bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of donor sodium levels on clinical outcomes in liver transplant recipients: a systematic review
Authors: Basmaji John , Hornby Laura , Rochwerg Bram , Luke Patrick , Ball Ian M
Published: August 2020

We performed a systematic review of the literature to examine the effects of donor sodium levels on liver graft function and recipient survival, as well as to identify the optimal serum sodium target in donors. We searched MEDLINE, Cochrane, and trial registries from 1946 to May 2019 for studies that evaluated the effect of serum sodium levels in neurologically deceased liver donors on transplant outcomes. We used a two-step review process with four independent reviewers to identify relevant articles based on inclusion/exclusion criteria. We summarize the results narratively, assess the risk of bias, and apply the Grading of Recommendations Assessment, Development, and Evaluation methods to evaluate the certainty in the evidence. We included 25 cohort studies were in our final analysis (total n = 19 389). Twenty-two reported on graft function and survival. Summary data suggest an association between donor serum sodium and recipient liver graft dysfunction, with very low certainty in evidence due to serious concerns with risk of bias, inconsistency, indirectness, and imprecision. Seven studies reported on recipient mortality, with results suggesting no association between donor sodium and recipient survival. The certainty in evidence for this outcome was also very low due to serious concerns with imprecision, indirectness, and risk of bias. Donor sodium dysregulation is associated with liver graft dysfunction, but not recipient mortality. Further research is needed to determine the effects of correcting donor sodium levels on transplant outcomes, quantify the dose-response curve, and identify liver recipients most vulnerable to sodium dysregulation.
Endoscopic remission can be predicted by golimumab concentrations in patients with ulcerative colitis treated with the changed label
Authors: Stefanovic Sebastian , Detrez Iris , Compernolle Griet , Brouwers Els , Sever Nejc , Stabuc Borut , Smrekar Natasa , Kurent Tina , Novak Gregor , Kozelj Matic , Ferrante Marc , Gils Ann , Drobne David
Published: August 2020

Background

In 2018, the European Medicines Agency (EMA) replaced a fixed 50 mg every 4-week maintenance regimen of golimumab for ulcerative colitis (UC) patients weighing <80 kg with new, flexible dosing that allows reactive dose optimization to 100 mg if clinically needed. We analyzed the endoscopic remission rates and pharmacokinetics of this new dosing regimen in real-life settings.

Methods

We prospectively recruited 30 consecutive (17 with body weight <80 kg) patients with UC who received golimumab with the new EMA label. The primary endpoint was endoscopic remission (Mayo ≤1) assessed by centrally-read endoscopy at week 14 and year 1. Golimumab concentrations, measured at nine prespecified timepoints, were correlated with endoscopic remission and identified cut-offs.

Results

Endoscopic remission was achieved in 15/30 (50%) and 10/30 (33%) patients at week 14 and year 1, respectively. Reactive dose optimization to 100 mg maintenance was needed in 13/17 (76%) patients. Golimumab concentrations at week 6 predicted week 14 and year 1 endoscopic remission. Week 6 concentrations >10.7 µg/ml were a strong predictor for achievement and maintenance of endoscopic remission during the first year of treatment, while concentrations <5.1 µg/ml identified the opposite.

Conclusion

One-third of the patients reached and maintained endoscopic remission during the first year of golimumab treatment, but the need for dose optimization to 100 mg every 4 weeks of maintenance was high in patients weighing <80 kg. Golimumab concentrations <5.1 µg/ml at week 6 identified patients who are unlikely to reach and maintain endoscopic remission with the new, flexible EMA label.
Mapping the relationships between inflammatory bowel disease and comorbid diagnoses to identify disease associations
Authors: Waljee Akbar K. , Noureldin Mohamed , Berinstein Jeffrey A. , Cohen-Mekelburg Shirley A. , Wallace Beth I. , Cushing Kelly C. , Hanauer David A. , Keeney-Bonthrone Toby P. , Nallamothu Brahmajee , Higgins Peter D.R.
Published: August 2020

Background

Massive amounts of patient data are captured daily in electronic medical records (EMR). Utilizing the power of such large data may help identify disease associations and generate hypotheses that can lead to a better understanding of disease associations and mechanisms. We aimed to comprehensively identify and validate associations between inflammatory bowel disease (IBD) and concurrent comorbid diagnoses.

Methods

We performed a cross-sectional study using EMR data collected between 1986 and 2009 at a large tertiary referral center to identify associations with a diagnosis of IBD. The resulting associations were externally validated using the Truven MarketScan database, a large nationwide dataset of private insurance claims.

Results

A total of 6225 IBD patients and 31 125 non-IBD controls identified using EMR data were used to abstract 41 comorbid diagnoses associated with an IBD diagnosis. The strongest associations included Clostridiodes difficile infection, pyoderma gangrenosum, parametritis, pernicious anemia, erythema nodosum, and cytomegalovirus infection. Two IBD association clusters were found, including diagnoses of nerve conduction abnormalities and nonspecific inflammatory conditions of organs outside the gut. These associations were validated in a national cohort of 80 907 patients with IBD and 404 535 age- and sex-matched controls.

