bluuebunny/crossref_metadata_2025 huggingface dataset:
A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice
Authors: Kamnetz Sandra , Trowbridge Elizabeth , Lochner Jennifer , Koslov Steven , Pandhi Nancy
Published: September 2018

Background:

Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice.

Methods:

A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed.

Results:

After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients.

Conclusions:

The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.
Bile Collection Detected With BrIDA Scintigraphy in a Patient With Hepatocellular Carcinoma
Authors: Maccora Daria , Di Giuda Daniela , Ponziani Francesca Romana , Pompili Maurizio , Valenza Venanzio
Published: September 2018

A 47-year-old man, with a history of anabolic steroid abuse, developed hepatic adenomatosis and multifocal hepatocellular carcinoma. He underwent ultrasound and CT follow-up, showing multiple solid and fluid hepatic lesions. Consequently, hospitalization was required because of high fever (up to 39°C), weakness, and anorexia. An abdominal CT scan revealed an enlargement of one of the intrahepatic fluid collections. Biochemical and microbiological analyses of a fluid sample showed bilirubin and bile acids as well as Streptococcus cristatus and Enterobacter cloacae. Thus, the patient underwent 99mTc-trimethylbromo-iminodiacetic acid scintigraphy, demonstrating bile collection in the lesion with a flow from a bile duct.
Huge Abdominal Photopenic Area Due to Kidney Cyst Imaged by Bone Scintigraphy in a Prostate Cancer Patient
Authors: Sioka Chrissa , Gkika Evangelia , Paliouras Athanasios , Giannakis John , Fotopoulos Andreas
Published: September 2018

Bone scintigraphy is a method of choice in evaluating metastatic disease in patients with prostatic cancer. We describe the case of a 77-year-old man who was subjected to bone scan for evaluation of secondary metastatic disease due to an elevated prostatic-specific antigen level (7.2). Bone scintigraphy demonstrated a huge photopenic area in the left upper abdominal area, as a result of a huge kidney cyst (15 × 13 cm).
Incidental Orbital Neuroendocrine Metastases on 111In-OctreoScan and MRI
Authors: Chen Yin Jie , Farwell Michael D.
Published: September 2018

Neuroendocrine tumors have a propensity to metastasize, but rarely to the orbits. A 69-year-old woman with history of neuroendocrine tumor of pancreatic primary underwent routine follow-up 111In-pentetreotide (OctreoScan) imaging, with 24-hour whole-body planar images showing subtle right periorbital tracer uptake that localized to extraocular muscles on subsequent SPECT/CT. Orbital MRI further defined the location of these highly suspicious orbital metastases, which were treated with external radiation, with follow-up MRI showing decreased size of the orbital metastases. Early identification and treatment of orbital metastases is critical to help preserve vision and quality of life.
Making Augmented and Virtual Reality Work for the Plastic Surgeon
Authors: Kanevsky Jonathan , Safran Tyler , Zammit Dino , Lin Samuel J. , Gilardino Mirko
Published: September 2018

Augmented and virtual reality is an evolving technology at the forefront of medicine. It can provide physicians with hands-free, real-time access to the vast resources of the Internet and electronic medical records, allowing simultaneously recording of clinical encounters or procedures. Mixed reality platforms can be applied as a clinical tool, educational resource, or as an aid in enhancing communication in health care. This article will explore how various augmented and virtual reality platforms have enabled real-time visualization of patient information, recording of surgical cases, point-of-view photography, and intraoperative consults—all while remaining sterile in the operating room. Although this technology is of potential value to a number of different surgical and medical specialties, plastic surgery is ideally suited to lead this charge.
Depressor Reanimation After Facial Nerve Paralysis
Authors: Bassilios Habre Samer , Googe Benjamin J. , Depew James B. , Wallace Robert D. , Konofaos Petros
Published: September 2018

