bluuebunny/crossref_metadata_2025 huggingface dataset:
Detection of extensive optical emission from the extremely radio faint Galactic supernova remnant G182.4+4.3
Authors: Fesen Robert A , Neustadt Jack M M , How Thomas G , Black Christine S
Published: April 2019

Wide-field H α images of the radio faint Galactic supernova remnant G182.4+4.2 reveal a surprisingly extensive and complex emission structure, with an unusual series of broad and diffuse filaments along the remnant’s south-western limb. Deep [O iii] 5007 Å images reveal no appreciable remnant emission with the exception of a single filament coincident with the westernmost of the broad south-west filaments. The near total absence of [O  iii] emission suggests the majority of the remnant’s optical emission arises from relatively slow shocks (≤70 km s−1), consistent with little or no associated X-ray emission. Low-dispersion optical spectra of several regions in the remnant’s main emission structure confirm a lack of appreciable [O iii] emission and indicate [S  ii]/Hα line ratios of 0.73–1.03, consistent with a shock-heated origin. We find G182.4+4.2 to be a relatively large (d ∼ 50 pc at 4 kpc) and much older (age ∼ 40 kyr) supernova remnant than previously estimated, whose weak radio and X-ray emissions are related to its age, low shock velocity, and location in a low-density region some 12 kpc out from the Galactic Centre.
Cosmic ray transport and radiative processes in nuclei of starburst galaxies
Authors: Peretti Enrico , Blasi Pasquale , Aharonian Felix , Morlino Giovanni
Published: April 2019

The high rate of star formation and supernova explosions of starburst galaxies make them interesting sources of high-energy radiation. Depending on the level of turbulence present in their interstellar medium, the bulk of cosmic rays produced inside starburst galaxies may lose most of their energy before escaping, thereby making these sources behave as calorimeters, at least up to some maximum energy. Contrary to previous studies, here we investigate in detail the conditions under which cosmic ray confinement may be effective for electrons and nuclei and we study the implications of cosmic ray confinement in terms of multifrequency emission from starburst nuclei and production of high-energy neutrinos. The general predictions are then specialized to three cases of active starbursts, namely, M82, NGC 253, and Arp220. Both primary and secondary electrons, as well as electron–positron pairs produced by gamma-ray absorption inside starburst galaxies are taken into account. Electrons and positrons produced as secondary products of hadronic interactions are found to be responsible for most of the emission of leptonic origin. In particular, synchrotron emission of very high energy secondary electrons produces an extended emission of hard X-rays that represents a very interesting signature of hadronic process in starburst galaxies, potentially accessible to current and future observations in the X-ray band. A careful understanding of both the production and absorption of gamma-rays in starburst galaxies is instrumental to the assessment of the role of these astrophysical sources as sources of high-energy astrophysical neutrinos.
Occlusion Rate and Visual Complications With Flow-Diverter Stent Placed Across the Ophthalmic Artery's Origin for Carotid-Ophthalmic Aneurysms: A Meta-Analysis
Authors: Touzé Romain , Gravellier Bastien , Rolla-Bigliani Claudia , Touitou Valérie , Shotar Eimad , Lenck Stéphanie , Boch Anne-Laure , Degos Vincent , Sourour Nader-Antoine , Clarençon Frédéric
Published: April 2019

BACKGROUND

Flow-diverter stents (FDSs) have recently gained acceptance for the treatment of intracranial aneurysms, especially for carotid-ophthalmic aneurysms (COAs). However, complications have been reported after coverage of side branches, especially the ophthalmic artery (OA).

OBJECTIVE

To evaluate, through a meta-analysis, the occlusion rate, and the ophthalmic complications after treatment of COA by FDS.

METHODS

We reviewed on MEDLINE via PubMed, Embase via Ovid, and Cochrane central database via CENTRAL. We included all case series with at least 15 patients and clinical trials about flow diversion of aneurysms close to the OA’s origin. Among these studies, we only included articles with aneurysm occlusion rate and rate of new ophthalmic symptoms.

RESULTS

We included 16 studies with 913 COA treated by FDSs and covering the OA with a mean follow-up of 16.4 mo. The random-effect modeling analysis concerning the overall rate of new ophthalmic complications, after FDS deployment covering the OA, was 3.0% (CI95% 1.0-6.0). There was medium-high heterogeneity in the study reports P < .01, I2 = 70.2% [50.4%; 82.1%]. We were not able to statistically explain this heterogeneity with the performed analysis, which could be related to the design of the included studies. We found an overall aneurysm occlusion rate of 85.0% (95% CI 80.0-89.0).