Conclusion

We leveraged a big data approach to identify several associations between IBD and concurrent comorbid diagnoses. EMR and big data provide the opportunity to explore disease associations with large sample sizes. Further studies are warranted to refine the characterization of these associations and evaluate their usefulness for increasing our understanding of disease associations and mechanisms.
Individualized surveillance of chronic hepatitis B patients according to hepatocellular carcinoma risk based on PAGE-B scores
Authors: Kim Ji Hyun , Kang Seong Hee , Lee Minjong , Choi Hoon Sung , Jun Baek Gyu , Kim Tae Suk , Choi Dae Hee , Suk Ki Tae , Kim Moon Young , Kim Young Don , Cheon Gab Jin , Baik Soon Koo , Kim Dong Joon
Published: August 2020

Background and aims

Current guidelines for chronic hepatitis B (CHB) patients are to undergo surveillance for hepatocellular carcinoma (HCC) with 6-month ultrasonography. We aimed to compare detection rates of very-early-stage HCC in two groups: group A, undergoing 6-month ultrasonography versus group B, undergoing 6-month ultrasonography alternating with dynamic computed tomography (CT).

Methods

This retrospective study assessed 2151 CHB patients under entecavir/tenofovir therapy from 2007 to 2016. Detection rates of very-early-stage HCC were compared between groups A/B at intermediate/high risk based on platelets, age, gender-hepatitis B scores. The primary endpoint was the proportion of patients in each group with very-early-stage HCC. Cox proportional hazards model was used to assess the effect of surveillance modalities to detect very-early-stage HCC.

Results

Five-year cumulative HCC incidence rates in group A were 15.0% not significantly different from 18.2% in group B at high risk (P = 0.17). Detection rates of very-early-stage HCC were significantly higher in group B than in group A (P < 0.001), and surveillance using CT alternating with ultrasonography was significantly associated with detection of very-early-stage HCC (hazard ratio 3.89, P < 0.001). Among intermediate-risk patients, difference between detection rates of very-early-stage HCC in groups A and B was not significant (P = 0.30), and surveillance using CT alternating with ultrasonography was not significantly associated with detection of very-early-stage HCC (hazard ratio 1.61, P = 0.23).

Conclusion

In high-risk CHB patients, surveillance using CT alternating with ultrasonography led to higher detection rates of very-early-stage HCC compared to surveillance using ultrasonography.
IL-10-1082G>A polymorphism, use of opioids and age affect the course of acute pancreatitis
Authors: Matic Sanja , Radosavljevic Ivan , Jankovic Slobodan , Natasa Djordjevic
Published: August 2020

Purpose

We aimed to determine the association of two of the most important functional polymorphisms of IL-8 and IL-10 with the clinical course and outcome of acute pancreatitis.

Method

Ninety-three patients with acute pancreatitis were genotyped for IL-8-251T>A and IL-10-1082G>A using PCR-RFLP. The severity of the disease was determined based on the Atlanta Classification system.

Results

In patients treated with opioids, the odds for severe form of acute pancreatitis, its complications, and death were increased. Advanced age was associated with higher odds of organ/multiple organ failure and other systemic complications. Multivariate logistic regression analyses confirmed the observed effect of age and use of opioids, and revealed higher odds for the development of severe form of acute pancreatitis [P = 0.017, odds ratio (OR): 4.324, 95% confidence interval (CI): 1.305–14.323], its complications in general (P = 0.011, OR: 4.936, 95% CI: 1.442–16.897), pancreatic necrosis (P = 0.032, OR: 3.922, 95% CI: 1.122–13.707) and systemic inflammatory response syndrome (P = 0.037, OR: 3.838, 95% CI: 1.085–13.583) in the absence of IL-10-1082G>A variant allele. The effect of IL-8 -251T>A on acute pancreatitis severity or mortality was not detected.

Conclusion

Our study suggests the IL-10 -1082A allele as a protective factor in acute pancreatitis. Opioid analgesics treatment in acute pancreatitis is associated with severity, complications and mortality, while advanced age increases the risk of systemic complications.
Increased liver stiffness by transient elastography and acoustic radiation force impulse imaging in patients with extrahepatic cholestasis
Authors: Darweesh Samar K. , Zayed Naglaa , Atef Mira , Ramzy Eman , Yousry Ayman , Musa Sherief
Published: August 2020

Background

Transient elastography and acoustic radiation force impulse (ARFI) imaging are noninvasive tools for liver stiffness measurement (LSM), which may be influenced by cholestasis.

Aim

The aim of the study was to evaluate the performance of transient elastography and ARFI in extrahepatic cholestasis and correlate changes in LSM with biochemical activity.

Materials and methods

A total of 38 patients with extrahepatic cholestasis prospectively underwent transient elastography and ARFI. Changes in LSM by transient elastography/ARFI were evaluated after 1 week of ERCP and correlated with biochemical parameters. The optimal ARFI cutoffs according to stages of clinical interest were analyzed.

