bluuebunny/crossref_metadata_2025 huggingface dataset:
The female sexual function index: reliability and validity in Spanish postmenopausal women
Authors: Pérez-Herrezuelo Isabel , Hita-Contreras Fidel , Martínez-Amat Antonio , Aibar-Almazán Agustín , Cruz-Díaz David , Wangensteen Rosemary , Ochoa Alexander Achalandabaso , Díaz-Mohedo Esther
Published: January 2019

Objective:

To examine the reliability and validity of the Spanish version of the Female Sexual Function Index (FSFI) and its ability to discriminate between women with and without female sexual dysfunction (FSD) among Spanish postmenopausal women.

Methods:

A total of 152 postmenopausal women completed the Spanish version of FSFI. Internal consistency, test-retest reliability, and construct validity (exploratory factor analysis) were analyzed. Concurrent and divergent validity were assessed using a visual analog scale for overall satisfaction with sexual life and the Hospital Anxiety and Depression Scale, respectively. To determine the ability and the accuracy of the FSFI total score in discriminating between women with and without FSD, a receiver-operating characteristic curve analysis was performed.

Results:

Factor analysis suggested a three-factor structure (explained variance 77.77%). The Spanish FSFI showed substantial-to-excellent test-retest reliability, with good internal consistency in the FSFI total score (Cronbach's alpha = 0.964), and also in its three dimensions. The FSFI total and domains scores showed strong (r > 0.50) and significant correlations (P < 0.01) with overall satisfaction with sexual life (concurrent validity), and low correlations with anxiety and depression (divergent validity). The Spanish FSFI total score and dimensions were significantly able to discriminate between women with and without FSD (P < 0.05), with an optimal cut-off point of <24.95 for the FSFI total score (64.15% sensitivity and 75.76% specificity).

Conclusions:

The Spanish FSFI is a valid and reliable instrument for assessing and discriminating for FSD among Spanish postmenopausal women.
Secular trends and associated factors of age at natural menopause in Taiwanese women
Authors: Shen Te-Yi , Chen Hsin-Jen , Pan Wen-Harn , Yu Tsung
Published: January 2019

Objective:

Age at natural menopause (ANM) is considered an indicator for chronic disease and mortality risk in later life. Research suggests that ANM appears to vary across geographic regions and ethnicities. The aim of this study was to explore the secular trends and factors associated with ANM in Taiwanese women.

Methods:

We used data from three cross-sectional phases of the Nutrition and Health Survey in Taiwan. In all, 4,111 women aged 35 years and over were included. Information on ANM and sociodemographics, lifestyle, and health factors were collected using household questionnaires. A Cox proportional-hazards model was used to determine the association of ANM with relevant factors, and a life table method was used to estimate median ANM.

Results:

Life table method estimated the median ANM to be 50 years. ANM was getting later for women born in younger cohorts (hazard ratio [HR] 0.87 per 10-year difference, 95% confidence interval [CI] 0.81-0.95). ANM was also later among women who achieved higher educational levels (HR 0.91 per one-category difference, 95% CI 0.86-0.96) and who had been married (HR 0.64, 95% CI 0.42-0.96). ANM occurred later for parous than for nulliparous women. Multivariable analysis found no significant associations of ANM with age at menarche, smoking, or alcohol drinking.

Conclusions:

The results suggest that women in the younger cohorts, with higher educational levels, and who are parous and married may have later ANM. The trend effect of secular time and educational levels on ANM may reflect the influences of socioeconomic/nutritional status in their childhood or throughout their lifetime.
A Population-based Observational Study of Childhood Encephalitis in Children Admitted to Pediatric Intensive Care Units in England and Wales
Authors: Iro Mildred A. , Sadarangani Manish , Nickless Alecia , Kelly Dominic F. , Pollard Andrew J.
Published: January 2019

Background:

Encephalitis is a serious neurologic condition that can result in admission to intensive care. Yet, there are no studies on pediatric intensive care unit (PICU) admission rates and usage of intensive care resources by children with encephalitis in England and Wales. The objectives of this study were to (1) define the PICU incidence and mortality rates for childhood encephalitis, (2) describe the usage of intensive care resources by children with encephalitis admitted to PICU and (3) explore the associated cost from PICU encephalitis admissions.

Methods:

Retrospective analysis of anonymized data for 1031 children (0–17 years) with encephalitis admitted (January 2003 to December 2013) to PICU in England and Wales.

Results:

The PICU encephalitis incidence was 0.79/100,000 population/yr (95% confidence interval [CI]: 0.74–0.84), which gives an annual total of 214 bed days of intensive care occupancy for children admitted with encephalitis and an estimated annual PICU bed cost of £414,230 (interquartile range: 198,111–882,495) for this cohort. PICU encephalitis admissions increased during the study period (annual percentage change = 4.5%, 95% CI: 2.43%–6.50%, P ≤ 0.0001). In total, 808/1024 (78.9%) cases received invasive ventilation while 216/983 (22.0%) and 50/890 (5.6%) cases received vasoactive treatment and renal support, respectively. There were 87 deaths (8.4%), giving a PICU encephalitis mortality rate of 0.07/100,000 population (0–17 years)/yr (95% CI: 0.05–0.08).

Conclusions:

These data suggest that encephalitis places a significant burden to the healthcare service. More work is needed to improve outcomes for children with encephalitis.
Sedatives in neurocritical care: an update on pharmacological agents and modes of sedation
Authors: Opdenakker Olivier , Vanstraelen Anna , De Sloovere Veerle , Meyfroidt Geert
Published: January 2019

Purpose of review

In this article, the specific and general indications for sedatives in the neurocritical care unit are discussed, together with an overview on current insights in sedative protocols for these patients. In addition, physiological effects of sedative agents on the central nervous system are reviewed.

