bluuebunny/crossref_metadata_2025 huggingface dataset:
A Contraception Simulation Lab Developed for OB/GYN Residents in Catholic Hospitals
Authors: Wollschlaeger Karin , White Karen
Published: September 2016

BACKGROUND:

OB/GYN residents in Catholic hospitals are limited in performing procedures involving contraception. This was identified as a deficiency in training, by a needs assessment given to residents at a Catholic residency program. Once the residents graduate they will be expected to offer and perform these procedures for their patients.

METHODS:

A contraception simulation program was developed. It included 4 stations: IUDs and Nexplanons (high fidelity models), hysteroscopic Essure (high-fidelity virtual reality model), laparoscopic tubal ligation (low fidelity box trainer), and abdominal postpartum tubal ligation (PPTL) (low fidelity box trainer) training. The program started with a pre-test consisting of 27 questions. The residents were divided into groups and rotated through each station. They discussed answers pertaining to the specific questions for that station. The procedure was demonstrated and residents were given time to practice. After rotating through all stations, a post-test was given and again 2 weeks later.

RESULTS:

The results were analyzed using a Wilcoxon signed-rank test. Both OB/GYN residents (12) and medical students (8) participated. The average pre-test score for the residents was 63%, medical students 50%. After reviewing questions and simulation practice, the average post-test score for the residents was 93%, medical students 87%. The average 2 weeks post-test score for the residents was 91%, medical students 82%.

DISCUSSION:

This curriculum resulted in developing skills, improved knowledge about the procedures and showed excellent short term retention.
Assessment of Faculty and Resident Views on Resident Surgical Feedback
Authors: Biscette Shan , Ollendorff Arthur , Gaskins Jeremy
Published: September 2016

BACKGROUND:

Expert feedback has been identified as an important tool for acquisition of technical skill. The aim of this study is to assess the resident and faculty perceptions regarding operative feedback.

METHODS:

Faculty (academic and community practices) and residents were asked to take an anonymous survey regarding surgical feedback. The survey addressed the timing, amount, specificity, satisfaction, definition and importance of feedback. Participants were also questioned regarding the importance and frequency of feedback in areas such as pre-operative planning, intra-operative communication, respect for tissue, efficiency, instrument handling, knowledge of procedural steps and knowledge of anatomy.

RESULTS:

There were 23 study respondents (17 residents, 6 academic faculty, 0 community faculty). There was a significant difference in faculty and resident scores in the survey overall (P<.0001). Faculty perception on the timing of feedback was higher than that of residents (P=.0146). There was no difference in perception of the importance of feedback with regards to pre-operative planning, efficiency, instrument handling and knowledge of anatomy, however there was a difference in faculty and resident perception of the actual provision of feedback in all but one area of feedback (all P values<0.05).

DISCUSSION:

Faculty and residents both agree on the importance of surgical feedback, however there is a difference in the perception of provision of surgical feedback between faculty and residents. Perhaps this disparity can be rectified by implementation and adherence to procedure specific assessment tools by both faculty and residents.
Development of a Needs Assessment Tool to Guide Surgical Training
Authors: Braun Kelli , Stepleman Lara , Swift Steven
Published: September 2016

BACKGROUND:

Needs assessments are an effective process for addressing educational training gaps. Given the absence of a standardized one for Ob-Gyn surgical training, the new Ob-Gyn milestones, and an increase in simulation, we developed an assessment tool to align our curriculum with perceived resident and faculty needs; studies demonstrate these groups do not always agree on those needs.

METHODS:

Development of the needs assessment tool utilized a systematic multi-step process. Literature review and informal interviews with faculty generated an initial outline. Content areas included feedback, surgical preparation, intra-operative performance, simulation, and the Ob-Gyn milestones procedures for Obstetrics and Gynecology technical skills. The procedures were assessed for: 1) current satisfaction with training and 2) perceived helpfulness of simulation to improve procedure performance. The iterative item reduction and refinement process of the initial tool included receiving feedback from two Ob-Gyn experts and a psychometric expert with subsequent revisions. One faculty and one resident also completed the needs assessment survey to ensure item clarity.

RESULTS:

A final 50-item tool was developed. Two equivalent versions were written to capture faculty and resident perceptions.

DISCUSSION:

We describe the process of developing a needs assessment tool to guide a programs surgical training priorities; the tool will be utilized in academic year 2015, providing further evidence of tool validity. This process can be followed to address other educational gaps.
Evaluation of an Open Surgical Skills Curriculum
Authors: Beasley Anitra , Kilpatrick Charles , Swift Steven
Published: September 2016

BACKGROUND:

Work-hour limitations and focus on patient safety have necessitated changes to the traditional apprenticeship-based resident education model. This is especially true for surgical specialties where training opportunities must not only increase in efficiency but also shift to settings outside of the operating room. While validated curricula exist for laparoscopic skills, similar curricula for open skills are scare and not well validated across specialties.

METHODS:

The Southwestern Center for Minimally Invasive Surgery open knot-tying and suturing curriculum has been validated in a general surgery sample and consists of 11 standardized tasks using commercially available materials. The full curriculum includes an orientation, video tutorials, proctored baseline assessment, individual practice, and proctored post-testing. We tested elements of the curriculum through baseline assessment.