Results

Biliary obstruction was calcular in 21 (55.3%) and noncalcular in 17 (44.7%) (benign n = 15, malignant n = 2). After 1 week, adequate biliary drainage reduced total bilirubin from 7.7 to 2.2 mg/dL (P < 0.001) which significantly correlated with reduction of LSM by transient elastography from 12.38 ± 6.68 kPa to 8.08 ± 3.21 kPa (P < 0.001), and by ARFI from 1.73 ± 0.51 m/s to 1.56 ± 0.70 m/s (P = 0.014). The LSM percentage change showed a decrease (nonsignificant, P = 0.843) by 25.83% using transient elastography and a significant decrease (P < 0.001) by 18.42% using ARFI in the improved patients. At initial visit, transient elastography positively correlated with ARFI, bilirubin and platelets, also, transient elastography had a positive correlation with ARFI, bilirubin, alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGT) in follow-up visit. LSM by ARFI (visit 1) negatively correlated with ALT, while in (visit 2), ARFI positively correlated with bilirubin, ALP, GGT and negatively correlated with albumin.

Conclusion

The increased LSM in patients with extrahepatic cholestasis is reduced after adequate biliary drainage, implying that increased values are not solely due to liver fibrosis, but due to biliary congestion leading temporarily to increased elasticity.
The utility of two-dimensional real-time shear wave elastography for assessing liver fibrosis in patients with chronic hepatitis C virus infection
Authors: Numao Hiroshi , Shimaya Koji , Kakuta Akihisa , Shibutani Koichi , Igarashi Syohei , Hasui Keisuke , Hanabata Norihiro , Kanazawa Kosuke , Munakata Masaki
Published: August 2020

Objective

Two-dimensional shear wave elastography (2D-SWE) is a new ultrasound-based elastography method to evaluate liver fibrosis in the daily practice. However, the utility of 2D-SWE among the other liver fibrosis markers is unclear.

Methods

We enrolled 141 consecutive patients with hepatitis C virus infection, 66 men and 75 women (median age, 67 years), who underwent liver biopsy and 2D-SWE (LOGIQ E9, GE Healthcare, Wauwatosa, WI, USA). We compared the diagnostic accuracy of the 2D-SWE with those of magnetic resonance elastography (MRE; MR-Touch, GE Healthcare, Milwaukee, WI, USA), Mac-2 binding protein glycosylation isomer (M2BPGi), fibrosis-4 index (FIB-4) and platelet counts (PLT), using the histologic METAVIR scoring as the reference standard.

Results

The areas under the receiver operating characteristics curves (AUROCs) of 2D-SWE, MRE, M2BPGi, FIB-4 and PLT for ≥F2, ≥F3 and F4 were 0.86, 0.88, 0.79, 0.81 and 0.77; 0.92, 0.93, 0.86, 0.87 and 0.83; and 0.91, 0.97, 0.85, 0.85 and 0.82, respectively. For diagnosing ≥F2 and ≥F3, the AUROCs of 2D-SWE and those of MRE showed no significant differences, and both 2D-SWE and MRE showed significantly higher AUROCs than the other markers. For diagnosing F4, the AUROC of MRE was significantly higher than those of other fibrosis markers.

Conclusion

2D-SWE has an excellent diagnostic accuracy equivalent to that of MRE for assessing significant (≥F2) and severe (≥F3) fibrosis. MRE demonstrated a higher AUROC than 2D-SWE, but this last one has advantages such as lower cost, fewer contraindications and greater ease of performance than MRE.
A randomized, double-blind, placebo-controlled pilot study to evaluate the efficacy and tolerability of a novel oral bioadhesive formulation for the treatment of nonerosive reflux disease-related symptoms
Authors: Ribaldone Davide Giuseppe , Rajesh Pendlimari , Chandradhara Divya , Astegiano Marco , Pellicano Rinaldo
Published: August 2020

Objective

The use of antisecretory drugs can provide symptomatic relief in 70–80% of patients suffering from gastro-oesophageal reflux disease (GORD), although this benefit is reduced by 20–30% in the case of nonerosive reflux disease (NERD). The current study evaluates the efficacy and safety of a patented oral formulation (liquid sachets containing hyaluronic acid, a mixture of amino acids including proline, hydroxyl-proline and glutamine, and rice extract dispersed in a bioadhesive polymer matrix) for relieving the symptoms of NERD.

Methods

A single-centre, randomized, double-blind, parallel group, placebo-controlled clinical study was performed. Patients who experienced at least three episodes of moderate-severity heartburn during the 7-day run-in period were included and treated with three liquid sachets per day for 14 days. The primary objective was to evaluate the proportion of patients with at least a three-point reduction in the total symptom score (TSS).

Results

Overall, 20 patients were randomized to receive the investigational product and 20 to receive the placebo. At the end of treatment, a three-point reduction in the TSS was achieved by 95% of patients treated with the investigational product and by 20% of patients treated with placebo (P < 0.0001). No adverse events were reported.