Recent findings

In the general ICU population, a large body of evidence supports light protocolized sedation over indiscriminate deep sedation. Unfortunately, in patients with severe acute brain injury, the evidence from randomized controlled trials is scarce to nonexistent, and practice is supported by expert opinion, physiological studies and observational or small interventional trials. The different sedatives each have different beneficial effects and side-effects.

Extrapolating the findings from studies in the general ICU population suggests to reserve deep continuous sedation in the neuro-ICU for specific indications. Although an improved understanding of cerebral physiological changes in patients with brain injury may be helpful to guide individualized sedation, we still lack the evidence base to make broad recommendations for specific patient groups.
Among Medicare Patients With Hepatocellular Carcinoma, Non–alcoholic Fatty Liver Disease is the Most Common Etiology and Cause of Mortality
Authors: Hester Danubia , Golabi Pegah , Paik James , Younossi Issah , Mishra Alita , Younossi Zobair M.
Published: January 2019

Goals:

The main purpose of this study was to assess the recent trends in mortality and health care utilization of hepatocellular carcinoma (HCC) among Medicare population in the United States.

Background:

The incidence of HCC is increasing in the United States.

Materials and Methods:

Data were obtained for a sample of Medicare beneficiary from 2005 to 2014. Diagnosis of HCC and etiology of liver disease were based on ICD-9 codes. Temporal trends in HCC rates, clinical, demographical and utilization parameters were analyzed by joinpoint regression model.

Results:

Study cohort included 13,648 Medicare recipients with HCC (mean age: 70.0 y, 62.8% male and 76.0% white). Non–alcoholic fatty liver disease (NAFLD) was the most common cause of HCC in the inpatient (32.07%) and outpatient (20.22%) followed by hepatitis C virus (HCV) (19.2% and 9.75%, respectively). Between 2005 and 2014, HCC rate per 100,000 Medicare recipients increased from 46.3 to 62.8 [average annual percentage change (AAPC) =3.4%, P<0.001]. Rate of HCV-HCC increased from 6.18 to 16.54 (AAPC=11.8%, P<0.001) while the NAFLD-HCC increased from 9.32 to 13.61, P<0.001). Overall 1-year mortality decreased from 46.2% to 42.1% (AAPC=−1.7%, P=0.004). Total charges increased from $67,679 to $99,420 (AAPC=5.1%, P<0.001) for inpatients and from $11,933 to $32,084 (P<0.001) for outpatients. On comparison of patients with hepatitis B virus-HCC, those with NAFLD-HCC (odds ratio: 1.87, P<0.001) had higher risk of mortality. On comparison of patients with hepatitis B virus-HCC, those with HCV-HCC had higher charges (percent change: 24.33%, 95% confidence interval: 1.02%-53.02%, P=0.040).

Conclusions:

Although HCC rates are increasing, the overall mortality is decreasing. NAFLD is the most important cause of HCC and an independent predictor of HCC in the outpatient setting for Medicare patients with HCC.
Effectiveness of fixed-dose combination of paritaprevir, ritonavir, ombitasvir, and dasabuvir in patients with chronic hepatitis C virus infection and chronic kidney diseases: real-life experiences
Authors: Örmeci Necati , Sezgin Orhan , Karaali Ridvan , Aygen Bilgehan , Turan Dilara , Yaras Serkan , Erdem İlknur , Yildiz Orhan , Karakaya Fatih , Ateş Kenan , Asiller Özgün Ö.
Published: January 2019

Introduction

Both hepatitis C virus infection (HCV) and chronic kidney disease (CKD) have been comorbid illnesses with increasing morbidity and mortality. The present study was conducted to present real-life experiences about treatment of HCV and CKD with a fixed-dose combination of paritaprevir 150 mg/day, ritonavir 100 mg/day as a booster, ombitasvir 25 mg/day, and dasabuvir 250 mg twice/day, the PROD regimen.

Patients and methods

This was a multicenter, retrospective cohort study. Seventy-five patients with both HCV and CKD were treated with a PROD-based regimen with or without ribavirin. Fifty-three of 75 patients were on maintenance hemodialysis program. Seven patients had compensated liver cirrhosis. The patients with genotype 1a or compensated liver cirrhosis were treated with the PROD regimen and ribavirin in a dose of 200 mg every other day for 12 weeks. The patients with genotype 1b were treated with PROD for 12 weeks. The patients with genotype 4 were treated with a combination of paritaprevir, ritonavir, ombitasvir, and ribavirin 200 mg every other day.

Results

All patients except one were HCV-RNA negative (98.6%) at the end of treatment. One patient had decompensated after the fourth day of therapy. She stopped the treatment, and she was exitus after 2 months. Two patients died of reasons not related to the drugs 2 months after negativity of HCV-RNA. Sustained viral rate 12 weeks after treatment was found in 96% of the patients.

Conclusion

The PROD regimen was very effective and safe for treatment in patients with HCV and CKD who were in stages 4 and 5.
Alloimmunity and Cholestasis After Liver Transplantation in Children With Progressive Familial Intrahepatic Cholestasis
Authors: Krebs‐Schmitt Dorothee , Briem‐Richter Andrea , Brinkert Florian , Keitel Verena , Pukite Ieva , Lenhartz Henning , Fischer Lutz , Grabhorn Enke
Published: January 2019

Objectives:

Bile salt export pump (BSEP) deficiency is an important reason for chronic cholestasis leading to liver transplantation (LT) in early childhood. The underlying pathology is a dysfunction of BSEP due to various mutations in the ABCB11 gene. Cases of clinical recurrence after LT due to alloantibodies directed against BSEP (antibody‐induced BSEP deficiency [AIBD]) have been reported. Most of these patients could be controlled by intensified immunosuppression.