CONCLUSION

Our meta-analysis found a high aneurysm occlusion rate (85%) and low rate of iatrogenic visual complications, with only 3.0% of new visual symptoms, after treatment of COA by FDS.
Consumption Network Effects
Authors: De Giorgi Giacomo , Frederiksen Anders , Pistaferri Luigi
Published: April 2019

In this article we study consumption network effects. Does the consumption of our peers affect our own consumption? How large is such effect? What are the economic mechanisms behind it? We use administrative panel data on Danish households to construct a measure of consumption based on tax records on income and assets. We combine tax record data with matched employer–employee data to identify peer groups based on workplace, which gives us a much tighter and credible definition of networks than used in previous literature. We use the non-overlapping network structure of one’s peers group, as well as firm-level shocks, to build valid instruments for peer consumption. We estimate non-negligible and statistically significant network effects, capable of generating sizable multiplier effect at the macro-level. We also investigate what mechanisms generate such effects, distinguishing between intertemporal and intratemporal consumption effects as well as a more traditional risk sharing view.
Tracking Progress Toward Elimination of Mother to Child Transmission of HIV in Zambia: Findings from the Early Infant Diagnosis of HIV Program (2009–2017)
Authors: Mutanga Jane N , Mutembo Simon , Ezeamama Amara E , Fubisha Robert C , Sialondwe Derrick , Simuchembu Brenda , Mutukwa Macwani , Chinyonga Jelita , Thuma Philip E , Whalen Christopher C
Published: April 2019

Background

We carried out analyses of early infant testing results at Livingstone Central Hospital in Zambia to assess time of testing, linkages to care and availability of test results for clinical decision making.

Methods

We abstracted data from registers of HIV-exposed infants who had dried blood spots cards (DBS) collected for DNA-PCR from January 2009 to December 2017. Only those tested from 2014 to 2017 had additional data which were used to estimate risk factors for mother-to-child HIV transmission using logistic regression models.

Results

DBS were collected from 2630 children. The proportion of HIV-positive tests decreased from 21% in 2009 to 2% in 2016 and 2017. Median turnaround time for results was 9 weeks (IQR: 5, 15) for HIV-negative, 7 weeks (IQR: 5, 13) for HIV-positive children. Only 2% of infants whose mothers took antiretroviral therapy (ART) were HIV positive, while 18% of infants whose mothers took short course antiretroviral drugs (ARVs) were infected. Infants of mothers who did not take ARVs had 9 times the odds of an HIV positive test (OR = 8.9, 95% CI: 3.6, 22.6). Infants of mothers who received short course ARVs were 40% less likely to get an HIV test within the first 2 months of life (OR = 0.6, 95% CI: 0.4, 0.9) compared to infants of mothers who received ART. Only 52% had a third test at median age 52 weeks (IQR: 50, 54).

Conclusions

Long turnaround time for test results and low retention in care after the initial HIV test were critical challenges to clinical decision making.
Congenital absence of the pericardium
Authors: Elbadawi Ayman , Baig Basarat , Alotaki Erfan , Khalid Heena , Khan Muhammad
Published: April 2019

This article describes a patient who presented to the ED after multiple episodes of syncope. His physical examination was unremarkable and an initial workup was negative. Transthoracic echocardiography and chest CT confirmed the diagnosis of congenital complete absence of the pericardium, a rare developmental abnormality most common in men.
Is a Medical Mistake an Error or a Crime?
Authors: Sofer Dalia
Published: April 2019

The case of a Tennessee nurse has rekindled an old debate.
Psychiatric Advance Directives
Authors: Sofer Dalia
Published: April 2019

They can enhance the lives of patients with mental illness, but multiple obstacles impede their implementation.
Nursing and the Sustainable Development Goals: From Nightingale to Now
Authors: Dossey Barbara M. , Rosa William E. , Beck Deva-Marie
Published: April 2019

While health care often focuses on acute or chronic illness, the elements necessary for good health are far more complex than we tend to recognize. Florence Nightingale understood this complexity and wrote extensively on the myriad social and environmental factors that influence well-being. Today these factors are termed “health determinants” and undergird the United Nations 17 Sustainable Development Goals (SDGs). This article explores how nurses can contextualize the SDGs within their daily practice and create holistic plans of care for patients, families, communities, and nations.
Aspirin for Primary Prevention Reduces Cardiovascular Events, Increases Bleeding Risk
Authors: Rosenberg Karen
Published: April 2019

According to this study:

In people with no history of cardiovascular disease, aspirin is associated with a reduced risk of cardiovascular events but an increased risk of major bleeding.
Addressing transgender patients' barriers to access care
Authors: Rowe Denise , Ng Yeow Chye , O'Keefe Louise C.
Published: April 2019

The transgender population faces several barriers to accessing quality medical care in the US healthcare system. This article examines the challenges that prevent this marginalized group from obtaining high-quality healthcare services and discusses how NP advocacy can help create a welcoming environment for transgender patients.
Job Satisfaction Among Methadone Maintenance Treatment Clinic Service Providers in Jiangsu, China: A Cross-sectional Survey
Authors: Chen Guohong , Lin Chunqing , Chen Yuheng , Li Li , Luo Sitong , Liu Xiaoyan , Huan Xiping , Cao Xiaobin , McGoogan Jennifer M. , Wu Zunyou
Published: April 2019

Objective:

Service providers’ job satisfaction is critical to the stability of the work force and thereby the effectiveness of methadone maintenance treatment (MMT) programs. This study aimed to explore MMT clinic service providers’ job satisfaction and associated factors in Jiangsu, China.

Methods:

This secondary study used baseline data of a randomized interventional trial implemented in Jiangsu, China. A survey was conducted among 76 MMT service providers using the computer-assisted self-interview (CASI) method. Job satisfaction responses were assessed via a 30-item scale, with a higher score indicating a higher level of job satisfaction. Perceived institutional support and perceived stigma due to working with drug users were measured using a 9-item scale. Correlation and multiple linear regression analyses were performed to identify factors associated with job satisfaction.