Conclusion

The investigational product showed a statistically significant superiority to the placebo in relieving common symptoms in patients with NERD. Future studies will be aimed at clarifying the hypothesis that this symptomatic benefit is related to the strengthening of the oesophageal barrier against the damage induced by gastric contents.
A state-of-the-art comprehensive review summarizing the emerging data on endoscopic ultrasound-guided liver diseases management
Authors: Sbeit Wisam , Kadah Anas , Mahamid Mahmud , Mari Amir , Khoury Tawfik
Published: August 2020

Liver diseases are among the most common diseases worldwide accounting for substantial morbidity and mortality. Most liver diseases necessitate radiological evaluation or accurate diagnosis and recently for management as well. In the last decade, the application of therapeutic endoscopic ultrasound (EUS) procedure has been increasingly utilized for the management of various liver diseases. In this comprehensive narrative review article, we provide systematic overview on EUS-guided therapeutic interventions in various liver diseases summarizing most updated data regarding technical success, outcomes and safety profiles. Overall, 35 articles have reported on the use of EUS in the treatment of liver diseases with excellent technical success, favorable radiological response and high safety profiles for EUS-guided treatment of solid and cystic liver lesion and for EUS-guided angiotherapy for gastric varices, except for EUS-guided cyanoacrylate glue injection which was associated with life-threatening fatal systemic embolization adverse events. This suggests that EUS-guided intervention is a new promising therapeutic intervention for the treatment of various liver diseases with durable effect and a limited potential for adverse events.
Artificial intelligence can increase the detection rate of colorectal polyps and adenomas: a systematic review and meta-analysis
Authors: Li Jianglei , Lu Jiaxi , Yan Jin , Tan Yuyong , Liu Deliang
Published: August 2020

Colonoscopy is an important method to diagnose polyps, especially adenomatous polyps. However, the rate of missed diagnoses is relatively high. In this study, we aimed to determine whether artificial intelligence (AI) improves the polyp detection rate (PDR) and adenoma detection rate (ADR) with colonoscopy. We performed a systematic search in PubMed, Cochrane Library, Embase, and Web of Science databases; the search included entries in the databases up to and including 29 February 2020. Five articles that involved a total of 4311 patients fulfilled the selection criteria. The results of these studies showed that both PDR and ADR increased with the assistance of AI compared with those in control groups {pooled odds ratio (OR) = 1.91 [95% confidence interval (CI) 1.68–2.16] and 1.75 (95% CI 1.52–2.01), respectively}. Good bowel preparation reduced the impact of AI, but significant differences were still apparent in PDR and ADR [pooled OR = 1.69 (95% CI 1.32–2.16) and 1.36 (95% CI 1.04–1.78), respectively]. The characteristics of polyps and adenomas also influenced the results. The average number of polyps and adenomas detected varied significantly by location, and small polyps and adenomas were more likely to be missed. However, the effect of the morphology of polyps and AI-assisted detection needs further studies. In conclusion, AI increases the detection rates of polyps and adenomas in colonoscopy. Without AI assistance, detection rates can be improved with better bowel preparation and training for small polyp and adenoma detection.
Association of out of hospital paediatric early warning score with need for hospital admission in a Scottish emergency ambulance population
Authors: Corfield Alasdair R. , Booth Katherine L. , Clerihew Linda , Staines Harry , Stewart Elaine , Rooney Kevin D.
Published: August 2020

Objective

Physiological derangement, as measured by paediatric early warning score (PEWS) is used to identify children with critical illness at an early point to identify and intervene in children at risk. PEWS has shown some utility as a track and trigger system in hospital and also as a predictor of adverse outcome both in and out of hospital. This study examines the relationship between prehospital observations, aggregated into an eight-point PEWS (Scotland), and hospital admission.

Methods

A retrospective analysis of all patients aged less than 16 transported to hospital by the Scottish Ambulance Service between 2011 and 2015. Data were matched to outcome data regarding hospital admission or discharge and length of stay.

Results

Full data were available for 21 202 paediatric patients, of whom 6340 (29.9%) were admitted to hospital. Prehospital PEWS Scotland was associated with an odds ratio for admission of 1.189 [95% confidence interval (CI): 1.176–1.202; P < 0.001]. The area under receiver operating curve of 0.617 (95% CI: 0.608–0.625; P < 0.001) suggests poorly predictive ability for hospital admission. There was no association between prehospital PEWS Scotland and length of hospital stay.

Conclusion

These data show that a single prehospital PEWS Scotland was a poor predictor of hospital admission for unselected patients in a prehospital population. The decision to admit a child to hospital is not solely based on the physiological derangement of vital signs, and hence physiological-based scoring systems such as PEWS Scotland cannot be used as the sole criteria for hospital admission, from an undifferentiated prehospital population.
Sexuality After Treatment of Diffuse Large B-cell Lymphoma: Patients' Experiences and Psychometric Testing of the Sexual Adjustment Questionnaire-Swedish Version II
Authors: Olsson Cecilia , Josse Eklund Anna , Larsson Maria , Ringnér Anders
Published: August 2020

Background

Sexuality is an important part of health-related quality of life. To ensure adequate supportive interventions, valid and reliable instruments specific to sexual changes and adjustments after cancer treatment are needed.

Objectives

The aims of this study were to test the psychometric properties of the Sexual Adjustment Questionnaire-Swedish version II (SAQ-SII) in patients treated for diffuse large B-cell lymphoma and to describe and explore patients' experiences of sexuality after treatment.

Methods

A cross-sectional study was conducted in 2019, using SAQ-SII and data from the National Quality Registry for Leukemia–subregistry for Lymphoma, which included 257 patients (25% response rate). An exploratory factor analysis was performed for psychometric evaluation. Internal consistency was assessed by Cronbach's α. Independent t tests, analysis of variance, and multiple regression were used to describe patients' experiences of sexuality.