RESULTS:

Residents from all levels of our program attended orientation and rotated through the skills stations for baseline assessment. With minor exceptions, tasks were able to be performed as described. Baseline performance between intern and upper level trainees was significantly different for basic knot tying and suturing (P<.05).

DISCUSSION:

We were able to provisionally implement a simple yet comprehensive curriculum for open knot-tying and suturing. The differential performance of upper and lower level residents demonstrates construct validity in our sample. We anticipate that skill acquisition will be demonstrated by a majority of trainees by completion of the entire curriculum.
Knowing Operative Tying: The KnOT Study
Authors: Lewicky-Gaupp Christina , Bochenska Katarzyna , Milad Magdy
Published: September 2016

BACKGROUND:

The purpose of this study was to determine if viewing an expert knot tying training video, in addition to the standard medical student curriculum, will result in more proficient surgical knot tying.

METHODS:

At the start of the clerkship, 20 students were videotaped tying surgical knots for 2 minutes using a board model. Two blinded gynecologic surgeons evaluated proficiency with a standard checklist (score range 0–16) and anchored scoring scale (range 0–20); higher numbers represent better skill. Students were randomized to either (1) expert video or (2) no video. The “video” group was given unlimited access to a knot tying instructional video. At the completion of the clerkship, students were again videotaped and evaluated.

RESULTS:

At initial evaluation, overall the group mean checklist score was 8.7±4.9, and the anchored scale score was 9.9±4.6 (range 0–18). These pre-clerkship scores did not differ between groups (P=.11 and 0.12, respectively). Post-clerkship checklist scores significantly improved in both the non-video group (14.2±1.6, P=.02) and video group (13.5±2.9, P=.003); similarly, anchor scores also improved in both groups (17.1±3.0, P=.004 and 16.5±3.4, P=.003, respectively). Knot board practice frequency was not different between groups (P=.23). In the expert video group, increased practice significantly correlated with higher post-rotation scores on both the checklist (r=0.69, P<.05) and anchored scales (r=0.68, P<.05).

DISCUSSION:

The addition of an instructional video appears to have a positive impact on medical student knot tying proficiency.
Sterilization and Contraception Costs: An Educational Needs Assessment and Intervention
Authors: Martinez Anjali , Weeks Corinne , Keller Jennifer
Published: September 2016

BACKGROUND:

Understanding the costs associated with healthcare is an essential component of being an effective physician and has been recognized as one of the five essential competencies of systems-based practice. Despite this level of importance, there is little published about assessing knowledge associated with sterilization costs or strategies to educate trainees about cost. This project was designed to perform a needs assessment, create a curriculum to teach residents about costs of sterilization, and to determine the impact of the educational intervention.

METHODS:

Obstetrics and Gynecology residents and faculty were surveyed regarding their baseline knowledge and attitudes of the cost of sterilization and long-term contraceptive options. An interactive curriculum was designed for the residents around cognitive gaps, and the residents were resurveyed after the educational session.

RESULTS:

Twelve residents including PGY-2 (n=3), PGY-3 (n=4) and PGY-4 (n=5) and 15 faculty members participated in the study. Residents considered it important to understand the cost of comparable sterilization options (mean: 4.14; scale: 1–5) but did not feel knowledgeable about these costs (mean: 1.83; scale 1–5). Faculty also felt this topic was important (mean: 4.3; scale 1–5) but felt more knowledgeable (mean: 3.0; scale 1–5). After implementation of the curriculum, residents felt significantly more knowledgeable (mean: 3.25 versus 1.83, P<.01).

DISCUSSION:

Residents recognize the knowledge deficit associated with sterilization costs and consider understanding costs to be important. Using an educational intervention, we demonstrate improved knowledge about costs and plan to reassess in 6 months to determine retention.
The Labor Games
Authors: Bou Nemer Laurice , Kalin Dawn , Fiorentino Desiree , Garcia Jorge J. , Estes Christopher M.
Published: September 2016

OBJECTIVE:

To develop and evaluate a simulation laboratory designed to stimulate learning and increase medical students' preparedness for an obstetrics and gynecology clinical clerkship.

METHODS:

Ninety-seven medical students participated in the games during their obstetrics and gynecology clerkship in 1 year. Using the resident-as-teacher model, students rotated through seven stations, each with a simulated obstetric task. Points were awarded at each station, and the student with the highest score won. Self-perceived proficiency level and general preparedness for the clerkship were evaluated through paired pregame and postgame assessments.

RESULTS:

Postassessment results showed statistically significant (P<.001) increases in self-perceived competence performing all tested skills including reading fetal heart tracings, knot-tying, measuring cervical dilation, amniotomy, estimating fetal weight, and estimating blood loss. Approximately 97% enjoyed The Labor Games, 97.9% reported increased knowledge, and 96.9% learned valuable skills. Students also reported feeling more prepared for the obstetrics and gynecology rotation (2.6 compared with 3.3, P<.001).