Methods:

We here report on 3 children with BSEP‐deficiency and end‐stage liver disease, which developed AIBD after LT refractory to extensive immunosuppressive and immunomodulatory treatments; retransplantation was necessary in all 3 patients. In 1 patient, a stem cell transplantation was performed successfully.

Results:

AIBD seems to be induced by triggering factors such as initial impaired graft function or infections after LT.

Conclusions:

The underlying mutation may play a role in this process. Intensifying immunosuppression may be able to control AIBD, but some cases seem to be refractory to treatment and require retransplantation. Stem cell transplantation may provide a new therapeutic option for cases refractory to conservative treatment.
Temporal Self, Psychopathology, and Adaptive Functioning Deficits
Authors: Sokol Yosef , Serper Mark R.
Published: January 2019

Individuals with psychiatric illness have difficulty remembering specific events from their personal past and imagining their future. We examined psychotic psychiatric inpatients' sense of self-continuity over time, predicting that low levels of temporal continuity would predict increased psychopathology and lower functionality. Inpatients (n = 60) were compared with healthy controls (n = 60) on a validated measure of self-continuity, psychiatric symptoms, insight, and adaptive functioning capacity. Results revealed that patients had significant difficulty perceiving their past, present, and future selves as unified over time compared with controls. Within the inpatient group, deficits in present to future self-continuity was associated with patients' severity of positive, negative, and mood symptoms, degree of insight, and adaptive capacity. It may be the case that temporal self-unity provides a context for deriving reinforcement from daily life experiences in the moment and in anticipating the future as well as a worthwhile goal for treatment exploration.
Combat Posttraumatic Stress Disorder and Quality of Life
Authors: Kovačić Petrović Zrnka , Peraica Tina , Eterović Marija , Anđelinović Maja , Kozarić-Kovačić Dragica
Published: January 2019

A vast number of veterans with posttraumatic stress disorder (PTSD) have chronic somatic comorbidities. However, their relationship with quality of life (QoL) has received little attention. We aimed to compare QoL of veterans with similar intensity of PTSD but different number of chronic somatic disorders. Of 129 veterans, 78% had at least one somatic disorder, and they reported lower QoL across all domains than veterans without somatic comorbidities. The greatest effect size was observed on social relationship (d = 0.65), it was notable on environment (d = 0.4) and psychological health (d = 0.38), and it was not relevant on physical health (d = 0.05). There was a negative correlation between the number of somatic disorders and scores on psychological health (r
s = −0.217, p = 0.014), social relationships (r
s = −0.248, p = 0.005), and environment (r
s = −0.279, p = 0.001). The QoL of war veterans decreases significantly with the number of comorbid somatic conditions, particularly on the nonphysical domains of QoL.
Lifetime Physical Activity and White Matter Hyperintensities in Cognitively Intact Adults
Authors: Torres Elisa R. , Hoscheidt Siobhan M. , Bendlin Barbara B. , Magnotta Vincent A. , Lancaster Gabriel D. , Brown Roger L. , Paradiso Sergio
Published: January 2019

Background

White matter hyperintensities (WMHs) observed on magnetic resonance images are associated with depression and increase the risk of stroke, dementia, and death. The association between physical activity and WMHs has been inconsistently reported in the literature, perhaps because studies did not account for a lifetime of physical activity or depression.

Objectives

The aim of this study was to determine the extent to which a lifetime of leisure-time physical activity is associated with less WMHs while accounting for depression.

Methods

Face-to-face interviews were conducted with the Lifetime Total Physical Activity Questionnaire, where the metabolic equivalent of task hours per week per year was calculated. Cognitively intact participants also underwent magnetic resonance imaging, where WMHs as a percentage of intracranial volume was obtained. Hierarchical multiple linear regression was performed to compare WMHs in a more active group with a group with no psychiatric history (n = 20, mean age = 62.2 years), with a less active group with no psychiatric history (n = 13, mean age = 64.0 years), and a less active group with history of late-onset depression (n = 14, mean age = 62.8 years).

Results

There was not a statistically significant difference in WMHlg10 between the more and less active groups without a psychiatric history (b = .09, p > .05) or between the more active group without a psychiatric history and the less active group with a history of depression (b = .01, p > .05). The model was predictive of WMHlg10, explaining an adjusted 15% of the variance in WMHs (p = .041).

Discussion

A lifetime of leisure-time physical activity was not associated with WMHs when accounting for depression.
Pediatric Pulmonary Emboli at Autopsy: An Update and Case Series Review
Authors: O’Conor Christopher J. , Zhou Huifang , Ritter Jon , Dehner Louis , He Mai
Published: January 2019

Objectives:

Identify and characterize pediatric pulmonary emboli present at autopsy.

Design:

Retrospective single institution observational study with clinicopathologic correlation.

Setting:

Tertiary medical center.

Patients:

All autopsy cases performed at Washington University from 1997 to 2017 in pediatric patients (≤ 18 yr old).

Main Results:

Of 1,763 pediatric autopsies, 13 cases of pulmonary emboli were identified, including thromboemboli (6/13, 46.1%), septic emboli (3/13, 23.1%), fat emboli, and foreign body emboli.