Results

The exploratory factor analysis resulted in a 4-factor structure, explaining 65.7% of the total scale variance (SAQ-SII). The Cronbach's α for the SAQ-SII was 0.88 and varied between 0.70 and 0.89 across subscales. Sexuality was affected in various ways and extent. Sexual Interest was most affected, whereas Sexual Function was least affected. Being male, of younger age, without comorbidities, and in a relationship were associated to a higher Sexual Interest.

Conclusions

The SAQ-SII is a valid and reliable instrument to measure changes and adjustments in sexuality in patients treated for lymphoma.

Implications for Practice

Assessments of sexuality in a broad sense should be an integrated part of cancer care to ensure timely interventions for those who need and want support.
From Probands to Relatives
Authors: Seven Memnun , Shah Lisa L. , Yazici Hülya , Daack-Hirsch Sandra
Published: August 2020

Background

The genetic risk communication from proband to relatives varies from family to family, and patients often need support with the communication of genetic test results and making decisions to manage hereditary cancer risks.

Objective

The aim of this study was to characterize the communication of BRCA1 or BRCA2 (BRCA1/2) genetic risk from proband to first-degree relatives (FDRs) using a social network framework.

Methods

We characterized network and nonnetwork factors to explore their association with which FDRs were told about the genetic risk and whether or not relatives underwent genetic testing. Ninety-two female probands with hereditary breast and ovarian cancer who have confirmed BRCA1/2 mutations participated in the study. Communication of hereditary breast and ovarian cancer risk was assessed between 92 probands and their 417 FDRs.

Results

Of 92 probands, 94.5% (n = 87) communicated their genetic test result to at least one of their FDRs. Of FDRs older than 18 years, 19.9% (n = 72) have genetic testing. Emotional closeness, educational level of the proband, and relative's age were significantly associated with communicating test results with FDRs.

Conclusion

Communication of genetic risk with the FDRs after having a BRCA1/2 gene-mutation–positive test result was high in this group of cancer patients. However, the rate of genetic testing among FDRs was low.

Implications for Practice

Probands' educational level and age of relatives for cascade genetic screening should be considered during counseling. Interventions to support women with BRCA1/2 mutations during the communication process and their family members' engagement in testing and risk-reducing strategies are needed.
Exploring Perceptions of Shift Length: A State-Based Survey of Registered Nurses
Authors: Haller Teresa , Quatrara Beth , Miller-Davis Claiborne , Noguera Ashley , Pannone Aaron , Keim-Malpass Jessica , Guterbock Thomas M. , Letzkus Lisa
Published: August 2020

OBJECTIVE

The aim of this study was to explore clinical nurses' perspectives of shift length.

BACKGROUND

Discussions about scheduling practices, work rotations, and shift length are pervasive among nurses and nursing leadership. However, the science surrounding nurse perceptions of longer shifts is limited.

METHODS

A survey instrument was developed and distributed to nurses engaged in the state's professional association.

RESULTS

Data from 190 clinical nurses were included. When working a 40-hour work week, 76.3% reported a preference for 10-hour shifts, whereas 83.5% preferred a 12-hour shift during a 36-hour week. Those who chose longer shifts perceived improved work life balance and better patient care. Those identifying 8-hour shifts also pointed to work life balance as benefit.

CONCLUSIONS

The results capture the voice of the nurse regarding shift length. The preference for the 10-hour shift within the 40-hour work week is novel. These results may assist with efforts to initiate change, improve the work environment and enhance home life.
Developing Leadership Competencies in Midlevel Nurse Leaders
Authors: Nghe Megan , Hart Jennifer , Ferry Susan , Hutchins Larissa , Lebet Ruth
Published: August 2020

A pediatric teaching hospital developed a comprehensive leadership training program for midlevel nurse leaders with varying levels of management knowledge and experience. Content was based on American Organization for Nursing Leadership nurse manager competencies and data from a comprehensive needs assessment. Learners identified differentiating between leadership and management, influencing behavior, managing change, and communication as areas of increased confidence. This program is applicable to any hospital with multiple midlevel nurse leaders new to the role.
A Case of Crossbow Homicide With Review of Crossbow Injuries and Manner of Death Considerations
Authors: Tamburro Lo , Brown Theodore , Bauler Laura D.
Published: August 2020

Crossbow fatalities are a rare occurrence, but crossbow use is on the rise. The manner of death in crossbow fatalities is overwhelmingly opined accident or suicide, not homicide. Despite their increasing use and reports of at least 14 crossbow-related homicides in the media for the last 5 years, crossbow homicides are rarely reported in the medical literature; only 10 articles that discussed 20 crossbow homicides were identified in the PubMed database. Here, we describe a case of a 20-year-old man who was found dead in his driveway after being shot in the abdomen with a crossbow by another person. The crossbow bolt had a mechanical 2-blade broadhead that transected the descending aorta and lodged in his vertebra. When completing a medicolegal death investigation and postmortem examination on suspected crossbow-related deaths, knowledge of crossbow components, its utility as a weapon, wound patterns, and how it can cause death are important. This case serves to build on the limited medical literature of crossbow homicides, educate forensic pathologists about the features of crossbow deaths, and highlight manner of death considerations.
Lost in the Clinics and Found in the Morgue
Authors: Krishnamurthy Kritika , Kochiyil Jyotsna , Tuda Claudio , Sriganeshan Vathany
Published: August 2020

In modern medicine, there is an increasing dependence on noninvasive imaging modalities, for diagnosis and management of diseases. Though there are definite advantages to this, they are at times offset by diagnostic pitfalls especially in entities with elusive clinical presentation.

Peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS) is an aggressive subtype of T-cell lymphomas that does not meet criteria for a specific subtype. Peripheral T-cell lymphoma usually has varied clinical presentations depending on the site of involvement. Vast majority of PTCL patients present with systemic disease, generalized lymphadenopathy and constitutional symptoms. Pulmonary involvement is relatively rare and is seen in approximately 10% of patients.

Here in we highlight a rare case of PTCL, masquerading as pneumonia due to extensive pulmonary involvement that went undiagnosed and was discovered at autopsy. This case of malignant lymphoma of T-cell origin involving the lung, which is very rare, highlights the continued importance of medical autopsies not only as a teaching tool but also as an important adjunct to investigative medicine in uncovering lapses that can subsequently be avoided to improve patient care and decrease mortality.
Progression of Respiratory Support Following Pediatric Extubation
Authors: Krasinkiewicz Johnny M. , Friedman Matthew L. , Slaven James E. , Tori Alvaro J. , Lutfi Riad , Abu-Sultaneh Samer
Published: August 2020

Objectives:

High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor.

Design:

Single-center retrospective cohort study.

Setting:

A 36-bed quaternary medical-surgical PICU.

Patients:

Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status.

Interventions:

None.

Measurements and Main Results:

Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation.

Conclusions:

High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.
Verifying the Versatility and Reliability of Free Lateral Arm Flap for Head and Neck Reconstruction
Authors: Kang Shin Hyuk , Jeon Sungmi , Jung Young Ho , Eun Seokchan
Published: August 2020

The lateral arm flap is an alternative to the conventional radial forearm flap and has been widely used due to advancements in flap characteristics. Especially, the fasciocutaneous flap has been widely used in head and neck reconstruction due to its versatile characteristics and surgical feasibility. This flap has successfully undergone several useful modifications based on various anatomical studies. Here, the authors aimed to verify the versatility and reliability of free lateral arm flap reconstruction of numerous head and neck defects. Twelve patients (6 men and 6 women; mean age, 66 years) with various types of lateral arm flaps from May 2017 to April 2019 were included. The anatomical reconstruction area was widely distributed across the facial subunits, tongue and oral cavity, and hypopharynx, among others. The flap varied in size from 3 × 5 cm to 17 × 7 cm, and the average pedicle length was 5.58 cm. The versatility of the lateral arm flap enabled successful coverage of various defects in all cases. Among 12 patients, the donor site outcome was rated as excellent and good by 2 and 10 patients, respectively. Three patients complained of post-operative hypoesthesia, which was subsequently resolved. The lateral arm flap is a unique and extremely versatile soft tissue free flap. Its versatility facilitates continuous modification of the flap and its application in various areas in different forms with excellent contour outcomes. The authors successfully verified the evolving methods and advantages of lateral arm flaps in the treatment of various head and neck defects.
Recurrent Syndrome of the Trephined in the Setting of Multiple Craniectomy and Cranioplasty
Authors: Kaura Arminder S. , Fahrenkopf Matthew P. , Kelpin John P. , Krebiehl Johanna R.
Published: August 2020

Decompressive craniectomy is an increasingly implemented intervention for relief of intracranial hypertension refractory to medical therapy. Despite its therapeutic benefit, a myriad of short and long-term complications may arise when the once fixed-volume cranial vault remains decompressed. The authors present a case of recurrent Syndrome of the Trephined in a patient undergoing repeated craniectomy and cranioplasty.

A 70-year old male with history significant for smoking and chronic obstructive pulmonary disease presented with frontoparietal subdural hematoma with midline shift following a ground level fall necessitating craniotomy and hematoma evacuation. Three months postoperatively, the patient developed an infection of his craniotomy bone flap necessitating craniectomy without cranioplasty. Six weeks post-craniectomy the patient began demonstrating right sided sensorimotor deficits with word finding difficulties. Alloplastic cranioplasty was performed following resolution of infection, with resolution of neurologic symptoms 6 weeks post cranioplasty. Due to recurrent cranioplasty infections, multiple alloplastic cranioplasties were performed, each with reliable re-demonstration of neurologic symptoms with craniectomy, and subsequent resolution following each cranioplasty. Final cranioplasty was successfully performed using a new alloplastic implant in combination with latissimus muscle flap, with subsequent return of neurologic function.

Decompressive craniectomy is a life-saving procedure, but carries many short- and long-term complications, including the Syndrome of the Trephined. Our case is the first published report, to our knowledge, to demonstrate recurrent Syndrome of the Trephined as a complication of craniectomy, with reliable resolution of the syndrome with restoration of the cranial vault.
Evaluation of Outcomes Related to Hearing and Tinnitus After Ossicular Chain Reconstruction
Authors: Erden Burak , Doblan Ahmet
Published: August 2020

Objective:

The aim of this study was to evaluate both audiological and tinnitus related results in patients with tinnitus undergoing ossicular chain reconstruction (OCR) for ossicular chain injury.