DISCUSSION:

The Labor Games improved medical students' self-confidence and self-perceived skill level on obstetric tasks. Students also felt more prepared for the obstetrics and gynecology clerkship. This study creates a low-cost and reproducible simulation laboratory that is identified as effective by medical students in teaching skills, knowledge, and preparedness for an obstetrics and gynecology clerkship.
Resuscitation and Treatment of Shock
Authors: Beltran Michael J. , Becker Tyson E. , Hurley Richard K. , Gurney Jennifer M. , Hayda Roman A.
Published: September 2016

Hemorrhage continues to be the most common cause of death among service members wounded in combat. Injuries that were previously nonsurvivable in previous wars are now routinely seen by combat surgeons in forward surgical units, the result of improvements in body armor, the universal use of field tourniquets to control extremity hemorrhage at the point of injury, and rapid air evacuation strategies. Combat orthopaedic surgeons remain a vital aspect of the forward surgical unit, tasked with assisting general surgical colleagues in the resuscitation of patients in hemorrhagic shock while also addressing traumatic amputations, open and closed long bone fractures, and mechanically unstable pelvic trauma. Future military and civilian trauma research endeavors will seek to identify how the advances made in the past 15 years will translate toward the emerging battlefield of the future, one where forward surgical units must be lighter, smaller, and more mobile to address the changing scope of military combat operations.
Debridement and Irrigation: Evolution and Current Recommendations
Authors: Erdle Nicholas J. , Verwiebe Eric G. , Wenke Joseph C. , Smith Christopher S.
Published: September 2016

Debridement is an integral step in the orthopaedic management of traumatic wounds, from open soft tissue injuries and routine open fracture care to the management of extensive high-energy blast injuries. While the necessity of debridement has been well established, the level of energy and degree of contamination of blast wounds encountered in recent armed conflict has offered a challenge and a new opportunity for military surgeons to revisit the most recent literature to guide our practice with the best evidence currently available. While the core tenants of removing the nonviable tissue and preserving the viable to maintain the best functional outcome have not changed, new wound care therapies and advances in prosthetics and salvage techniques and the ability to rapidly evacuate casualties have changed the approach to care provided on the front lines. This paper seeks to review the core principles of debridement and guide treatment using evidence-based methods that can be applied to contaminated open injuries on the battlefront and disaster and intentional violence injuries abroad and at home.
Preventing Seal Leak During Negative Pressure Wound Therapy Near External Fixators: A Technical Tip
Authors: Mannino Brian J. , Pullen Michael W. , Gaines Robert
Published: September 2016

Negative pressure wound therapy is an effective tool for the treatment of open wounds. Occasionally these wounds are associated with injuries or procedures that require treatment with an external fixator. This article shows how a simple, inexpensive, and commercially available product can be used to prevent loss of suction around external fixator pins within the negative pressure wound treatment area.
Graf Type-IV Hips Have a Higher Risk of Residual Acetabular Dysplasia at 1 Year of Age Following Successful Pavlik Harness Treatment for Developmental Hip Dysplasia
Authors: Novais Eduardo N. , Sanders Julia , Kestel Lauryn A. , Carry Patrick M. , Meyers Mariana L.
Published: September 2016

Background:

We asked whether patient-specific factors and ultrasound (US) measurements of hip dysplasia severity at initial examination influence short-term residual acetabular dysplasia in patients successfully treated with Pavlik harness for developmental hip dysplasia.

Methods:

After IRB approval, 134 hips (84 patients) successfully treated by the Pavlik method between August 2011 and October 2014 with follow-up at 12 months of age were identified. Early successful treatment was defined as normal examination and US after approximately 12 weeks of Pavlik treatment. Multivariate linear and logistic regression models were used to identify factors associated with acetabular index (AI) measurements at 12 months as well as factors associated with an increase in AI between the 6- and 12-month timepoints (dysplastic progression).

Results:

The study consisted of 134 hips (84 patients). The distribution of dysplastic, Barlow, and Ortolani hips was 44.8% (N=60), 30.6% (N=41), and 24.6% (N=33), respectively. The crude incidence of residual dysplasia at the 6-month visit (AI>30 degrees) was 11.7% (12/102). The incidence of residual dysplasia at the 12-month visit (AI>28 degrees) was 11.8% (13/111). Graf type was the only variable associated with AI values at the 12-month visit (mean difference: Graf type-IV—Other, 2.6; 95% confidence interval, 0.3-4.9; P=0.026).

Conclusions:

The risk of residual acetabular dysplasia after normal hip US following Pavlik treatment is not negligible. Radiographic surveillance is warranted to monitor and screen for dysplasia progression. Patients with dislocated Graf type-IV hips at diagnosis are at increased risk of residual acetabular dysplasia at 1 year after successful treatment with the Pavlik method.

Level of Evidence:

Level III—therapeutic study.
A New Subtype of Lichen Planopilaris Affecting Vellus Hairs and Clinically Mimicking Androgenetic Alopecia
Authors: Abbasi Ali , Kamyab-Hesari Kambiz , Rabbani Ramin , Mollaee Farzaneh , Abbasi Sheida
Published: September 2016

BACKGROUND

Lichen planopilaris (LPP) is a follicular variant of lichen planus. A new subtype of LPP mimicking androgenetic alopecia (AGA) may be misdiagnosed. Inappropriate medical therapy or hair transplantation may exacerbate this subtype.

OBJECTIVE

To introduce clinicopathologic findings of a new subtype of LPP that selectively affects vellus hair in the pattern of AGA.