Conclusions:

Pulmonary embolus is a relatively rare but potentially fatal cause of death in pediatric age patients and is often associated with congenital abnormalities, malignancy, or recent surgical procedures. Half of the fatal pulmonary emboli found in our series (3/6) show microscopic and diffuse, rather than large central or saddle emboli, potentially make a clinicoradiographic diagnosis more difficult. This series is also the first to report a case of hemostatic matrix pulmonary embolism in a pediatric age patient.
Positive Cumulative Fluid Balance Is Associated With Mortality in Pediatric Acute Respiratory Distress Syndrome in the Setting of Acute Kidney Injury
Authors: Zinter Matt S. , Spicer Aaron C. , Liu Kathleen D. , Orwoll Benjamin E. , Alkhouli Mustafa F. , Brakeman Paul R. , Calfee Carolyn S. , Matthay Michael A. , Sapru Anil
Published: January 2019

Objectives:

As acute kidney injury and elevated cumulative fluid balance commonly co-occur in pediatric acute respiratory distress syndrome, we aimed to identify risk factors for their development and evaluate their independent relationships with mortality. We hypothesized that acute kidney injury and elevated cumulative fluid balance would be associated with markers of inflammation and that children with elevated cumulative fluid balance and concomitant acute kidney injury would have worse outcomes than other children.

Design:

Prospective observational study using the pediatric Risk, Injury, Failure, Loss, End-Stage acute kidney injury classification.

Setting:

Five academic PICUs.

Patients:

Two-hundred sixty patients 1 month to 18 years old meeting the Berlin definition of acute respiratory distress syndrome between 2008 and 2014.

Interventions:

None.

Measurements and Results:

PICU mortality was 13% (34/260). Relative to survivors, nonsurvivors had greater cumulative fluid balance on day 3 of acute respiratory distress syndrome (+90.1 mL/kg; interquartile range 26.6–161.7 vs +44.9 mL/kg; interquartile range 10.0–111.3; p = 0.008) and also had higher prevalence of acute kidney injury on day 3 of acute respiratory distress syndrome (50% vs 23%; p = 0.001). On stratified analysis, greater cumulative fluid balance on day 3 of acute respiratory distress syndrome was associated with mortality among patients with concomitant acute kidney injury (+111.5 mL/kg for nonsurvivors; interquartile range 82.6–236.8 vs +58.5 mL/kg for survivors; interquartile range 0.9–176.2; p = 0.041) but not among patients without acute kidney injury (p = 0.308). The presence of acute kidney injury on acute respiratory distress syndrome day 3 was associated with mortality among patients with positive cumulative fluid balance (29.1% vs 10.4% mortality; p = 0.001) but not among patients with even or negative cumulative fluid balance (p = 0.430). Day 1 plasma interleukin-6 levels were associated with the development of day 3 positive cumulative fluid balance, day 3 acute kidney injury, and PICU mortality and the association between elevated day 1 interleukin-6 and PICU mortality was partially mediated by the interval development of day 3 positive cumulative fluid balance and day 3 acute kidney injury (p < 0.001).

Conclusions:

In pediatric acute respiratory distress syndrome, elevated cumulative fluid balance on day 3 of acute respiratory distress syndrome is associated with mortality specifically in patients with concomitant acute kidney injury. Plasma interleukin-6 levels are associated with the development of positive cumulative fluid balance and acute kidney injury, suggesting a potential mechanism by which inflammation might predispose to mortality.
Reducing Exposure to Opioid and Benzodiazepine Medications for Pediatric Cardiac Intensive Care Patients: A Quality Improvement Project*
Authors: Donnellan Amy , Sawyer Jaclyn , Peach Anne , Staveski Sandra , Nelson David P. , Pratap J. Nick
Published: January 2019

Objectives:

To evaluate the effect of implementation of a comfort algorithm on infusion rates of opioids and benzodiazepines in postneonatal postoperative pediatric cardiac surgery patients.

Design:

A quality improvement project, using statistical process control methodology.

Setting:

Twenty-five-bed tertiary care pediatric cardiac ICU in an urban academic Children’s hospital.

Patients:

Postoperative pediatric cardiac surgery patients.

Interventions:

Implementation of a guided comfort medication algorithm which consisted of key components; a low dose opioid continuous infusion, judicious use of frequent as needed opioids, initiation of dexmedetomidine infusion postoperatively, and minimal use of benzodiazepines.

Measurements and Main Results:

Among the baseline group admitted over the 18 month period prior to comfort algorithm implementation, 58 of 116 intubated patients (50%) received a continuous opioid infusion, compared with 30 of 41 (73%) for the implementation group over the 9-month period following implementation. Following algorithm implementation, opioid infusion rates were decreased and benzodiazepine infusions were nearly eliminated. Dexmedetomidine use and infusion rates did not change. Although mean duration of sedative drug infusions did not change with implementation, the frequency of high outliers was diminished. Duration of mechanical ventilation, length of ICU stay (outcome measures), and the frequency of unplanned extubation (balancing measure) were not affected by implementation.

Conclusions:

Implementation of a pediatric comfort algorithm reduced opioid and benzodiazepine dosing, without compromising safety for postoperative pediatric cardiac surgical patients.
Development of the Pediatric Extracorporeal Membrane Oxygenation Prediction Model for Risk-Adjusting Mortality*
Authors: Bailly David K. , Reeder Ron W. , Winder Melissa , Barbaro Ryan P. , Pollack Murray M. , Moler Frank W. , Meert Kathleen L. , Berg Robert A. , Carcillo Joseph , Zuppa Athena F. , Newth Christopher , Berger John , Bell Michael J. , Dean Michael J. , Nicholson Carol , Garcia-Filion Pamela , Wessel David , Heidemann Sabrina , Doctor Allan , Harrison Rick , Bratton Susan L. , Dalton Heidi
Published: January 2019

Objectives:

To develop a prognostic model for predicting mortality at time of extracorporeal membrane oxygenation initiation for children which is important for determining center-specific risk-adjusted outcomes.