Results:

Correlation analyses found a significant association between job satisfaction and having professional experience in the prevention and control of HIV, other sexually transmitted infections, or other infectious diseases (P = 0.046). Multiple regression analyses revealed that working at MMT clinics affiliated with Center for Disease Control and Prevention sites was associated with a lower level of job satisfaction (P = 0.014), and perception of greater institutional support (P = 0.001) was associated with a higher level of job satisfaction.

Conclusion:

Job satisfaction among MMT clinic service providers was moderate in our study. Our findings suggest that institutional support for providers should be improved, and that acquisition of additional expertise should be encouraged.
Pain Anxiety as a Mechanism Linking Pain Severity and Opioid Misuse and Disability Among Individuals With Chronic Pain
Authors: Rogers Andrew H. , Bakhshaie Jafar , Zvolensky Michael J. , Vowles Kevin E.
Published: April 2019

Objective:

Chronic pain affects a significant number of individuals in the United States and is associated with several negative health-related outcomes, including possibility of opioid misuse and disability. The identification of factors associated with both opioid misuse and disability is of critical public health importance, and significant research suggests that pain severity has been shown to be associated with both. Pain-related anxiety has been uniquely associated with both opioid misuse and disability, yet little research has examined pain-related anxiety as a potential mechanism linking pain severity with opioid misuse and disability.

Method:

Therefore, the current study examined whether pain-related anxiety explains, in part, the relationship between pain severity, opioid misuse, and disability among 396 adults with chronic pain (55.8% female, Mage 36.61, SD 11.40).

Results:

Cross-sectional analyses indicated that pain-related anxiety significantly mediated the relationship between pain severity, opioid misuse outcomes, and psychosocial disability, but not physical disability.

Conclusions:

These results build upon the literature indicating the importance of pain-related anxiety in those with chronic pain by suggesting this construct may account, in part, for the relation of pain intensity to opioid misuse and psychosocial disability. Future research should longitudinally examine these associations.
Application of machine learning in the diagnosis of axial spondyloarthritis
Authors: Walsh Jessica A. , Rozycki Martin , Yi Esther , Park Yujin
Published: April 2019

Purpose of review

In this review article, we describe the development and application of machine-learning models in the field of rheumatology to improve the detection and diagnosis rates of underdiagnosed rheumatologic conditions, such as ankylosing spondylitis and axial spondyloarthritis (axSpA).

Recent findings

In an attempt to aid in the earlier diagnosis of axSpA, we developed machine-learning models to predict a diagnosis of ankylosing spondylitis and axSpA using administrative claims and electronic medical record data. Machine-learning algorithms based on medical claims data predicted the diagnosis of ankylosing spondylitis better than a model developed based on clinical characteristics of ankylosing spondylitis. With additional clinical data, machine-learning algorithms developed using electronic medical records identified patients with axSpA with 82.6–91.8% accuracy. These two algorithms have helped us understand potential opportunities and challenges associated with each data set and with different analytic approaches. Efforts to refine and validate these machine-learning models are ongoing.

We discuss the challenges and benefits of machine-learning models in healthcare, along with potential opportunities for its application in the field of rheumatology, particularly in the early diagnosis of axSpA and ankylosing spondylitis.
New therapeutic agents in gastrointestinal stromal tumours
Authors: Falkenhorst Johanna , Hamacher Rainer , Bauer Sebastian
Published: April 2019

Purpose of review

The aim of this study was to provide an update on the most recent developments regarding systemic treatments in the various molecular subtypes of gastrointestinal stromal tumour (GIST).

Recent findings

Several novel direct inhibitors of KIT and PDGFRA have entered the advanced clinical development in later treatment lines based on promising early clinical trial experience. Both avapritinib and ripretinib are more potent and more specific against various KIT and PDGFRA mutations. For patients with PDGFRA D842V mutations, the next generation of drugs may become the first active treatment options.

Comprehensive molecular testing of KIT/PDGFRA-wildtype GIST may unmask clinically relevant targets, including NTRK fusions.

The treatment landscape in GIST is expected to undergo a profound transformation with more potent drugs currently in late-stage clinical development.
Leiomyosarcomas: whole genome sequencing for a whole biology characterization
Authors: Chibon Frédéric , Darbo Elodie , Pérot Gaëlle
Published: April 2019

Purpose of review

Leiomyosarcoma (LMS) is among the more aggressive sarcomas and still suffers from the lack of efficient systemic treatment after, or before, surgery. During the last decades, one provider of therapeutic improvement has been the targeting of genome alterations. Efforts have thus been done to apply next-generation sequencing approaches to those tumours to decipher their oncogenesis and find out such targets.

Recent findings

Sequencing performed so far, based on exome, mostly confirmed that p53 and RB1 are the two main pathways altered in LMS oncogenesis. There are few point mutations in LMS genome, which is mainly characterized by numerous chromosomal rearrangements. Data from whole genome sequencing are now mandatory to decipher mechanisms triggering chromosomal instability and mutational process.