MATERIALS AND METHODS

In a cross-sectional study, 433 (66.6%) men and 217 (33.4%) women with alopecia who were candidates of medical treatment or hair transplantation were included. Gross and microscopic attributes of their diseases were investigated.

RESULTS

Among the total of 650 patients, 58 (8.9%; 95% confidence interval, 6.7%–11.1%) patients, including 52 women and 6 men, had LPP. We identified a distinct category of LPP presenting with diffuse hair loss in the pattern of AGA with predominant terminal hair, significant decrease in vellus hair, and minute punctuate scars in histopathology. Vellus hair follicles were the main sites of involvement. Perifollicular fibrosis and mild fibrosis with lichenoid lymphocytic infiltration around infundibular area of vellus hair follicles were present.

CONCLUSION

There is a new form of LPP with clinical features similar to AGA. This form is histopathologically similar to LPP but selectively affects vellus hair follicles.
Immune Checkpoint Inhibitors for Treatment of Metastatic Melanoma of the Orbit and Ocular Adnexa
Authors: Ford Joshua , Thuro Bradley A. , Thakar Sudip , Hwu Wen-Jen , Richani Karina , Esmaeli Bita
Published: September 2016

Programmed cell death 1 (PD-1) inhibitors are members of a new class of drugs known as immune checkpoint inhibitors and have proven efficacy in the treatment of metastatic melanoma. Herein, the authors report the use of nivolumab and pembrolizumab, 2 recently Food and Drug Administration-approved PD-1 inhibitors, in 3 patients: 1 with metastatic conjunctival melanoma and 2 with metastatic cutaneous melanoma and orbital involvement. The patients’ metastatic disease responded well to drug treatment. As of this writing, 2 patients have completed therapy and remain disease free at least 1 year after treatment completion; the other patient is still receiving treatment, and his orbital disease is responding. The authors herein describe the use of PD-1 inhibitors as a new alternative in the treatment of metastatic melanoma to the orbit or metastatic ocular adnexal melanomas in these clinical settings.
Cannula Design and Recirculation During Venovenous Extracorporeal Membrane Oxygenation
Authors: Palmér Oscar , Palmér Kenneth , Hultman Jan , Broman Mikael
Published: September 2016

Extracorporeal membrane oxygenation (ECMO) is used as a lifesaving rescue treatment in refractory respiratory or cardiac failure. During venovenous (VV) ECMO, the presence of recirculation is known, but quantification and actions to minimize recirculation after measurement are to date not routinely practiced. In the current study, we investigated the effect of draining cannula design on recirculation fraction (R
f) during VV ECMO; conventional mesh cannula was compared with a multistage cannula. The effect of adjusting cannula position was also studied. Recirculation was measured with ultrasound dilution technique at different ECMO flows and after cannula repositioning. All patients who were admitted to our unit between October 2014 and July 2015 catheterized by the atrio-femoral single lumen method were included. A total of 108 measurements were conducted in 14 patients. The multistage cannula showed significantly less recirculation (19.0 ± 12.2%) compared with the conventional design (38.0 ± 13.7). Pooled data in cases improved from adjustment showing reduced R
f by 7%. In conclusion, the choice of cannula matters, as does adjustment of the draining cannula position during atrio-femoral VV ECMO. By utilizing the ultrasound dilution technique to measure R
f before and after repositioning, effective ECMO flow can be improved for a more effective ECMO treatment.
CRRT Connected to ECMO: Managing High Pressures
Authors: de Tymowski Christian , Augustin Pascal , Houissa Hamda , Allou Nicolas , Montravers Philippe , Delzongle Alienor , Pellenc Quentin , Desmard Mathieu
Published: September 2016

Metabolic disorders and fluid overload are indications of continuous renal replacement therapy (CRRT) including continuous venovenous hemofiltration in patients on extracorporeal membrane oxygenation (ECMO). Direct connection of CRRT machine to the ECMO circuit provides many advantages. Nevertheless, because pressures in CRRT lines relate to ECMO blood flow, high ECMO blood flow may be associated with high pressures in CRRT lines. Thus, management of CRRT pressure lines becomes challenging. We evaluated a protocol for managing high CRRT pressures. Connections were performed according to a standardized protocol to maintain CRRT lines in the correct pressure ranges without modifying ECMO settings or inhibiting pressure alarms. To achieve this goal, the way of connecting of CRRT lines was adapted following a standardized protocol. Connection was first attempted between pump and oxygenator in the 12 patients. In five cases, high pressures in CRRT lines were successfully managed by changing the connection segment. Continuous renal replacement therapy parameters were within target levels and reduction of serum creatinine was 37%. In conclusion, management of high pressures in CRRT lines induced by ECMO could be achieved without modifying ECMO blood flow or inhibiting CRRT alarms. Iterative stops were avoided allowing efficient procedures.
Sources of Circuit Thrombosis in Pediatric Extracorporeal Membrane Oxygenation
Authors: Hastings Susan M. , Ku David N. , Wagoner Scott , Maher Kevin O. , Deshpande Shriprasad
Published: September 2016

Extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support of critically ill patients is used frequently in the pediatric population. ECMO is burdened by complications, including thrombosis and hemorrhage. Here we demonstrate the focused location of clots, their histologic composition, and the relationship of in situ thrombus to local hemodynamics in ECMO circuits. Pediatric ECMO circuits from Children’s Healthcare of Atlanta, Emory University (Atlanta, GA) were obtained after removal from extracorporeal support over a 2.5 year period (n = 50). All clots and material deposited within the circuit were recorded. Location of clot was compared with local hemodynamics. Most clots were adherent to the junctions made by the tubing and connectors, as opposed to being randomly disturbed throughout the circuit tubing (p << 0.05). Loose, nonadherent clots were also found at the entry side of oxygenators. The clots colocated directly with zones of low shear rate. Histology revealed a fibrinous composition, consistent with coagulation potentiated by low shear. Centrifugal pump circuits (n = 16) had more clots than roller pump (n = 34) circuits (p << 0.05). In addition, all centrifugal pumps had clots that formed at the top of the pump shaft. The ECMO circuits from our single-center study demonstrate the concentrated location of fibrin clots at low shear zones created by tubing-connector junctions. Type of pump also influences the frequency of clot formation. Since the mechanism of the majority of ECMO circuit thrombosis is low shear and fibrin driven, optimization of hemodynamics and anticoagulation regimen may reduce clot formation and bleeding.
Role of Thromboelastography Platelet Mapping and International Normalized Ratio in Defining “Normocoagulability” During Anticoagulation for Mechanical Circulatory Support Devices: A Pilot Retrospective Study
Authors: Volod Oksana , Lam Lee D. , Lin Gloria , Kam Clarice , Kolyouthapong Kristica , Mac Jessica , Mirocha James , Ambrose Peter J. , Czer Lawrence S. C. , Arabia Francisco A.
Published: September 2016

Thromboembolic (TE) events and hemorrhagic complications continue to remain as frequent adverse events and causes of death after mechanical circulatory support device (MCSD) implantation. To counterbalance this postimplant multifactorial hypercoagulable state, antithrombotic therapy given postimplant must be individually tailored to keep patient adequately anticoagulated yet normocoagulable. Prior studies describing different anticoagulation protocols do not define normocoagulability for patients on MCSDs. We evaluated the role of thromboelastography platelet mapping (TEG PM) in defining “normocoagulability” for MCS patients on anticoagulant (warfarin) and antiplatelet agents. Ninety-eight MCSD patients who underwent TEG PM assay at our institution from 2012 to 2014 were included for retrospective analysis. Eleven (11.2%) subjects developed at least one TE event during the study period. Of the 13 TE events, 8 occurred in patients with total artificial heart (TAH). TEG parameters closest to the event or when patient was clinically adequately anticoagulated and corresponding international normalized ratio (INR) were measured. Thromboelastography coagulation index (CI) appears to be the single most statistically significant parameter that can be used to designate a patient as normocoagulable. Based on our results, patients with HeartMate II (HM II) and Heart Ware (HW) devices should be maintained at a CI value of less than or equal to 1.5 whereas patients with TAH devices should be maintained at a CI less than or equal to 1.2. The CI should be correlated with the degree of Vitamin K-dependent coagulation factor inhibition that is achieved using device-specific goal INR ranges. A recent modification, TEG PM assesses the effects of antiplatelet drug. Maximal amplitude arachidonic acid (MA-AA) < 50 and maximal amplitude adenosine diphosphate (MA-ADP) < 50 are desired for normocoagulable state.
Sepsis-induced acute kidney injury
Authors: Gómez Hernando , Kellum John A.
Published: September 2016

Purpose of review

Sepsis is a common and frequently fatal condition in which mortality has been consistently linked to increasing organ dysfunction. For example, acute kidney injury (AKI) occurs in 40–50% of septic patients and increases mortality six to eight-fold. However, the mechanisms by which sepsis causes organ dysfunction are not well understood and hence current therapy remains reactive and nonspecific.

Recent findings

Recent studies have challenged the previous notion that organ dysfunction is solely secondary to hypoperfusion, by showing, for example, that AKI occurs in the setting of normal or increased renal blood flow; and that it is characterized not by acute tubular necrosis or apoptosis, but rather by heterogeneous areas of colocalized sluggish peritubular blood flow and tubular epithelial cell oxidative stress. Evidence has also shown that microvascular dysfunction, inflammation, and the metabolic response to inflammatory injury are fundamental pathophysiologic mechanisms that may explain the development of sepsis-induced AKI.

The implications of these findings are significant because in the context of decades of negative clinical trials in the field, the recognition that other mechanisms are at play opens the possibility to better understand the processes of injury and repair, and provides an invaluable opportunity to design mechanism-targeted therapeutic interventions.
Prognostic Significance of Hemodynamic and Clinical Stages in the Prediction of Hepatocellular Carcinoma
Authors: Suk Ki Tae , Kim Eun Jin , Kim Dong Joon , Kim Hyo Sun , Bang Chang Seok , Park Tae Young , Baik Gwang Ho , Kim Sung Eun , Park Ji Won , Park Sang Hoon , Lee Myung Seok , Kim Hyoung Su , Jang Myoung Kuk , Park Seung Ha , Choi Eunhee , Kim Chang H. , Sung Hotaik , Park Choong Kee
Published: September 2016

Background & Goals:

Early identification of hepatocellular carcinoma (HCC) is associated with improved survival for patients with chronic liver disease (CLD). We evaluated the prognostic significance of hemodynamic stage (HS) and clinical stage (CS) in predicting HCC in CLD patients.