Design:

Multivariable logistic regression using a large national cohort of pediatric extracorporeal membrane oxygenation patients.

Setting:

The ICUs of the eight tertiary care children’s hospitals of the Collaborative Pediatric Critical Care Research Network.

Patients:

Five-hundred fourteen children (< 19 yr old), enrolled with an initial extracorporeal membrane oxygenation run for any indication between January 2012 and September 2014.

Interventions:

None.

Measurements and Main Results:

A total of 514 first extracorporeal membrane oxygenation runs were analyzed with an overall mortality of 45% (n = 232). Weighted logistic regression was used for model selection and internal validation was performed using cross validation. The variables included in the Pediatric Extracorporeal Membrane Oxygenation Prediction model were age (pre-term neonate, full-term neonate, infant, child, and adolescent), indication for extracorporeal membrane oxygenation (extracorporeal cardiopulmonary resuscitation, cardiac, or respiratory), meconium aspiration, congenital diaphragmatic hernia, documented blood stream infection, arterial blood pH, partial thromboplastin time, and international normalized ratio. The highest risk of mortality was associated with the presence of a documented blood stream infection (odds ratio, 5.26; CI, 1.90–14.57) followed by extracorporeal cardiopulmonary resuscitation (odds ratio, 4.36; CI, 2.23–8.51). The C-statistic was 0.75 (95% CI, 0.70–0.80).

Conclusions:

The Pediatric Extracorporeal Membrane Oxygenation Prediction model represents a model for predicting in-hospital mortality among children receiving extracorporeal membrane oxygenation support for any indication. Consequently, it holds promise as the first comprehensive pediatric extracorporeal membrane oxygenation risk stratification model which is important for benchmarking extracorporeal membrane oxygenation outcomes across many centers.
A Cost Analysis of Pulse Oximetry as a Determinant in the Decision to Admit Infants With Mild to Moderate Bronchiolitis
Authors: Mendlowitz Andrew B. , Widjaja Elysa , Phan Cathy , Sun Zhuolu , Moretti Myla E. , Schuh Suzanne , Coyte Peter C. , Hancock-Howard Rebecca , Freedman Stephen B. , Ungar Wendy J.
Published: January 2019

Objectives

A previous randomized controlled trial showed that artificially elevating the pulse oximetry display resulted in fewer hospitalizations with no worse outcomes. This suggests that management decisions based mainly on pulse oximetry may unnecessarily increase health care costs. This study assessed the incremental cost of altered relative to true oximetry in infants with mild to moderate bronchiolitis.

Methods

A cost analysis was undertaken from the health care system and societal perspectives using patient-level data from the randomized controlled trial, with a 5-day time horizon after emergency department visit. Infants aged 4 weeks to 12 months with mild to moderate bronchiolitis were randomized to pulse oximetry measurements with true or altered saturation values displayed by artificially increasing saturation 3% points above true values. Direct and indirect health care costs were measured. Sensitivity analyses were performed to assess parameter uncertainty.

Results

From the health care system perspective, the average cost per patient was Can $1155 for altered oximetry and $1967 for true oximetry, with a net savings of $812. From a societal perspective, the average cost per patient was $1559 for altered oximetry and $2473 for true oximetry, with a net savings of $914. Probabilistic analyses demonstrated that altered oximetry remained the less costly study group, with an average savings of $810 (95% confidence interval, $748–$872) from the health care system perspective and $910 (95% confidence interval, $848–$973) from the societal system perspective.

Conclusions

Reliance on oximetry as a major determinant in the decision to hospitalize infants with mild to moderate bronchiolitis is associated with significantly greater costs.
Credentialing Pediatric Emergency Medicine Faculty in Point-of-Care Ultrasound
Authors: Abo Alyssa M. , Alade Kiyetta H. , Rempell Rachel G. , Kessler David , Fischer Jason W. , Lewiss Resa E. , Raio Christopher C. , Marin Jennifer R.
Published: January 2019

As point-of-care ultrasound (POCUS) becomes standard practice in pediatric emergency medicine (PEM), it is important to have benchmarks in place for credentialing PEM faculty in POCUS. Faculty must be systematically trained and assessed for competency in order to be credentialed in POCUS and granted privileges by an individual institution. Recommendations on credentialing PEM faculty are needed to ensure appropriate, consistent, and responsible use of this diagnostic and procedural tool. It is our intention that these guidelines will serve as a framework for credentialing faculty in PEM POCUS.
Foreign Body Reaction Due to a Forgotten Rubber Band on the Neck of a Toddler Girl
Authors: Yetim Aylin , Aygüler Emrullah , Özçetin Mustafa , Bayramoğlu Zuhal , Hançerli Törün Selda , Çelik Mehmet , Güdek Kemal , Korur Fincanci Şebnem , Kiliç Ayşe
Published: January 2019

In the presence of an unhealed granulation tissue–like wound, a possibility of abuse and neglect along with a foreign body should come to mind. However, it may be difficult to recognize a foreign body in patients with atypical clinical presentations. We demonstrated delayed diagnosis of a rubber band embedded into subcutaneous tissue in a 2½-year-old girl who presented with a circumferential scar with 2 granulation tissue–like wounds on her neck due to a foreign body reaction developed over years. With this rare case presentation, we remind the possibility of abuse/neglect along with foreign bodies in neck lesions of children.
Unintentional Pediatric Marijuana Exposures at a Tertiary Care Children's Hospital in Washington State
Authors: Thomas Anita Anne , Dickerson-Young Tavis , Mazor Suzan
Published: January 2019

Background

Recreational marijuana became commercially available in Washington State in 2014. Children with marijuana intoxication can have lethargy and altered mental status, often resulting in extensive workup.

