-bed, Level I adult, Level II pediatric trauma center located in Myrtle Beach, SC. In September 2015, a Trauma Nurse Lead (TNL) program was developed and implemented to allow for consistent, expert clinical nursing care across the trauma continuum. This TNL program has led to measurable improvements in patient care and quality metrics. These improvements include decreases in hospital and intensive care unit length of stay, arrival to administration of massive transfusion and anticoagulation reversal, and arrival to final disposition time. The TNL program has ensured the presence of highly trained trauma nurses at all times within the hospital. With the consistent availability of these highly trained and specialized nurses, trauma patients are cared for more efficiently and in a timely manner.
Addressing adverse childhood experiences in diverse racial and ethnic settings: a review
Authors: Wang Yingna , Nerwen Renana , Gabris Carla
Published: March 2019

Purpose of review

This article reviews the current literature on adverse childhood experiences (ACEs) with particular focus on racial and ethnic factors.

Recent findings

Limited research exists with respect to ACEs and certain racial and ethnic groups. In this article, we highlight the unique challenges specific populations may face in their lives. Further research on ACEs in these and other racial and ethnic groups is needed to help clinicians contextualize their cases in the clinical setting.

As the US population continues to diversify, it is pivotal that clinicians and researchers understand some of the challenges faced by different racial and ethnic populations and demonstrate more sensitivity to patient needs. Clinicians who are sensitive to an individual's history of ACEs would be expected to have a better understanding of his/her patient's predilection to specific mental health issues.
Improving Knowledge, Comfort, and Confidence of Nurses Providing End-of-Life Care in the Hospital Setting Through Use of the CARES Tools
Authors: Stacy Alison , Magdic Kathy , Rosenzweig Margaret , Freeman Bonnie , Verosky Denise
Published: March 2019

Although most individuals prefer to die at home, approximately 60% of Americans die in the hospital setting. Nurses are inadequately prepared to provide end-of-life (EOL) care because of cure-focused education. Friends and family of dying patients report poor quality of death largely as a result of inadequate communication from health care professionals about the dying process. The purpose of this project was to improve nursing knowledge and comfort related to EOL care through use of the CARES tool and to improve the EOL experience of families of dying patients in the hospital setting through use of Final Journey. These acronym organized tools were developed based upon the common symptom management needs of the dying including Comfort, Airway, Restlessness and delirium, Emotional and spiritual support, and Self-care. The CARES tool for nurses improved nursing knowledge and comfort related to EOL care and common symptom management needs of the dying and also enhanced nurses' confidence in communicating about the dying process with friends and family. Final Journey, the friends and family version of the CARES tool, reinforced EOL information for friends and family, helped nurses answer difficult questions, and promoted and enhanced communication between health care professionals and friends and family of the dying.
Clinicopathologic and Molecular Features of a Series of 41 Biphenotypic Sinonasal Sarcomas Expanding Their Molecular Spectrum
Authors: Le Loarer François , Laffont Sophie , Lesluyes Tom , Tirode Franck , Antonescu Cristina , Baglin Anne-Catherine , Delespaul Lucile , Soubeyran Isabelle , Hostein Isabelle , Pérot Gaëlle , Chibon Frédéric , Baud Jessica , Le Guellec Sophie , Karanian Marie , Costes-Martineau Valérie , Castain Claire , Eimer Sandrine , Le Bail Brigitte , Wassef Michel , Coindre Jean-Michel
Published: March 2019

Biphenotypic sinonasal sarcoma (BSNS) is a locally aggressive tumor occurring in the sinonasal region. It harbors both myogenic and neural differentiation and is characterized by PAX3 rearrangement with MAML3 as the most frequent fusion partner, but the partner of PAX3 remains unidentified in a subset of cases. About 70 cases have been reported so far. In this study, we report a series of 41 cases with clinical, pathologic, and molecular description. Twenty-five (61%) patients were female individuals, and the median age was 49 years. Tumors arose predominantly in the nasal cavity and ethmoidal sinuses. Local recurrences occurred in 8 cases of the 25 (32%). Histologic features were characteristic of BSNS, with 5 cases showing focal rhabdomyoblastic differentiation. Immunohistochemistry showed a constant positivity of S100 protein and PAX3 and negativity of SOX10. MyoD1 was focally positive in 91% of cases, whereas only 20% were positive for myogenin. Molecular analysis showed a PAX3-MAML3 transcript in 37 cases (90%). RNA sequencing was performed in the 4 negative cases for PAX3-MAML3 fusion, and it showed that 1 case harbored a PAX3-FOXO1 fusion, as previously described in the literature, and 2 novel fusions: PAX3-WWTR1 fusion in 2 cases and PAX3-NCOA2 fusion in 1 case. RNA sequencing results were confirmed by fluorescence in situ hybridization, reverse transcription-polymerase chain reaction, and Sanger sequencing. The PAX3-NCOA2-positive case showed focal rhabdomyoblastic differentiation. In conclusion, we report 2 novel fusions (PAX3-WWTR1 and PAX3-NCOA2) in BSNS and show that MyoD1 is more sensitive than myogenin for demonstrating myogenic differentiation in this tumor.
Psychometric Testing of Errors of Care Omission Survey: A New Tool on Patient Safety in Primary Care
Authors: Poghosyan Lusine , Norful Allison A. , Ghaffari Affan , Liu Jianfang
Published: March 2019

Objective

The aim of the study was to evaluate the psychometric properties of a newly developed survey tool measuring omissions in primary care.