Facial expressions play a fundamental role in interpersonal communication and interaction; consequently, facial palsy has profound effects on the quality of life of patients. Reanimation of lower lip depressors is rarely addressed during facial reanimation but is as important as treating the eye sphincter and the lip levators. Depressors of lower lip are vital for full denture smile and the expression of facial emotions. Static and dynamic techniques are used to reanimate the lower lip depressors. Static techniques provide stationary results either by weakening the contralateral normal side to achieve symmetry using botulinum toxin injection, depressor labi inferioris myectomy and marginal mandibular nerve neurectomy, or by creating static slings and tightening procedures on the affected side. Dynamic techniques provide functional results by reanimating the affected depressor complex using nerve transfers, muscle transfers, and direct muscle neurotization. The purpose of this article is to present an overview of the literature on the applications of these techniques in lower lip reanimation. Furthermore, preoperative evaluation and indications are also discussed.
Early Experiences With the Buttonhole Modification of the Double-Incision Technique for Gender-Affirming Mastectomies
Authors: Rothenberg Kara A. , Tong Winnie M. Y. , Yokoo Karen M.
Published: September 2018

Background

Little has been published about transmasculine and nonbinary gender-affirming mastectomies, particularly for patients with skin excess who desire reliable vascularity and sensation to the nipple-areolar complex. In this case series, we describe our experiences with the “buttonhole technique.”

Methods

This was a retrospective case series of all consecutive patients who had a buttonhole mastectomy by a single surgeon. This technique maintains the nipple-areolar complex on a dermal pedicle rather than using a free nipple graft.

Results

Seventeen patients were included, with ages ranging from 21 to 49 years (median, 28 years). There were no major complications. Four patients had minor complications and/or required revision.

Conclusions

The buttonhole technique should be considered for transmasculine and nonbinary patients with skin excess who are concerned about nipple vascularity and sensation.
Prevention of Burn Wound Progression by Mesenchymal Stem Cell Transplantation
Authors: Abbas Ozan Luay , Özatik Orhan , Gönen Zeynep Burçin , Öğüt Serdal , Entok Emre , Özatik Fikriye Yasemin , Bahar Dilek , Bakir Zehra Burcu , Musmul Ahmet
Published: September 2018

Introduction

Burns are dynamic wounds that may present a progressive expansion of necrosis into the initially viable zone of stasis. Therefore, salvage of this zone is a major subject of focus in burn research. The beneficial effects of mesenchymal stem cells (MSCs) on the survival of the zone of stasis have been previously documented. However, many gaps still exist in our knowledge regarding the underlying protective mechanisms. Hence, this study was designed to evaluate the pathophysiological basis of MSCs in the prevention of burn wound progression.

Methods

Wistar rats received thermal trauma on the back according to the “comb burn” model. Animals were randomly divided into sham, control, and stem cell groups with sacrifice and analysis at 72 hours after the burn. The stasis zones were evaluated using histochemistry, immunohistochemistry, biochemistry, real-time polymerase chain reaction assay, and scintigraphy to evaluate the underlying mechanisms.

Results

Gross evaluation of burn wounds revealed that vital tissue percentage of the zone of stasis was significantly higher in the stem cell group. Semiquantitative grading of the histopathologic findings showed that MSCs alleviated burn-induced histomorphological alterations in the zone of stasis. According to CC3a staining and expression analysis of Bax (B-cell leukemia 2–associated X) and Bcl-2 (B-cell leukemia 2) genes, MSCs attenuated increases in apoptosis postburn. In addition, these transplants showed an immunomodulatory effect that involves reduced neutrophilic infiltration, down-regulation of proinflammatory cytokines (tumor necrosis factor α, interleukin 1β [IL-1β], and IL-6), and up-regulation of the anti-inflammatory cytokine IL-10 in the zone of stasis. Burn-induced oxidative stress was significantly relieved with MSCs, as shown by increased levels of malondialdehyde, whereas the expression and activity of the antioxidant enzyme superoxide dismutase were increased. Finally, MSC-treated interspaces had enhanced vascular density with higher expression levels for vascular endothelial growth factor A, platelet-derived growth factor, fibroblast growth factor, and transforming growth factor β. Gamma camera images documented better tissue perfusion in animals treated with MSCs.