Methods:

Between January 2015 and January 2019, patients who underwent OCR due to ossicular chain pathology and developed tinnitus symptoms were included in the study group. Middle ear pathologies were standardized using the middle ear risk index (MERI) scoring system and the tinnitus handicap inventory (THI) was used to determine the severity of tinnitus. The surgical methods used for reconstruction were partial ossicular replacement prosthesis (PORP) or total ossicular replacement prosthesis (TORP), depending on the patient's pathology.

Results:

The study group consisted of 43 patients aged between 34 and 65 years. Mean MERI score of the patients was 6.42 ± 2.52. When assessed categorically, 18.6% of the study group was identified in the ‘mild’, 46.5% were in the ‘moderate’, and 34.5% were in the ‘severe’ MERI category. Patients in the TORP group and those who were undergoing second session OCR had higher MERI and preop THI scores. Post-operative tinnitus levels were higher in patients who had OCR in the second session and were in the severe risk group. The ABG and tinnitus scores of patients were found to improve with OCR. In patients who underwent TORP, both ABG and tinnitus scores decreased significantly. Whereas, in patients who underwent PORP, only ABG values decreased significantly. After OCR, both ABG value and tinnitus scores significantly decreased compared to pre-operative results. ABG recovery rate was 100% in the study group.

Conclusion:

It can be said that OCR positively changes both audiological parameters and tinnitus levels in ossicular chain pathologies.
Pseudo Hemifacial Microsomia With Condylar-Coronoid Collapse: New Therapeutic Approach in Growing Patients
Authors: Perrotta Stefania , Bocchino Tecla , D’Antò Vincenzo , Michelotti Ambrosina , Valletta Rosa
Published: August 2020

The purpose of this study is to describe the management of 2 dimorphic patients affected by Hemimandibular Hypoplasia with Condylar-Coronoid Collapse (HH-CCC), also called Pseudo Hemifacial Microsomia, where the orthopedic treatment gave an excellent long-term follow-up. The patients were a 7-year-old female and a 6-year-old male with a HH-CCC on the left side, an asymmetrical face with chin deviation, class II dental malocclusion and canting of the occlusal plane. An X-ray evaluation and clinical observation confirmed the unilateral mandibular deficiency and the collapse of the condyle on the coronoid process on the affected side. The treatment plan consisted of the use of an asymmetrical functional appliance with a vertical screw. The appliance was gradually activated on the vertical plane on one side by a screw incorporated on an acrylic plate. It was used for 22 hours/day, including sleep time but not during meals. This treatment improved the patient’ s facial appearance. HH-CCC showed a positive response to functional therapy.
Clinical Management of Nasal Skin Necrosis Caused by Hyaluronic Acid Filler
Authors: Vieira Marcelo Germani , Machado-Filho Daniel Augusto , Alcantara Allan Rafael , Mendonça Adriana , Kim Jun Ho , Gonzalez Cortes Arthur Rodriguez
Published: August 2020

Nose augmentation with Hyaluronic acid (HA) fillers has been considered the preferred technique for minimally invasive cosmetic procedures. Despite severe complications related to HA injection are rare, none of the existing treatment protocols has been established as standard. The aim of this report is to present an alternative approach to treat nasal skin necrosis related to HA injection. A high dose of hyaluronidase – 6000 IU was applied in the nose, for the purpose of reversing a necrotic process. The present findings suggest that a high dose of hyaluronidase could be a promising approach to treat severe nasal skin necrosis caused by HA filler.
The Shapes and Normal Dimensions of the Sella Turcica
Authors: Çullu Neşat , Yeniçeri Ibrahim Önder , Kilinç Rabia Mihriban , Güney Bünyamin , Elibol Funda Dinç
Published: August 2020

Objective:

The aim of this study was to evaluate the normal dimensions and shape of the sella turcica (ST) in the Turkish population using multidetector computed tomography.

Methods:

This single-center, retrospective study included 188 patients who met the study criteria and had paranasal multidetector computed tomography taken between January 2019 and December 2019. The patients included in the study comprised 77 females and 111 males. The whole patient group was separated into 3 age groups of 18 to 25 years (group 1), 25 to 40 years (group 2), and 40 years and over (group 3). They were also separated according to gender.

Results:

The mean length of the ST was determined as 8.52 ± 1.42 mm (min-max 4.61–12.73 mm), mean height as 7.00 ± 1.31 mm (min-max 3.00–10.51 mm), mean aperture as 6.50 ± 2.00 mm (min-max 2.24–12.51 mm), and mean width as 11.01 ± 1.50 mm (min-max 7.78–14.94 mm). No statistically significant difference was determined between the length, height, width, and aperture size values of the ST according to gender and age groups.

Conclusion:

The results of this study demonstrated no significant difference in ST dimensions according to gender or age groups. It can be considered that the shape and dimensions of the ST can be more accurately evaluated with computed tomography and classification can be more robustly applied.
Differences in Early Immunosuppressive Therapy Among Liver Retransplantation Recipients in a National Cohort
Authors: Mezochow Alyssa K. , Abt Peter L. , Bittermann Therese
Published: August 2020

Background.

There is no unified consensus as to the preferred immunosuppression (IS) strategy following liver retransplantation (reLT).

Methods.

This was a retrospective cohort study using the United Network for Organ Sharing database. Recipient, donor, and center characteristics associated with induction use and early maintenance IS regimen were described. Multivariable Cox proportional hazards analysis evaluated induction receipt as a predictor of post-reLT survival.