Objectives

The aim of this study was to quantify the incidence of pediatric marijuana exposure before and after marijuana legalization/commercial availability in Washington State at a tertiary care children's hospital.

Methods

Charts of patients 9 years or younger evaluated at a tertiary care pediatric hospital from October 8, 2007, to October 31, 2016, were retrospectively reviewed. Inclusion criteria were positive tetrahydrocannabinol urine toxicology screen and diagnosis consistent with unintentional marijuana exposure. Data included age, sex, exposure date range, symptoms, ancillary tests, consults, disposition, and marijuana source. Data were analyzed in R using descriptive statistics.

Results

Seventeen unintentional marijuana exposures were identified during our study period, 8 cases before and 9 cases after legalization of recreational marijuana, which is 1.19 events per year in the 6.75 years before legalization compared with 3.88 events per year in the 2.32 years after (P < 0.05). Age range was 17 months to 7 years, with a median age of 21 months. Eighty-two percent received laboratory tests, 47% underwent head computed tomography, 6% underwent lumbar puncture, and 100% underwent social work evaluation. Thirty-five percent were discharged from the emergency department, 47% were admitted to general medicine, and 18% were admitted to the critical care unit.

Conclusions

Unintentional marijuana exposure incidence increased after legalization of recreational marijuana in Washington State at a tertiary care children's hospital. Providers should be aware of this increasing incidence. These data should be considered in the drafting of future marijuana legislation.
Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments
Authors: Hudgins Joel D. , Neuman Mark I. , Monuteaux Michael C. , Porter John , Nelson Kyle A.
Published: January 2019

Objectives

National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs.

Methods

Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care.

Results

More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17–2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07–2.02]) were independently associated with guideline-based care in a multivariate analysis.

Conclusions

Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.
Randomized Controlled Trial of Acute Illness Educational Intervention in the Pediatric Emergency Department
Authors: Lepley Bryn E. , Brousseau David C. , May Meghan F. , Morrison Andrea K.
Published: January 2019

Objectives

The aim of this study was to determine the (1) feasibility, (2) demand, (3) acceptability, and (4) usefulness of a mobile health (mHealth) application (app) compared with a written intervention distributed in a pediatric emergency department (ED).

Methods

This was a randomized controlled trial with parents of children 12 years or younger presenting to the ED for nonurgent complaints. Parents were randomized to receive a (1) low literacy pediatric health book with video, (2) pediatric mHealth app, (3) both 1 and 2, or (4) car-seat safety video and handout (control). Demand, acceptability, and usefulness were assessed at 1-, 3-, and 6-month follow-ups. Modified intention-to-treat analysis was completed for proportional data.

Results

Ninety-eight parents completed randomization (83% approached). One or more follow-up was completed for 80.6% of parents. Only 57.1% downloaded the app. Parents used the app less than the book (35.1% vs 73.0%, P < 0.01), found the app to be harder to understand (26.0% vs 94.6%, P < 0.001) and less useful (37.8% vs 70.3%, P < 0.01), and were less likely to recommend the app to others (48.7% vs 100%, P < 0.01). No parent who received both book and app would prefer to have only the app; 88.9% of parents wanted either the book or both.

Conclusions

There was low demand for an mHealth app with parents who prefer, accept, and use the book more. Giving written health information to vulnerable populations in a pediatric ED has the capacity to empower parents with knowledge to care for a child and potentially decrease future nonurgent ED use with translation into a larger study.
Surgical Emphysema in a Pediatric Tertiary Referral Center
Authors: Harrison Rebecca , Knowles Stuart , Doherty Catherine
Published: January 2019

Background

Laryngeal trauma in pediatrics is extremely rare; however, because of the smaller pediatric larynx, it can have catastrophic consequences. Following laryngeal trauma, surgical emphysema is a relatively common presentation. In pediatrics, it can be a life-threatening condition. Here we describe 2 cases of laryngeal trauma resulting in extensive surgical emphysema.

Cases

The first case described involves bilateral pneumothoraces, airway compromise, and respiratory arrest and was managed with bilateral chest drains, intubation, and tracheostomy. The second case resulted in widespread surgical emphysema in a stable patient and was managed conservatively. Both cases were monitored closely for a period of time to ensure there were no further sequelae.

Discussion

Patients with laryngeal trauma resulting in surgical emphysema have the potential to deteriorate rapidly. Furthermore, surgical emphysema degrades the quality of ultrasound images, which may delay the diagnosis. If there are any concerns about the safety of the airway, then it should be secured definitively with either endotracheal intubation or emergency tracheostomy depending on clinical judgment. It is acceptable to monitor patients closely in a high-dependency unit setting if they are stable and do not show any evidence of laryngeal edema.