Methods

The Errors of Care Omission Survey (ECOS) is the only known tool to measure critical omissions (“errors”) in primary care from the perspectives of primary care providers (PCPs), both physicians and nurse practitioners. The tool has 31 items grouped into the following four subscales: Self-Management Support, Follow-up, Emotional Health Support, and Care Integration. A cross-sectional survey design was used to mail the tool to PCPs and 582 PCPs in one state in the U.S. completed and returned the survey. Exploratory factor analysis with target rotation was carried out. Internal consistency reliability of identified subscales was investigated.

Results

Four factors emerged representing domains of omissions in primary care. The original Follow-up and Care Integration subscales were retained. The items on Self-Management Support and Emotional Health Support subscales loaded differently on two factors, which were labeled Patient Self-Management and Family Engagement subscales, suggesting that conceptually PCPs separate patient and family involvement in patient care. Seven poorly performing or redundant items were removed. The remaining 24 items measure patient self-management, family engagement, follow-up, and care integration domains of omissions in primary care. The ECOS subscales have acceptable internal consistency reliability with Cronbach’s α ranging from 0.90 to 0.97.

Conclusions

The ECOS can be used in primary care to identify critical omissions, so actions can be taken by clinicians and administrators to prevent them before they result in patient harm. Further testing of the ECOS is recommended with diverse samples.
Lymphoscintigraphic Evaluation of Systemic Tracer Uptake in Patients With Primary Lymphedema
Authors: Goss Jeremy A. , Maclellan Reid A. , Greene Arin K.
Published: March 2019

Background

Lymphoscintigraphy is used to confirm the diagnosis of lymphedema. One end point for the test is to ensure a patent thoracic duct by uptake of tracer in the organs. The purpose of this study was to evaluate transit of radiolabeled colloid to the organs to gain insight into the etiopathophysiology of primary lymphedema.

Methods

Patients treated in our Lymphedema Program between 2009 and 2018 were reviewed. Only subjects with bilateral lower extremity primary lymphedema were included (individuals with unilateral leg lymphedema were excluded because the tracer will reach the venous circulation and organs through the normal extremity). Disease severity and lymphoscintigraphy findings were documented.

Results

Sixty-one patients were included. Ten subjects had no radiolabeled tracer transit to the inguinal lymph nodes on lymphoscintigraphy. However, 8 of these individuals had tracer uptake to the liver, kidney, and/or bladder, illustrating clearance of tracer into the systemic venous circulation. All 8 patients had infant-onset primary lymphedema and mild disease. The 2 patients who did not have clearance of tracer to the systemic venous circulation developed lymphedema in adolescence and had clinically moderate or severe disease.

Conclusions

Patients with primary lower extremity lymphedema often have pathways for lymph fluid to reach the venous circulation other than through the inguinal nodes and thoracic duct. Documentation of systemic tracer uptake during lymphoscintigraphy to confirm a patent thoracic duct has limited clinical significance in subjects with primary disease of the legs.
The value of failure to rescue in determining hospital quality for pediatric trauma
Authors: Rosenfeld Eric H. , Zhang Wei , Johnson Brittany , Shah Sohail R. , Vogel Adam M. , Naik-Mathuria Bindi
Published: March 2019

BACKGROUND

In adult trauma patients, high- and low-mortality trauma hospitals have similar rates of major complications but differ based on failure to rescue (mortality following a major complication), which has become a marker of hospital quality. The aim of this study is to examine whether failure to rescue is also an appropriate hospital quality indicator in pediatric trauma.

METHODS

Children younger than 15 years were identified in the 2007 to 2014 National Trauma Databank research data sets. Hospitals were classified as a high, average or low mortality based on risk-adjusted observed-to-expected in-hospital mortality ratios using the modified Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and failure to rescue.

RESULTS

Of 125,057 children, 31,600 were treated at low-mortality outlier hospitals, and 7,014 at high-mortality outlier hospitals. Low-mortality hospitals had a lower rate of major complications compared with high-mortality hospitals (0.5% [low] vs. 0.8% [high]; adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.61–0.83; p < 0.01) and a lower failure-to-rescue rate (17.6% [low] vs. 24.1% [high]; adjusted OR, 0.53 [high; 95% CI 0.34–0.83; p < 0.01]). When patients who died within 48 hours were excluded, low-mortality hospitals had a lower complication rate (OR, 0.81; 95% CI, 0.68, 0.96; p = 0.02), but similar failure-to-rescue rate compared to high-mortality hospitals. There was no correlation between trauma verification level and hospital mortality status based on the model.

CONCLUSION

For pediatric trauma patients, mortality is more strongly associated with major complication rate than with failure to rescue. Thus, failure to rescue does not appear to be the key driver of hospital quality in this population as it does in the adult trauma population.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.