Methods:

Between January 2006 and May 2014, 801 patients with CLD who underwent hepatic venous pressure gradient (HVPG) measurement were prospectively enrolled. HS was classified by HVPG (mm Hg) as follows: HS-1 (HVPG≤6), HS-2 (6<HVPG≤10), HS-3 (10<HVPG≤12), HS-4 (12<HVPG≤20), and HS-5 (20<HVPG). CS was classified as follows: CS-0 (no cirrhosis), CS-1 (cirrhosis without varix), CS-2 (cirrhosis with varix), CS-3 (varix bleeding without other complications), CS-4 (first nonbleeding decompensating event), and CS-5 (any second decompensating event). The HCC development and risk factors for HCC were evaluated in all patients and patients with cirrhosis, respectively.

Results:

HCC developed in 53 patients (6.6%). The incidence densities of HCC according to HS-1 to HS-5 and CS-0 to CS-5 were 4, 16, 36, 45, and 49/1000 person years and 0, 15, 25, 33, 36, and 53/1000 person years of observation, respectively. Ascites aggravation [P=0.008, odd ratio (OR)=2.33], HVPG>12 mm Hg (P=0.033, OR=2.17), CS>2 (P=0.039, OR=2.36), and alpha-fetoprotein (AFP; P=0.017, OR=1.01) were significant predictors of HCC development in all patients. For patients with cirrhosis, ascites aggravation (OR=2.51), HVPG >12 mm Hg (OR=2.46), and CS >2 (OR=2.62) were correlated with HCC development. Areas under receiver operating characteristic curves of the prediction-model, CS, HVPG score, and AFP were 0.797, 0.707, 0.701, and 0.653, respectively.

Conclusions:

HCC development correlates with advancing liver fibrosis or disease as measured by HS and CS. In addition, ascites aggravation and elevated AFP appears to be associated with increased incidence of HCC.
Acute gastrointestinal bleeding cases presenting to the emergency department are associated with age, sex and seasonal and circadian factors
Authors: Lenzen Henrike , Musmann Eliane , Kottas Martina , Schönemeier Bastian , Köhnlein Thomas , Manns Michael P. , Lankisch Tim O.
Published: September 2016

Background

Gastrointestinal bleeding (GIB) is one of the most common emergencies in gastroenterology. The aim of this study was to investigate the association between the incidence of GIB and seasonal, circadian and meteorological patterns in the emergency department (ED) of a tertiary hospital.

Patients and methods

From January 2007 until December 2012, we retrospectively evaluated patients presenting to the ED with respect to the number and location of GIB, season, time of day and weather.

Results

Of 45 458 patients, 578 (1.3%) presented with a GIB. Of these, 62.5% were men compared with 54.7% of all patients in the ED (χ
2, P=0.0002). Patients with GIB were on average 4.4 years older than those without GIB (95% confidence interval 2.76–5.98, t-test, P<0.001). In addition, 304 (52.6%) patients had upper GIB and 138 (23.9%) had lower GIB. In total, 136 (23.5%) patients required no endoscopy because of initial laboratory and circulatory stability. In univariate analysis, meteorological parameters, including air temperature, cloud cover, relative humidity, vapour pressure, amount of precipitation, sunshine duration and snow height, were each associated with an increased risk of acute GIB (all P-values<0.05). In the 6-year study period, patients with GIB presented to the ED mainly during the winter months. Independent predictors of GIB on multivariate logistic regression were older age, male sex, season and daytime, all P less than 0.005. Emergency admissions during the night were associated with a 54 and 35% higher risk of GIB compared with daytime (8 a.m. to 4 p.m., P=0.0002) and late evening hours (4 p.m. to midnight, P=0.0142), respectively.

Conclusion

Presentation of patients with acute GIB in the ED is age and sex specific and shows seasonal and circadian differences in distribution, with an increased incidence in winter months and during night-time. This should be considered when determining possible emergency endoscopic interventions and the availability of emergency endoscopy services.
Do Sleep Disturbances Predict or Moderate the Response to Psychotherapy in Bipolar Disorder?
Authors: Sylvia Louisa G. , Salcedo Stephanie , Peters Amy T. , Magalhães Pedro Vieira da Silva , Frank Ellen , Miklowitz David J. , Otto Michael W. , Berk Michael , Nierenberg Andrew A. , Deckersbach Thilo
Published: September 2016

This study examined whether sleep disturbance predicted or moderated responses to psychotherapy in participants who participated in STEP-BD, a national, multisite study that examined the effectiveness of different treatment combinations for bipolar disorder. Participants received either a brief psychosocial intervention called collaborative care (CC; n = 130) or intensive psychotherapy (IP; n = 163), with study-based pharmacotherapy. Participants (N = 243) were defined as current (past week) short sleepers (<6 hours/night), normal sleepers (6.5–8.5 hours/night), and long sleepers (≥9 hours/night), according to reported average nightly sleep duration the week before randomization. Sleep disturbances did not predict the likelihood of recovery nor time until recovery from a depressive episode. There was no difference in recovery rates between IP versus CC for normal sleepers, and medium effect sizes were observed for differences in short and long sleepers. In this study, sleep did not play a major role in predicting or moderating response to psychotherapy in bipolar disorder.
Prediction of Catheter-Associated Thrombosis in Critically Ill Children
Authors: Marquez Alexandra , Shabanova Veronika , Faustino Edward Vincent S.
Published: September 2016

Objective:

We determined whether in critically ill children with an untunneled central venous catheter, the risk of catheter-associated deep venous thrombosis can be predicted within 24 hours after insertion of the catheter.