Although each LMS appears to have quite private genetic alterations leading to oncogenesis, it is likely that the altered biological pathways are relatively homogeneous within each of the LMS subgroups. Understanding this oncogenesis, thanks to integrated approaches involving whole genome and transcriptome sequencing together with functional and clinical characterizations will certainly give us the keys to relevant and effective new therapeutic approaches.
Infertility treatment decision-making in Ghana and contestations that may arise: a prospective sociological study
Authors: Hiadzi Rosemond A. , Woodward Bryan J.
Published: April 2019

Introduction:

This study aimed to explore contestations within infertile couples seeking infertility therapy in a sub-Saharan society. Their views regarding infertility treatment were explored, including their arguments for or against different treatment options. The effects of the contributions of the various partners were analyzed.

Material and methods:

Semistructured in-depth interviews were conducted with people seeking infertility treatment at 3 different fertility clinics in Accra, Ghana. Participants were restricted to 45 persons from married heterosexual couples, with 15 respondents (5 male and 10 female) from each setting. Respondents were asked questions relating to the decision-making process toward seeking treatment and the reactions of their partners.

Results:

Contestations tended to relate to 5 main themes: the cause of the infertility and who was to blame; male apathy; reluctance to provide semen samples for evaluation; an absentee husband due to work pressure; and finance relating to the cost of infertility treatment.

Discussion:

This is the first study to highlight the contestations that arise between couples regarding their decision-making about alleviating their infertility via 3 different types of fertility clinics in Accra, Ghana. It is apparent that globalization and changing norms of family life have to a large extent, accounted for the changing ideas and practices surrounding infertility in urban Ghana.
Enlarging Red-to-Purple Nodule on the Forehead
Authors: Martin Kari L.
Published: April 2019

Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. In store-and-forward teledermatology, patient medical information (including history and visual data) obtained in one location is transferred electronically to a provider who is in another location. The construct of this column is such that cases are presented in a standardized teledermatology reader format. This is a case of an enlarging red-to-purple nodule on the forehead.
Tinnitus Severity Change Following Stapedotomy in Patients With Otosclerosis
Authors: Dziendziel Beata , Skarżyński Henryk , Gos Elżbieta , Skarżyński Piotr H.
Published: April 2019

Objective:

To determine whether stapedotomy was effective in reducing tinnitus severity. In addition, the relationship between reduction in tinnitus and improvement in hearing after stapedotomy was analyzed.

Study Design:

Prospective clinical study.

Setting:

Tertiary referral center.

Patients:

A group of 168 otosclerosis patients diagnosed with chronic tinnitus.

Intervention:

Stapedotomy.

Main Outcome Measures:

The Tinnitus Functional Index questionnaire (TFI) was used to assess tinnitus severity before surgery, and at 3 and 6 months postoperatively. Pure-tone audiometry was conducted before surgery and 6 months postoperatively.

Results:

The TFI Total score before the operation was M = 34.5 (standard deviation [SD] = 1.6) points, and decreased 3 months after stapedotomy to M = 17.5 (SD = 1.7), a statistically significant change (T = –8.200; p < 0.001). A weak correlation was found between the pre- and postoperative difference of TFI Total score and air-conduction thresholds (r = 0.21; p = 0.013) as well as between the TFI Total score and the size of the air-bone gap (r = 0.21; p = 0.013). Preoperatively, 86 patients tinnitus was a not or small problem, and for 82 it was moderate to very big. After stapedotomy, 93 (55%) of patients experienced a significant reduction in tinnitus severity. Of the whole group, 62 patients (37%) reported complete disappearance of their tinnitus. No change in tinnitus severity was reported by 63 patients (38%), and an increase was observed by 12 patients (7%).

Conclusion:

Stapedotomy not only improves hearing but also reduces tinnitus severity. The current results extend knowledge of postoperative results in terms of tinnitus severity, and might benefit patients undergoing tinnitus counseling. It might also be useful to otolaryngologists when making decisions regarding qualification criteria.
Quality improvement and crisis resource management in pediatric resuscitation
Authors: Myers Sage R. , Donoghue Aaron J.
Published: April 2019

Purpose of review

The pediatric resuscitation environment is a high-stakes, environment in which a multidisciplinary team must work together with patient outcomes dependent, at least in part, on the performance of that team. Given constraints of the environment and the nature of these events, quality improvement work in pediatric resuscitation can be challenging. Ongoing collection of accurate and reliable data on team performance is necessary to inform and evaluate change.

Recent findings

Despite the relative difficulty of quality improvement analysis and intervention implementation in the resuscitation environment, these efforts can have significant impact on patient outcomes. Although there are barriers to accurate data collection in real-life resuscitation, team performance of both technical and nontechnical skills can be reliably measured in video-based quality improvement programs. Training of nontechnical skills, using crisis resource management principles, can improve care delivery in resuscitation.

Striving toward a learning healthcare system model in resuscitation care delivery can allow for efficient performance improvement. Given the possible impacts on mortality and quality of life of care delivered in the resuscitation environment, all providers who could possibly face a resuscitation event – no matter how rare – should consider how they are evaluating the quality of their care delivery in this arena.
The impact of asymptomatic antibody-mediated rejection on outcome after heart transplantation
Authors: Kfoury Abdallah G. , Miller Dylan V.
Published: April 2019

Purpose of review

Defining criteria for antibody-mediated rejection (AMR) in heart transplantation were standardized a few years ago, but very little is known about asymptomatic cardiac AMR. We will start the review with a background summarizing the timeline of cardiac AMR. Then we will cover past and current knowledge about asymptomatic cardiac AMR and its impact on outcome after transplantation, with added insight from experience with other solid-organ transplants.