Conclusions

The protective effects of MSCs are mediated by the inhibition of apoptosis through immunomodulatory, antioxidative, and angiogenic actions.
Biomechanical Comparison of a New Loop Suture Technique With Conventional Techniques of Flexor Tendon Repair
Authors: Yildiran Gokce , Akdag Osman , Tosun Zekeriya
Published: September 2018

Introduction

Flexor tendon repair techniques that can resist active forces are widely accepted. Despite that many suture techniques have been described, the “perfect repair” for flexor tendons cannot be achieved yet. We aimed to compare a new loop suture technique with commonly used flexor tendon repair methods biomechanically in hen tendon.

Method

We used 25 hen flexor tendons for each group (4-strand modified Kessler, grasping cruciate, Tsuge, and new technique groups). After the tendons were divided into 2, they were repaired according to these 4 techniques, were subjected to the initial stretching of 0.5 N, and pulled in the opposite directions. When a gap of 2 mm occurred, the test was terminated and the forces at that time were recorded. These strain forces were compared and evaluated statistically.

Results

New technique had the best tensile strength results statistically. Modified Kessler and grasping cruciate took the second place and Tsuge repair gave the worst strain forces results.

Conclusions

With loop suture, 4 strands can be obtained with only 2 passes of the needle, and we think that much more tensile strength can be achieved because of the vertical transition and locking configurations of the new loop suture technique.
Incidence and Efficacy of Stent Placement in Leak Management After Bariatric Surgery
Authors: Kanters Arielle E. , Shubeck Sarah P. , Varban Oliver A. , Dimick Justin B. , Telem Dana A.
Published: September 2018

Objective:

The aim of this study was to evaluate the rates of use and efficacy of stent placement for postoperative leak following bariatric surgery.

Summary of Background Data:

Endoscopically placed stents can successfully treat anastomotic and staple line leaks after bariatric surgery. However, the extent to which stents are used in the management of bariatric complications and rates of reoperation remain unknown.

Methods:

Data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant use files were analyzed for patients who experienced anastomotic or staple line leaks after bariatric surgery, and then evaluated for use of an endoscopically placed stent. Patient and procedure-level data were compared between those who underwent stent placement versus those who required reoperation. Multivariable logistic regression was used to compare outcomes between groups.

Results:

A total of 354,865 bariatric cases were captured in 2015 to 2016. One thousand one hundred thirty patients (0.3%) required intervention for a leak, of whom 275 (24%) were treated with an endoscopically placed stent. One hundred seven (39%) of the patients who received stents required reoperation as part of their care pathway. Patient characteristics were statistically similar when comparing leaks managed with stents to those treated with reoperation alone. Those treated with stents, however, had a higher likelihood of readmission (odds ratio 2.59, 95% confidence interval –1.59 to 4.20).

Conclusion:

Placement of stents for management of leaks after bariatric surgery is common throughout the United States. The use of stents can be effective; however, it does not prevent reoperation and is associated with an increased likelihood of readmission. Both technique and resource utilization should be considered when choosing a management pathway for leaks.
Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis
Authors: Bolkenstein Hendrike E. , Consten Esther C. J. , van der Palen Job , van de Wall Bryan J. M. , Broeders Ivo A. M. J. , Bemelman Willem A. , Lange Johan F. , Boermeester Marja A. , Draaisma Werner A.
Published: September 2018

Objective:

The aim of this study was to establish whether surgical or conservative treatment leads to a higher quality of life (QoL) in patients with recurring diverticulitis and/or ongoing complaints.

Summary of Background Data:

The 6 months’ results of the DIRECT trial, a randomized trial comparing elective sigmoidectomy with conservative management in patients with recurring diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode of diverticulitis, demonstrated a significantly higher QoL after elective sigmoidectomy. The aim of the present study was to evaluate QoL at 5-year follow-up.

Methods:

From January 2010 to June 2014, 109 patients were randomized to either elective sigmoidectomy (N = 53) or conservative management (N = 56). In the present study, the primary outcome was QoL measured by the Gastrointestinal Quality of Life Index (GIQLI) at 5-year follow-up. Secondary outcome measures were SF-36 score, Visual Analogue Score (VAS) pain score, EuroQol-5D-3L (EQ-5D-3L) score, morbidity, mortality, perioperative complications, and long-term operative outcome.