Design:

Secondary analysis of two multicenter prospective cohort studies.

Setting:

PICUs in Northeastern United States.

Patients:

A total of 175 children admitted to the PICU within 24 hours after insertion of an untunneled central venous catheter who did not receive anticoagulation were included. Of these, 53 (30.3%) developed catheter-associated thrombosis detected with active surveillance with ultrasonography.

Interventions:

None.

Measurements and Main Results:

We used logistic regression (models 1 and 2) and recursive partitioning (models 3 and 4) methods to develop risk prediction models with predictors present at any time while catheterized (models 1 and 3), or within 24 hours after insertion of the catheter (models 2 and 4). Age, recent surgery, catheter in the subclavian vein, and blood product transfusion were included in models 1 and 2. Areas under the receiver operating characteristic curves were similar for these models (model 1: 0.80 vs model 2: 0.80; p = 0.44). Except for recent surgery, predictors in model 1 were identified as partitioning variables for model 3. In addition to the predictors in model 2, severity of illness was used in partitioning for model 4. The area under the curve of model 3 appeared smaller than that of model 4 (0.75 vs 0.80; p = 0.08). Groups of children at low, intermediate, and high risks of catheter-associated thrombosis were identified using model 4.

Conclusions:

Critically ill children at high risk of catheter-associated thrombosis can be identified within 24 hours after insertion of an untunneled central venous catheter.
Changes in Motor Development During a 4-Year Follow-up on Children With Univentricular Heart Defects
Authors: Mäenpää Heidi , Häkkinen Arja , Sarajuuri Anne
Published: September 2016

Purpose:

To compare changes in motor development from 1 to 5 years of age among 18 children with hypoplastic left heart syndrome and 12 with univentricular heart to 42 children without heart defect.

Methods:

Motor development was assessed with the Alberta Infant Motor Scale and Movement Assessment Battery for Children (Movement ABC).

Results:

Children with hypoplastic left heart syndrome or univentricular heart had significantly lower scores on the Alberta Infant Motor Scale test at the age of 1 and on the Movement ABC test at the age of 5 years compared with controls. Children with clear abnormalities on brain magnetic resonance imaging had lower scores compared with those with normal images or mild changes, and their relative motor scores decreased during follow-up.

Conclusions:

Some children with univentricular heart defects may benefit from physiotherapeutic interventions to support their motor development.
Effects of Testosterone Therapy on Cognitive Function in Aging: A Systematic Review
Authors: Hua Jeremy T. , Hildreth Kerry L. , Pelak Victoria S.
Published: September 2016

Endogenous testosterone in the aging man has been scrutinized extensively in regard to its effects on performance in many cognitive domains, especially verbal fluency, visuospatial and visuoperceptual abilities, memory, and executive function. Studies of testosterone supplementation have sought to identify potential cognitive improvements in men with and without baseline cognitive impairment, and have had a wide range of results. The variability in outcomes is likely related, in part, to the lack of consensus on methods for testosterone measurement and supplementation and, in part, to the disparate measures of cognitive function used in randomized controlled studies. Despite the limitations imposed by such inconsistent methods, promising associations have been found between cognition and testosterone supplementation in both eugonadal men and men with low testosterone levels, with and without baseline cognitive dysfunction. This systematic review highlights the cognitive measures used in and the outcomes of existing studies of testosterone and cognition in aging men. The review suggests that larger studies and a more standardized approach to assessment will be needed before we can fully understand and realize sustained benefits from testosterone supplementation in the elderly male population, particularly given the substantial increase in testosterone supplementation in clinical practice.
Ciliary Body/Iris Appositioning Producing Mechanical Pupillary Defects in Carotid-Cavernous Sinus Fistula: An Overlooked Pathophysiologic Mechanism
Authors: Todorova Margarita G. , Parsa Cameron F.
Published: September 2016

Background:

Variable pupillary responses have been described with carotid-cavernous sinus fistulas. These often are associated with a decrease in visual acuity and attributed to retinal ischemia. We propose a novel pathophysiologic mechanism for changes in pupillary reactivity involving anatomic changes secondary to choroidal effusion.

Methods:

To demonstrate proof-of-concept, we investigated 2 consecutive patients with carotid-cavernous sinus fistulas and pupillary disturbances using repeated refractions and anterior segment ultrasound biomicroscopy.

Results:

Ultrasound biomicroscopy demonstrated choroidal thickening and ciliary body effusion with forward rotation of the lens–iris diaphragm altering refraction and mechanically limiting iris movements.