Recent findings

The incidence of asymptomatic cardiac AMR had likely been under-estimated because biopsy surveillance for it in the absence of clinical manifestation was not the norm. Recent data indicate that it may be more common especially when counting concomitant acute cellular rejection (mixed rejection). Also a higher risk of cardiac allograft vasculopathy (CAV) and cardiovascular mortality have been linked to it. The primary implication of these findings is whether therapeutic intervention is warranted, but the appropriate target patient population likely to benefit from treatment is yet to be determined.

Asymptomatic cardiac AMR is not uncommon and it negatively impacts outcome after heart transplantation.
Investigation of Dynamic Thiol/Disulfide Homeostasis in Children With Acute Immune Thrombocytopenia
Authors: Beyazit Husam , Demiryürek Abdullah T. , Temel Münevver T. , Pekpak Esra , Demiryürek Seniz , Akbayram Sinan
Published: April 2019

Oxidative stress may play a role in the pathogenesis of immune thrombocytopenia (ITP), but the role of dynamic thiol/disulfide homeostasis has not been studied. The objective of this study was to assess whether there is a change in thiol/disulfide homeostasis in children with acute ITP. A total of 40 children with acute ITP and 50 healthy age-matched and sex-matched controls were included in this study. Serum total thiol and native thiol levels have been measured with a novel automatic spectrophotometric method. The amount of dynamic disulfide bonds and related ratios were calculated from these values. The average total thiol and native thiol levels of the patient group were found to be significantly lower than those levels of controls (P<0.01). However, intravenous immunoglobulin (IVIG) treatment with 1 g/kg/d prevented these reductions. disulfide level was slightly, but not significantly, depressed in ITP patients, but it recovered following IVIG treatment. We detected no marked changes in disulfide/total thiol, disulfide/native thiol, and native thiol/total thiol ratios between groups. These results are the first to demonstrate that thiol/disulfide homeostasis plays a role in ITP pathogenesis, and IVIG treatment can prevent the reduced thiol levels in children.
Prediction of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation
Authors: Kim Doo Young , Pyun Sung-Bom
Published: April 2019

As the survival rate of traumatic brain injury increases, the burden of care for patients with traumatic brain injury is emerging as a socioeconomic issue and the discharge destination is one of the important outcome measures in the post-acute rehabilitation unit. To investigate the predictors of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation. A retrospective review was performed on 86 patients who were admitted to the rehabilitation unit between January 2010 and June 2017. Multiple regression analysis was used as a statistical method to identify the factors affecting Modified Barthel Index and discharge destination. The number of days from traumatic brain injury onset to rehabilitation unit admission (odds ratio = 0.959, P = 0.049), brain surgery for traumatic brain injury management (odds ratio = 0.160, P = 0.021), initial Glasgow Coma Scale score (odds ratio = 1.269, P = 0.022) and Mini-Mental State Examination score at admission (odds ratio = 1.245, P < 0.001) were the predictive factors for higher Modified Barthel Index after rehabilitation. Underlying vascular risk factors (odds ratio = 0.138, P = 0.015), Modified Barthel Index score after rehabilitation (odds ratio = 1.085, P < 0.001) and deductible-free insurance (odds ratio = 0.211, P = 0.032) were the predictive factors of home discharge. The functional outcome of patients with traumatic brain injury after rehabilitation was related to the severity of initial injury, cognitive function at admission and rehabilitation timing. The discharge destination after rehabilitation was related to functional outcome, insurance issues and underlying vascular risk factors.
Barriers to Skin-to-Skin Contact after Cesarean Birth
Authors: Balatero Joelene S. , Spilker Arlene F. , McNiesh Susan G.
Published: April 2019

Objectives:

The aim of this research was to understand obstetric nurses' perceived barriers to immediate skin-to-skin contact (SSC) in the operating room (OR) after cesarean birth.

Methods:

Semistructured, open-ended interviews were conducted via videoconferencing. Conventional content analysis methods were used to analyze the data for common themes. Investigation team consensus was reached to validate the analysis findings.

Results:

Ten nurses who care for women during labor and birth were interviewed. The primary overarching theme was performing safe and effective SSC after cesarean birth. Nurses strongly believe in the benefits of SSC after cesarean and try to implement it as often as possible, but various factors prevented SSC in the OR from occurring on a regular basis. Providing immediate SSC is not considered a priority during the cesarean by all members of the team. All participants reported that there were no formal policies and procedures in their facilities for SSC in the OR. Challenges with safety, nurse staffing, and logistics were described as well as professional barriers, and varying practices between geographical location and facilities. Nurses discussed concepts that were facilitators for changing their current practices to support SSC after cesarean.

Clinical Implications:

Implications: Developing effective policies and procedures that support SSC in the OR after cesarean and changing practice accordingly is recommended. Adequate nurse staffing in the OR is essential.
Daily versus weekly evidence reports for orthopaedic surgeons in India
Authors: Kheterpal Sunita , Busse Jason W. , Baxter Pamela , Sonnadara Ranil , Bhandari Mohit
Published: April 2019

Background:

There is a dearth of research regarding the impact of evidence-based medicine (EBM) tools, such as evidence summaries, in developing countries. The goals of this study were to: investigate accessibility, use, and impact of an online EBM knowledge dissemination portal in orthopaedic surgery in India; explore whether receiving daily targeted evidence summaries results in more frequent use of an EBM tool compared with receiving general weekly reports; and identify and explain the barriers and benefits of an online EBM resource in the Indian context.