Conclusions

We present 2 cases of laryngeal trauma that were dealt with effectively so that both patients made a full recovery. It is important to act quickly to secure the airway if there are any concerns about its patency. Stable patients with no evidence of laryngeal edema can be managed conservatively. Close monitoring is essential to prevent any potential airway compromise.
Whole-Body Staging of Metastatic Atypical Meningioma Using 68Ga-DOTATATE PET/CT
Authors: Unterrainer Marcus , Ilhan Harun , Vettermann Franziska , Cyran Clemens C. , Tonn Joerg C. , Niyazi Maximilian , Bartenstein Peter , Albert Nathalie L.
Published: January 2019

A 43-year-old woman with suspected recurrence of atypical meningioma World Health Organization grade II presented extensive intracranial lesions with high 68Ga-DOTATATE uptake. Moreover, numerous 68Ga-DOTATATE–positive bone, lung, and liver lesions were seen. For final diagnosis, biopsies taken from a lung lesion revealed distant metastases of the atypical meningioma. This case underlines the high diagnostic power of 68Ga-DOTATATE PET/CT for the staging of meningioma even beyond cerebral or spinal lesions; in case of distant lesions in patients with known meningioma, differential diagnosis should also contain metastases despite their rare occurrence. Moreover, this case emphasizes radioligand therapy especially in metastatic meningioma.
Atypical Presentation of T-Cell Large Granular Lymphocytic Leukemia Mimicking Pleural Malignancy on 18F-FDG PET/CT
Authors: Senthil Raja , Visakh R. Arun , Pratap Thara , Mahadevan Pushpa , Gangadharan V P
Published: January 2019

T-cell large granular lymphocytic leukemia is a rare form of leukemia, caused by clonal proliferation of cytotoxic T-cells, characterized by modest lymphocytosis and cytopenias of other lineage with hepatosplenomegaly and relatively rare lymph nodal involvement. Involvement of other organs is extremely rare. It is predominantly an indolent disease and most of patients remain asymptomatic for a long period. We present a rare case of aggressive form (CD56 positive) of large granular lymphocytic leukemia with atypical presentations mimicking pleural malignancy on 18F-FDG PET/CT.
Splenic Hemangioma as a Potential Pitfall on PSMA-Targeted 18F-DCFPyL PET/CT
Authors: Chaussé Guillaume , Laufer Jerome , Abikhzer Gad , Probst Stephan
Published: January 2019

A 69-year-old man with biochemical recurrence after radical prostatectomy underwent 6 months of androgen deprivation therapy. Upon discontinuation of androgen deprivation therapy, serum prostate-specific antigen rose again to 0.69 ng/mL, and 18F-DCFPyL PET/CT was performed to identify the site of recurrence. However, only an intense focus of uptake in the spleen could be found. Subsequent contrast-enhanced MRI findings were pathognomonic for splenic hemangioma.
A Nodular Lesion of the Foot Detected by 18F-FDG PET/CT in Mycosis Fungoides
Authors: Fujita Yasuyuki , Natsuga Ken , Manabe Osamu , Hirata Kenji , Shimizu Hiroshi
Published: January 2019

A 34-year-old Japanese woman presented with widespread scaly erythema that had enlarged over 2 years. A skin biopsy revealed the diagnosis of mycosis fungoides (patch stage, T1b N0 M0 B0), a most frequent cutaneous T-cell lymphoma. 18F-FDG PET/CT scan unexpectedly showed intense uptake on the left sole, which suggested a tumorous mycosis fungoides lesion (SUVmax = 6.2). Careful examination revealed the mass to be a typical plantar wart of 2 cm in diameter that the patient had not recognized. With repeated cryotherapy, the wart disappeared in 6 months, and follow-up 18F-FDG PET/CT showed no abnormal uptake on the left sole.
Parapharyngeal Ganglioneuroma Detected by 18F-FDG PET/CT in a Patient With Hodgkin Lymphoma
Authors: Yi Wan-Ling , Chen Tzu-Pai , Chiu Nan-Tsing , Liu Chiang-Shin , Lin Yu-Hsuan
Published: January 2019

A 38-year-old woman with anterior mediastinal Hodgkin lymphoma underwent 18F-FDG PET/CT, revealing abnormal uptake at the left retrostyloid parapharyngeal space. After chemotherapy, follow-up PET/CT showed regression of previously avid lesions but not the left retropharyngeal mass. Subsequent MRI revealed findings suggestive of neurogenic tumor. Transoral biopsy revealed ganglioneuroma, which is uncommon in the parapharyngeal space, although usually of benign nature. This case therefore highlights the importance of PET/CT in both initial diagnostic screening for tumor development and posttreatment evaluation of ambiguous lesions.
Anaplastic Oligodendroglioma Found as an Incidental Photopenic Lesion on 18F-FP-CIT PET/CT Image
Authors: An Young-Sil , Yoon Joon-Kee , Lee Su Jin , Jeong Eugene , Kim Il-hyun
Published: January 2019

18F-FP-CIT PET is a useful modality for imaging dopamine transporters. It has excellent resolution compared with 123I-beta-CIT SPECT and is widely used clinically for the evaluation of Parkinson disease. In general, the main focus of 18F-FP-CIT PET imaging is the basal ganglia, and it is important to observe whether 18F-FP-CIT uptake is normal in the putamen and caudate nuclei. However, abnormal findings may be seen in other brain regions besides the basal ganglia. Here, we present a case of anaplastic oligodendroglioma, a high-grade tumor, which was found as an incidental photopenic lesion on 18F-FP-CIT PET/CT.
The Association Among Quantitative Contrast-Enhanced Ultrasonography Features, Thyroid Imaging Reporting and Data System and BRAF V600E Mutation Status in Patients With Papillary Thyroid Microcarcinoma
Authors: Chen Luzeng , Chen Lei , Liu Jinghua , Nong Lin , Zhang Hong
Published: January 2019

Objective

The objective of this study was to analyze the association among the thyroid imaging reporting and data system (TI-RADS), quantitative parameters obtained from contrast-enhanced ultrasonography (CEUS), and BRAF V600E mutation status in patients with papillary thyroid microcarcinoma.