Results:

At 5-year follow-up, mean GIQLI score was significantly higher in the operative group [118.2 (SD 21.0)] than the conservative group [108.5 (SD 20.0)] with a mean difference of 9.7 (95% confidence interval 1.7–17.7). All secondary QoL outcome measures showed significantly better results in the operative group, with a higher SF-36 physical (P = 0.030) and mental score (P = 0.010), higher EQ5D score (P = 0.016), and a lower VAS pain score (P = 0.011). Twenty-six (46%) patients in the conservative group ultimately required surgery due to severe ongoing complaints. Of the operatively treated patients, 8 (11%) patients had anastomotic leakage and reinterventions were required in 11 (15%) patients.

Conclusion:

Consistent with the short-term results of the DIRECT trial, elective sigmoidectomy resulted in a significantly increased QoL at 5-year follow-up compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints. Surgeons should counsel these patients for elective sigmoidectomy weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.
Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis
Authors: Driedger Michael , Zyromski Nicholas J. , Visser Brendan C. , Jester Andrea , Sutherland Francis R. , Nakeeb Atilla , Dixon Elijah , Dua Monica M. , House Michael G. , Worhunsky David J. , Munene Gitonga , Ball Chad G.
Published: September 2018

Objective:

The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients.

Background:

WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention.

Methods:

A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant.

Results:

One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%).

Conclusion:

Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.
Microsatellite Instability (MSI) as an Independent Predictor of Pathologic Complete Response (PCR) in Locally Advanced Rectal Cancer
Authors: Hasan Shaakir , Renz Paul , Wegner Rodney E. , Finley Gene , Raj Moses , Monga Dulabh , McCormick James , Kirichenko Alexander
Published: September 2018

Objective:

The relationship between microsatellite instability (MSI) and response to neoadjuvant chemoradiation in rectal cancer is not well understood.

Background:

We utilized the National Cancer Database (NCDB) to investigate the association between MSI and pathologic complete response (pCR) in this patient population.

Methods:

We analyzed 5086 patients between 2010 and 2015 with locally advanced rectal cancer who were tested for MSI and treated definitively with chemoradiation followed by surgery. Primary comparison groups were between 4450 MSI-negative(−) and 636 MSI-positive(+) patients. Multivariable regression analysis was conducted to identify demographic, therapeutic, and clinical characteristics predictive of pCR. Cox proportional-hazard ratios were used for survival.

Results:

All patients were treated with definitive chemoradiation (median dose 50.4 Gy) followed by resection within 4 months. MSI(+) patients were associated with earlier year of diagnosis and higher-grade tumors (P < 0.05).

The overall pCR rate was 8.6%, including 8.9% for MSI(−) and 5.9% for MSI(+) tumors (P = 0.01). Along with lower T stage, MSI(+) cases were significantly associated with a reduced pCR rate (odds ratio 0.65, 95% confidence interval 0.43–0.96) with multivariable analysis. The 5-year survival for patients with pCR was 93% compared with 73% without it (<0.001).

Conclusion:

Microsatellite instability was independently associated with a reduction in pCR for locally advanced rectal cancer after neoadjuvant chemoradiation in this NCDB-based analysis.
NASA-TLX Assessment of Surgeon Workload Variation Across Specialties
Authors: Lowndes Bethany R. , Forsyth Katherine L. , Blocker Renaldo C. , Dean Patrick G. , Truty Mark J. , Heller Stephanie F. , Blackmon Shanda , Hallbeck M. Susan , Nelson Heidi
Published: September 2018

Objective:

With advancements in surgical equipment and procedures, human–system interactions in operating rooms affect surgeon workload and performance. Workload was measured across surgical specialties using surveys to identify potential predictors of high workload for future performance improvement.

Summary Background Data:

Surgical instrumentation and technique advancements have implications for surgeon workload and human–systems interactions. To understand and improve the interaction of components in the work system, NASA-Task Load Index can measure workload across various fields. Baseline workload measurements provide a broad overview of the field and identify areas most in need of improvement.