Methods:

Forty-four orthopaedic surgeons in Pune, India, were provided free access to OrthoEvidence (OE), a for-profit, online EBM knowledge dissemination portal. Participants were subsequently randomized into 2 groups—1 group received daily targeted evidence summaries while the other received general weekly summaries. This study employed an explanatory sequential mixed methods design that incorporated 2 questionnaires, OE usage data, and semi-structured interviews to gain insight into the surgeons’ usage, perceptions, and impact of OE.

Results:

There were no observable differences in OE usage between groups. OE was deemed to be comprehensive, practical, useful, and applicable to clinical practice by the majority of surgeons. The exit survey data revealed no differences between groups’ perceptions of the OE tool. semi-structured interviews revealed barriers to keeping up with evidence that included limited access to relevant medical literature and limited incentive to keep up with current evidence.

Conclusions:

Neither frequency of delivery (daily versus weekly) nor targeted versus general content affected the use of evidence summaries. Facilitating uptake of current evidence into clinical practice among Indian orthopedic surgeons may require additional components beyond dissemination of evidence summaries.
A 25-Year Review of Pediatric Suicides
Authors: Molina D. Kimberley , Farley Norma J.
Published: April 2019

Childhood and adolescent suicides have been increasing worldwide in recent years, and the investigation of such deaths is often complex. Forensic pathologists frequently find themselves having to opine as to the manner of death in these difficult cases. The present study was undertaken to identify distinguishing features in childhood and adolescent suicides to assist in the investigation and prevention of these deaths. A 25-year review of pediatric suicides in a metropolitan area was performed, which showed a steady increase in pediatric suicides over time. Male pediatric suicides were more common than female, with both having an average age of 15 years. Gunshots wounds and hanging were the most common methodologies seen, with drug toxicity being more common in females and gunshot wounds more common in males. Approximately 20% of decedents had a psychiatric history, 25% had a previous history of a suicide attempt or ideation, and 24% had a history of drug use. Only a minority of decedents made their intentions known prior to the suicidal act (16%) or left a note of intent (16%). In 62% of cases, a temporal, precipitating event could be identified, of which conflict with a significant other (boyfriend or girlfriend) was the most common. No specific trends over time were identified. While these features may assist forensic pathologists in assessing a possible suicidal death in the pediatric age group, medicolegal death investigators must approach these deaths as they would any violent death in an attempt to accurately determine the manner of death regardless of the societal and familial implications of such a determination.
Acute Methamphetamine-Induced Hepatic and Pancreatic Ischemia
Authors: Merchant Krupa , Schammel Christine , Fulcher James
Published: April 2019

Methamphetamine is a central nervous system stimulant that induces arousal, a positive mood, cardiac stimulation, and an acute improvement in cognitive domains. Its illicit exploitation is rapidly growing in North America. Typically, extended use of the drug induces organ damage via vasoconstriction and subsequent ischemia. This case specifically discusses hepatic and pancreatic pathology resulting from methamphetamine overdose alongside an unusual discovery of globally necrotic von Meyenburg complexes.
Recommendations for Tissue Microarray Construction and Quality Assurance
Authors: Glinsmann-Gibson Betty , Wisner Lee , Stanton Melissa , Larsen Brandon , Rimsza Lisa , Maguire Alanna
Published: April 2019

Tissue microarrays (TMAs) are important tools to conserve precious tissue resources from increasingly smaller biopsies and to control experimental costs and variation across sample sets. The quality assurance assessment of TMA materials created at centralized biobanks has not been standardized. Herein, we outline 2 processes for the construction of TMAs (“recipient block” and “tape” methods) and the associated preconstruction quality control measures (pathology review, protein and RNA assessment, map creation, and storage conditions) developed by the AIDS Cancer Specimen Resource (ACSR) Network’s Science and Technology Core. These steps provide a suggested framework for quality assessment that allows end-users, receiving materials from tissue banks, confidence in their experimental results.
A Standard Operation Procedure of Clean and Fast Craniotomy Technique for Retrosigmoid Approach
Authors: Chen Songyu , Yang Ning , Li Weiguo , Xu Shujun , Li Xingang , Ma Xiangyu
Published: April 2019

Clean and fast craniotomy and closure (CAC) for retrosigmoid approach with safe and satisfactory exposure remains our primary goal. A standard operation procedure (SOP) of retrosigmoid approach was developed and reviewed. Between January 2015 and January 2017, 97 patients suffering various lesions underwent surgeries using this technique in the Department of Neurosurgery, Qilu Hospital of Shandong University. The records concerning time of craniotomies, blood losses, and complications were reviewed. By applying this SOP, a craniotomy generally took 15 to 35 minutes, with an average of around 25 minutes. Six cases had a blood loss of more than 30 mL during craniotomy. One patient had cerebrospinal fluid rhinorrhea and another case had subcutaneous effusion. There was no record of venous sinus injury or wound infection. To sum up, the SOP of retrosigmoid approach is simple, reliable and bloodless. In addition to avoiding complications such as venous sinus injury effectively, the SOP also benefits training of residents and early recovery after surgery (ERAS).
“Three Subunit” Classification of Lesser-Form Cleft Lip and Muscle Analysis and Reconstruction of These Subunits Based on the Microanatomic Structures of Muscles in the Normal Upper Lip
Authors: Sun Min , Wang Yong Q. , Li Hai D. , Wu Di , Yin Ning B. , Song Tao
Published: April 2019

Background:

The main phenotypic features of lesser-form cleft lip include nasal, philtrum, and vermilion deformities. The manifestations of lesser-form cleft lip vary greatly, and it is difficult to rebuild these subunits during the operation.