Patients

From November 2016 to June 2017, 54 patients who had undergone thyroid CEUS and BRAF V600E mutation analysis for papillary thyroid microcarcinoma were enrolled in our study. The patients were divided into 2 groups based on mutation status. Sex, age, pathology results, TI-RADS score, and quantitative CEUS parameters were compared between the 2 groups.

Results

There were 43 patients in the BRAF V600E–positive group and 11 patients in the BRAF V600E–negative group. Age and TI-RADS score were not associated with mutation status. The arrival time (17.2 ± 5.1 seconds) and time to peak enhancement (TTP) (26.5 ± 7.4 seconds) of the lesions in the BRAF V600E–positive group were longer than the arrival time (13.2 ± 3.1 seconds) and TTP (21.1 ± 4.4 seconds) of the lesions in the BRAF V600E–negative group. Basic intensity and peak intensity were not associated with mutation status.

Conclusions

There is an association between the arrival time and TTP of CEUS and BRAF V600E mutation status. They may help infer the BRAF V600E mutation status in papillary thyroid carcinoma patients before invasive procedures.
Adenoviral βARKct Cardiac Gene Transfer Ameliorates Postresuscitation Myocardial Injury in a Porcine Model of Cardiac Arrest
Authors: Shang Deya , Zhu Fangfang , Tan Qi , Hu Bo , Liu Dongxing , Cong Mulin , Song Jiantao , Li Tao , Ji Xianfei
Published: January 2019

Objective:

The aim of the study was to determine whether the inhibition of the G-protein-coupled receptor kinase 2 by adenoviral βARKct cardiac gene transfer can ameliorate postresuscitation myocardial injury in pigs with cardiac arrest (CA) and explore the mechanism of myocardial protection.

Methods:

Male landrace domestic pigs were randomized into the sham group (anesthetized and instrumented, but ventricular fibrillation was not induced) (n = 4), control group (ventricular fibrillation 8 min, n = 8), and βARKct group (ventricular fibrillation 8 min, n = 8). Hemodynamic parameters were monitored continuously. Blood samples were collected at baseline, 30 min, 2 h, 4 h, and 6 h after the return of spontaneous circulation (ROSC). Left ventricular ejection fraction was assessed by echocardiography at baseline and 6 h after ROSC. These animals were euthanized, and the cardiac tissue was removed for analysis at 6 h after ROSC.

Results:

Compared with those in the sham group, left ventricular +dp/dtmax, −dp/dtmax, cardiac output (CO), and ejection fraction (EF) in the control group and the βARKct group were significantly decreased at 6 h after the restoration of spontaneous circulation. However, the βARKct treatment produced better left ventricular +dp/dtmax, −dp/dtmax, CO, and EF after ROSC. The βARKct treatment also produced lower serum cardiac troponin I, CK-MB, and lactate after ROSC. Furthermore, the adenoviral βARKct gene transfer significantly increased β1 adrenergic receptors, SERCA2a, RyR2 levels, and decreased GRK2 levels compared to control.

Conclusions:

The inhibition of GRK2 by adenoviral βARKct cardiac gene transfer can ameliorate postresuscitation myocardial injury through beneficial effects on restoring the sarcoplasmic reticulum Ca2+-handling proteins expression and upregulating the β1-adrenergic receptor level after cardiac arrest.
A Preventive Program for Work-related Musculoskeletal Disorders Among Surgeons
Authors: Giagio Silvia , Volpe Giovanni , Pillastrini Paolo , Gasparre Giuseppe , Frizziero Antonio , Squizzato Francesco
Published: January 2019

Objective:

To evaluate the effectiveness of a program to reduce work-related musculoskeletal disorders (WRMSD) among surgeons.

Background:

Surgeons are at high risk of WRMSD due to many physical and psychosocial factors.

Methods:

This study is a multicenter randomized clinical trial (UMIN000028557) conducted from January to August 2015. Following cluster randomization by surgical division, surgeons were allocated to 2 groups. The NPP group (No Preventive Program) underwent no intervention, while the PP group (Preventive Program) followed ergonomic principles in the operating room and specific physical exercises supervised by a physical therapist. A multiple logistic regression was performed to identify baseline WRMSD risk factors. WRMSD assessment was based on 1 ad hoc and 3 validated questionnaires: Nordic Musculoskeletal Questionnaire (NMQ), Numerical Rating Scale (NRS), and Short Form 36 Health Survey (SF-36). Follow-up was planned after 3 and 6 months.

Results:

One hundred forty-one surgeons matched the inclusion criteria and were randomized in the PP (n = 65) and NPP (n = 76) groups. At the initial analysis, physical activity was the only modifiable independent risk factor for WRMSD (OR, 2.44; P = 0.05). The PP group showed a significant improvement in the item “General Health” (GH) regarding quality of life at 3 (NPP: 70.5 ± 15.2 vs PP: 75.9 ± 14.1; P = 0.04) and 6 months (70.6 ± 13.4 vs 75.3 ± 13.0; P = 0.04). The PP group had a significant reduction of low back pain (66.2% vs 50.0%; P = 0.04) and analgesic consumption (30.9% vs 15.5%; P = 0.03) after 6 months.

Conclusions:

This study demonstrated the effectiveness of a global program based on the application of ergonomics in the operating room and specific physical exercises.