Conclusions:

Where there are acute elevations in orbital venous pressure causing ciliary body effusion, changes in visual acuity and pupillary abnormalities can be produced by mechanical effects.
Putatively novel serotypes and the potential for reduced vaccine effectiveness: capsular locus diversity revealed among 5405 pneumococcal genomes
Authors: van Tonder Andries J. , Bray James E. , Quirk Sigríður J. , Haraldsson Gunnsteinn , Jolley Keith A. , Maiden Martin C. J. , Hoffmann Steen , Bentley Stephen D. , Haraldsson Ásgeir , Erlendsdóttir Helga , Kristinsson Karl G. , Brueggemann Angela B.
Published: September 2016

The pneumococcus is a leading global pathogen and a key virulence factor possessed by the majority of pneumococci is an antigenic polysaccharide capsule (‘serotype’), which is encoded by the capsular (cps) locus. Approximately 100 different serotypes are known, but the extent of sequence diversity within the cps loci of individual serotypes is not well understood. Investigating serotype-specific sequence variation is crucial to the design of sequence-based serotyping methodology, understanding pneumococcal conjugate vaccine (PCV) effectiveness and the design of future PCVs. The availability of large genome datasets makes it possible to assess population-level variation among pneumococcal serotypes and in this study 5405 pneumococcal genomes were used to investigate cps locus diversity among 49 different serotypes. Pneumococci had been recovered between 1916 and 2014 from people of all ages living in 51 countries. Serotypes were deduced bioinformatically, cps locus sequences were extracted and variation was assessed within the cps locus, in the context of pneumococcal genetic lineages. Overall, cps locus sequence diversity varied markedly: low to moderate diversity was revealed among serogroups/types 1, 3, 7, 9, 11 and 22; whereas serogroups/types 6, 19, 23, 14, 15, 18, 33 and 35 displayed high diversity. Putative novel and/or hybrid cps loci were identified among all serogroups/types apart from 1, 3 and 9. This study demonstrated that cps locus sequence diversity varied widely between serogroups/types. Investigation of the biochemical structure of the polysaccharide capsule of major variants, particularly PCV-related serotypes and those that appear to be novel or hybrids, is warranted.
Repeated divergent selection on pigmentation genes in a rapid finch radiation driven by sexual selection
Authors: Campagna Leonardo , Repenning Márcio , Silveira Luis Fabio , Fontana Carla Suertegaray , Tubaro Pablo L , Lovette Irby J
Published: September 2016

The search for molecular targets of selection is leading to a better understanding of how evolution shapes biological diversity. Instances of recent and rapid speciation are suitable for associating phenotypes with their causal genotypes, because gene flow may homogenize areas of the genome that are not under divergent selection. Locating differentiated genomic regions among taxa allows us to test associations between the genes in these regions and their contributions to phenotypic diversity. Here we study a rapid radiation of nine sympatric bird species known as southern capuchino seedeaters, which are strikingly differentiated in sexually selected characters of male plumage and song. We sequenced the genomes of 72 individuals representing a diverse set of species and associated phenotypes to search for differentiated genomic regions. We asked what genes are harbored in divergent regions and to what extent has selection on the same targets shaped phenotypic diversity across different lineages. Capuchinos show differences in a small proportion of their genomes, yet selection has acted independently on the same targets during the groups’ radiation. Many divergence peaks contain genes involved in the melanogenesis pathway, with the strongest signal originating from a regulatory region upstream of the gene coding for the Agouti-signaling protein. Across all divergence peaks, the most differentiated areas are similarly likely regulatory. Our findings are consistent with selection acting on the same genomic regions in different lineages to shape the evolution of cis-regulatory elements, which control how more conserved genes are expressed and thereby generate diversity in sexually selected traits.
Intraspecific variation shapes community-level behavioural responses to urbanisation in spiders: from traits to function
Authors: Dahirel Maxime , Dierick Jasper , Cock Maarten De , Dries Bonte
Published: September 2016

Approaches based on functional traits have proven especially valuable to understand how communities respond to environmental gradients. Until recently, they have, however, often ignored the potential consequences of intraspecific trait variation (ITV). This position becomes potentially more problematic when studying animals and behavioural traits, as behaviours can be altered very flexibly at the individual level to track environmental changes.

Urban areas are an extreme example of human-changed environments, exposing organisms to multiple, strong, yet relatively standardized, selection pressures. Adaptive behavioural responses are thought to play a major role in animals’ success or failure in these new environments. The consequences of such behavioural changes for ecosystem processes remain understudied.

Using 62 sites of varying urbanisation level, we investigated how species turnover and ITV influenced community-level behavioural responses to urbanisation, using orb web spiders and their webs as models of foraging behaviour.

ITV explained around 30% of the total trait variation observed among communities. Spiders altered their web-building behaviour in cities in ways that increase the capture efficiency of webs. These traits shifts were partly mediated by species turnover, but ITV increased their magnitude. The importance of ITV varied depending on traits and on the spatial scale at which urbanisation was considered. Available prey biomass decreased with urbanisation; the corresponding decrease in prey interception by spiders was less important when ITV in web traits was accounted for.

By facilitating trait-environment matching despite urbanisation, ITV thus helps communities to buffer the effects of environmental changes on ecosystem functioning. Despite being often neglected from community-level analyses, our results highlight the importance of accounting for intraspecific trait variation to fully understand trait responses to (human-induced) environmental changes and their impact on ecosystem functioning.