Methods:

“Three subunits” classification of lesser-form cleft lip was identified as nasal deformity (N), philtrum deformity (P), or vermilion deformity (V); and slight deformity (0) or obvious deformity (1). A total of 200 patients with lesser-form cleft lip were classified into one of the following 8 types: N1P1V1, N1P1V0, N0P1V1, N1P0V1, N0P0V1, N1P0V0, N0P1V0, or N0P0V0. Then the authors discussed the deformities of the lesser-form cleft lip and the reconstruction of the muscles in these subunits based on the microanatomic structure of the nasolabial muscle.

Results:

This retrospective review included 200 patients with a lesser-form cleft lip, who were seen at our center from 2015 to 2017. There were 149 (74.5%) N1P1V1, 11 (5.5%) N1P1V0, 13 (6.5%) N0P1V1, 4 (2.0%) N1P0V1, 8 (4.0%) N0P0V1, 10 (5.0%) N1P0V0, 1 (0.5%) N0P1V0, and 4 (2%) N0P0V0 clefts. The various deformities of nasal floor, philtrum ridge, and vermilion may suggest that the muscle bundles in these subunits are abnormal and the operation should be performed to simulate the running directions and tension lines of these local muscles.

Conclusions:

The microanatomic structure and the tension lines of the nasolabial muscles can provide new perspectives for better understanding and repairing the lesser-form cleft lip in subunits.
Echo is a good, not perfect, measure of cardiac output in critically ill surgical patients
Authors: Olivieri Peter P. , Patel Rajan , Kolb Stephanie , Fatima Syeda , Galvagno Samuel M. , Haase Daniel J. , Ramani Gautam V. , Ludmir Jonathan , Alkhatib Hani , Herr Daniel , Bruno David A. , Scalea Thomas M. , Murthi Sarah B.
Published: April 2019

BACKGROUND

Compared with a pulmonary artery catheter (PAC), transthoracic echocardiography (TTE) has been shown to have good agreement in cardiac output (CO) measurement in nonsurgical populations. Our hypothesis is that the feasibility and accuracy of CO measured by TTE (CO-TTE), relative to CO measured by PAC thermodilution (CO-PAC), is different in surgical intensive care unit patients (SP) and nonsurgical patients (NSP).

METHODS

Surgical patients with PAC for hemodynamic monitoring and NSP undergoing right heart catheterization were prospectively enrolled. Cardiac output was measured by CO-PAC and CO-TTE. Pearson coefficients were used to assess correlation. Bland-Altman analysis was used to determine agreement.

RESULTS

Over 18 months, 84 patients were enrolled (51 SP, 33 NSP). Cardiac output TTE could be measured in 65% (33/51) of SP versus 79% (26/33) of NSP; p = 0.17. Inability to measure the left ventricular outflow tract diameter was the primary reason for failure in both groups; 94% (17/18) in SP versus 86% (6/7) NSP; p = 0.47. Velocity time integral could be measured in all patients. In both groups, correlation between PAC and TTE measurement was strong; SP (r = 0.76; p < 0.0001), NSP (r = 0.86; p < 0.0001). Bland-Altman analysis demonstrated bias of −0.1 L/min, limits of agreement of −2.5 and +2.3 L/min, percentage error (PE) of 40% for SP, and bias of +0.4 L/min, limits of agreement of −1.8 and +2.5 L/min, and PE of 40% for NSP.

CONCLUSION

There was strong correlation and moderate agreement between TTE and PAC in both SP and NSP. In both patient populations, inability to measure the left ventricular outflow tract diameter was a limiting factor.

LEVEL OF EVIDENCE

Diagnostic tests or criteria, level III.
Pediatric resuscitation: Weight-based packed red blood cell volume is a reliable predictor of mortality
Authors: Hanna Kamil , Hamidi Mohammad , Anderson Kathryn Tinsley , Ditillo Michael , Zeeshan Muhammad , Tang Andrew , Henry Marion , Kulvatunyou Narong , Joseph Bellal
Published: April 2019

BACKGROUND

The definition of massive transfusion (MT) in civilian pediatric trauma patients is not established. In combat-injured pediatric patients, the definition of MT is based on the volume of total blood products transfused. The aim of this study is to define MT in civilian pediatric trauma patients based on a packed red blood cell (PRBC) volume threshold and compare its predictive power to a total blood products volume threshold.

METHODS

An analysis of the pediatric American College of Surgeons Trauma Quality Improvement Program database was performed (2014–2016) including pediatric trauma patients (4–18 years) who received blood products within 24 hours. Receiver operator characteristic curves for predicting mortality determined the optimal PRBC MT threshold. Area under receiver operating characteristic curve (AUROC) curve analysis was performed to compare the predictive power of a PRBC threshold to a total blood product threshold.