Results.

There were 3483 adult reLT recipients from 2002 to 2018 at 116 centers with 95.6% being performed at the same center as the initial liver transplant. Timing of reLT was associated with induction IS use and the discharge regimen (P < 0.001 for both) but not with regimens at 6- and 12-month post-reLT (P = 0.1 for both). Among late reLTs (>365 d), initial liver disease cause was a more important determinant of maintenance regimen than graft failure cause. Low-reLT volume centers used induction more often for late reLTs (41.1% versus 22.6% high volume; P = 0.002) yet were less likely to wean to calcineurin inhibitors alone in the first year (19.1% versus 38.7% high volume; P = 0.002). Accounting for recipient and donor factors, depleting induction marginally improved post-reLT mortality (adjusted hazard ratio, 0.77; 95% CI, 0.61-0.99; P = 0.08), whereas nondepleting induction had no significant effect.

Conclusions.

Although several recipient attributes inform early IS decision-making, this does not occur in a uniform manner and center factors also play a role. Further studies are needed to assess the effect of early IS on post-reLT outcomes.
The Prognostic Value of Quantitative EEG in Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke
Authors: Dickey Adam S. , Mitsias Panayiotis D. , Olango Weredeselam M. , Agan Matthew C. , Roche William P. , Thomas Julien R. , Rodrigues Gabriel M. , Frankel Michael R. , Ratcliff Jonathan J. , Nogueira Raul G. , Haussen Diogo C. , Karakis Ioannis
Published: August 2020

Purpose:

Previous work has shown that quantitative EEG measures correlate with the severity of ischemic stroke. This has not been systematically validated in patients with acute ischemic stroke who have undergone mechanical thrombectomy.

Methods:

Data were collected from 73 patients who underwent mechanical thrombectomy and had a standard head set EEG performed during their hospital admission. For each patient, the global delta-alpha ratio (DAR) and its difference between the two hemispheres were calculated. Associations between the global and interhemispheric DAR difference with the patients' National Institutes of Health Stroke and Modified Rankin Scale scores at discharge and 3 months after thrombectomy were assessed.

Results:

The interhemispheric DAR difference correlated with the National Institutes of Health Stroke scores at discharge (Spearman R = 0.41, P = 0.0008), National Institutes of Health Stroke scores at 3 months (Spearman R = 0.60, P = 0.02) and Modified Rankin Scale scores at 3 months (Spearman R = 0.27, P = 0.01). In contrast, the global DAR did not correlate significantly with any of these clinical outcomes when evaluated as continuous variables. In a multivariate logistic regression model, both the interhemispheric DAR difference (β = 0.25, P = 0.03) and the infarct volume (β = 0.02, P = 0.03) were independently predictive of good versus poor functional outcome (Modified Rankin Scale score ≤2 vs. >2) at 3 months.

Conclusions:

The quantitative EEG measure of interhemispheric slow relative to fast frequencies power asymmetry correlated with the discharge and 3-month National Institutes of Health Stroke and Modified Rankin Scale scores and provided added value to infarct volume in predicting functional outcome at 3 months. These data support the prognostic value of quantitative EEG in ischemic stroke patients who have undergone mechanical thrombectomy.
Recent attempts to change the periodic table
Authors: Scerri Eric
Published: August 2020

The article concerns various proposals that have been made with the aim of improving the currently standard 18-column periodic table. We begin with a review of 8-, 18- and 32-column formats of the periodic table. This is followed by an examination of a possible, although rather impractical, 50-column table and how it could be used to consider the changes to the periodic table that have been predicted by Pyykkö in the domain of superheavy elements. Other topics reviewed include attempts to derive the Madelung rule as well as an analysis of what this rule actually provides. Finally, the notion of an ‘optimal’ periodic table is discussed in the context of recent work by philosophers of science who have examined the nature of classifications in general, as well as the notion of natural kinds. The article takes an unapologetically philosophical approach rather than focusing on specific data concerning the elements. Nevertheless, some pragmatic issues and educational aspects of the periodic table are also examined.

This article is part of the theme issue ‘Mendeleev and the periodic table’.
The tree and the table: Darwin, Mendeleev and the meaning of ‘theory’
Authors: Reznick David
Published: August 2020

Darwin and Mendeleev revolutionized their respective disciplines by organizing diverse facts into simple, pictorial representations—a tree and a table. Each representation provides a foundation for a scientific theory for two reasons. First, a successful theory unites diverse phenomena under a single explanatory framework. Second, it does so in a way that defines paths for future inquiry that extends its reach and tests its limits. For Mendeleev, this meant creating a table that accommodated the current understanding of the elements but also contained blanks that predicted the discovery of previously unknown elements. More importantly, the structure of the table helped shape future research to define the structure of matter. For Darwin, envisioning life as a tree meant defining the rules that govern the origin of adaptations, species and shape the constantly shifting diversity of life. At the same time, his theory inspired research into the laws of inheritance and created diverse new areas of research, like behaviour, sexual selection and biogeography. The shared property of Darwin and Mendeleev's contributions was to provide a unifying rational explanation for natural phenomena.

This article is part of the theme issue ‘Mendeleev and the periodic table’.