RESULTS

A total of 1,495 patients were included. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at a PRBC threshold of 20 mL/kg. As compared with total blood products threshold, 20 mL/kg PRBCs volume achieved higher discriminatory power for predicting 24-hour (AUROC, 0.803 vs. 0.672; p < 0.001) and in-hospital mortality (AUROC, 0.815 vs. 0.686, p < 0.001). Patients who received an MT had higher Injury Severity Score (p < 0.001) and were more likely to receive mechanical ventilation (p < 0.001) and intensive care unit admission (p < 0.001). Overall 24-hour mortality (23.1% vs. 7.6%, p < 0.001) and in-hospital mortality (44.9% vs. 15.8%, p < 0.001) were higher in the MT group. On regression analysis, MT significantly predicted in-hospital mortality (odds ratio, 3.8 [2.9–4.9, 95% CI]) and 24-hour mortality (odds ratio, 3.3 [2.4–4.7, 95% CI]).

CONCLUSION

The use of a PRBCs MT definition in civilian pediatric patients is a better predictor of mortality compared with total blood products threshold. These results provide a framework for MT protocol development.

LEVEL OF EVIDENCE

Prognostic study, level III.
Efficacy of intermittent versus standard resuscitative endovascular balloon occlusion of the aorta in a lethal solid organ injury model
Authors: Kuckelman John , Derickson Michael , Barron Morgan , Phillips Cody J. , Moe Donald , Levine Tiffany , Kononchik Joseph P. , Marko Shannon T. , Eckert Matthew , Martin Matthew J.
Published: April 2019

BACKGROUND

High-grade solid organ injury is a major cause of mortality in trauma. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) can be effective but is limited by ischemia-reperfusion injury. Intermittent balloon inflation/deflation has been proposed as an alternative, but the safety and efficacy prior to operative hemorrhage control is unknown.

METHODS

Twenty male swine underwent standardized high-grade liver injury, then randomization to controls (N = 5), 60-min continuous REBOA (cR, n = 5), and either a time-based (10-minute inflation/3-minute deflation, iRT = 5) or pressure-based (mean arterial pressure<40 during deflation, iRP = 5) intermittent schedule. Experiments were concluded after 120 minutes or death.

RESULTS

Improved overall survival was seen in the iRT group when compared to cR (p < 0.01). Bleeding rate in iRT (5.9 mL/min) was significantly lower versus cR and iRP (p = 0.02). Both iR groups had higher final hematocrit (26% vs. 21%) compared to cR (p = 0.03). Although overall survival was lower in the iRP group, animals surviving to 120 minutes with iRP had decreased end organ injury (Alanine aminotransferase [ALT] 33 vs. 40 in the iRT group, p = 0.03) and lower lactate levels (13 vs. 17) compared with the iRT group (p = 0.03). No differences were seen between groups in terms of coagulopathy based on rotational thromboelastometry.

CONCLUSION

Intermittent REBOA is a potential viable adjunct to improve survival in lethal solid organ injury while minimizing the ischemia-reperfusion seen with full REBOA. The time-based intermittent schedule had the best survival and prolonged duration of tolerable zone 1 placement. Although the pressure-based schedule was less reliable in terms of survival, when effective, it was associated with decreased acidosis and end-organ injury.
Artificial neural networks can predict trauma volume and acuity regardless of center size and geography: A multicenter study
Authors: Dennis Bradley M. , Stonko David P. , Callcut Rachael A. , Sidwell Richard A. , Stassen Nicole A. , Cohen Mitchell J. , Cotton Bryan A. , Guillamondegui Oscar D.
Published: April 2019

BACKGROUND

Trauma has long been considered unpredictable. Artificial neural networks (ANN) have recently shown the ability to predict admission volume, acuity, and operative needs at a single trauma center with very high reliability. This model has not been tested in a multicenter model with differing climate and geography. We hypothesize that an ANN can accurately predict trauma admission volume, penetrating trauma admissions, and mean Injury Severity Score (ISS) with a high degree of reliability across multiple trauma centers.

METHODS

Three years of admission data were collected from five geographically distinct US Level I trauma centers. Patients with incomplete data, pediatric patients, and primary thermal injuries were excluded. Daily number of traumas, number of penetrating cases, and mean ISS were tabulated from each center along with National Oceanic and Atmospheric Administration data from local airports. We trained a single two-layer feed-forward ANN on a random majority (70%) partitioning of data from all centers using Bayesian Regularization and minimizing mean squared error. Pearson's product-moment correlation coefficient was calculated for each partition, each trauma center, and for high- and low-volume days (>1 standard deviation above or below mean total number of traumas).

RESULTS

There were 5,410 days included. There were 43,380 traumas, including 4,982 penetrating traumas. The mean ISS was 11.78 (SD = 6.12). On the training partition, we achieved R = 0.8733. On the testing partition (new data to the model), we achieved R = 0.8732, with a combined R = 0.8732. For high- and low-volume days, we achieved R = 0.8934 and R = 0.7963, respectively.

CONCLUSION

An ANN successfully predicted trauma volumes and acuity across multiple trauma centers with very high levels of reliability. The correlation was highest during periods of peak volume. This can potentially provide a framework for determining resource allocation at both the trauma system level and the individual hospital level.

LEVEL OF EVIDENCE

Care Management, level IV.