Methods:

Surgeons were administered a modified NASA-Task Load Index survey (0 = low, 20 = high) following each procedure. Patient and procedural factors were retrieved retrospectively.

Results:

Thirty-four surgeons (41% female) completed 662 surgery surveys (M = 14.85, SD = 7.94), of which 506 (76%) have associated patient and procedural data. Mental demand (M = 7.7, SD = 5.56), physical demand (M = 7.0, SD = 5.66), and effort (M = 7.8, SD = 5.77) were the highest rated workload subscales. Surgeons reported difficulty levels higher than expected for 22% of procedures, during which workload was significantly higher (P < 0.05) and procedural durations were significantly longer (P > 0.001). Surgeons reported poorer perceived performance during cases with unexpectedly high difficulty (P < 0.001).

Conclusions:

When procedural difficulty is greater than expected, there are negative implications for mental and physical demand that result in poorer perceived performance. Investigations are underway to identify patient and surgical variables associated with unexpected difficulty and high workload. Future efforts will focus on re-engineering the surgical planning process and procedural environment to optimize workload and performance for improved surgical care.
The Impact of Magnesium Sulfate on Pain Control After Laparoscopic Cholecystectomy: A Meta-Analysis of Randomized Controlled Studies
Authors: Chen Cong , Tao Rui
Published: September 2018

Introduction:

Magnesium sulfate has emerged as an important drug to alleviate the pain after laparoscopic cholecystectomy. However, the use of magnesium sulfate for pain control after laparoscopic cholecystectomy has not been well established. We conduct a systematic review and meta-analysis to evaluate the impact of magnesium sulfate on pain control after laparoscopic cholecystectomy.

Materials and Methods:

PubMed, Embase, and the Cochrane Central Register of Controlled Trials are searched. Randomized controlled trials assessing the influence of magnesium sulfate treatment versus placebo on pain control after laparoscopic cholecystectomy are included. Two investigators have independently searched articles, extracted data, and assessed the quality of included studies. This meta-analysis is performed using the random-effect model.

Results:

Four randomized controlled trials involving 263 patients are included in the meta-analysis. Compared with control intervention after laparoscopic cholecystectomy, magnesium sulfate can substantially decrease pain scores at 2 hours [standard mean differences (MD)=−0.45; 95% confidence interval (CI)=−0.88 to −0.02; P=0.04] and 8 hours (standard MD=−0.62; 95% CI=−0.95 to −0.28; P=0.0003), as well as reduce analgesic consumption (standard MD=−0.40; 95% CI=−0.73 to −0.07; P=0.02), but has no substantial influence on pain scores at 24 hour (standard MD=−0.38; 95% CI=−0.79 to 0.02; P=0.07) and operation duration (standard MD=−0.09; 95% CI=−0.34 to 0.15; P=0.45).

Conclusions:

Magnesium sulfate is effective to reduce pain intensity in early stage and anesthetic consumption after laparoscopic cholecystectomy.
Balloon-occluded Retrograde Transvenous Obliteration of Portovenous Shunts During Endoscopic Therapy for the Treatment of Gastric Varices
Authors: Ma Li-Li , Luo Tian-Cheng , Tseng Yu-jen , Huang Xiao-Quan , Luo Jian-Jun , Zhang Wen , Li Bing , Chen Shi-Yao
Published: September 2018

Introduction:

To explore the safety and feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) of portovenous shunts during endoscopic cyanoacrylate injection for the treatment gastric varices (E-BRTO) secondary to portal hypertension.

Patients and Methods:

A total of 28 cirrhotic patients with gastroesophageal varices and concurrent gastrorenal or gastrosplenorenal shunt, treated with E-BRTO, were enrolled. Operative details were recorded to evaluate the safety, feasibility, and efficacy of the procedure. Short-term follow-up was conducted to denote any incidence of distant emboli, variceal rebleeding, or mortality (Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A179).

Results:

All the patients successfully received E-BRTO without intraoperative complications. The average volume of cyanoacrylate was 2.4±1.3 mL. During the 90 days follow-up, none of the patients experienced distant systemic emboli. However, 8 patients suffered from gastrointestinal rebleeding, including one death, while 2 patients were lost to follow-up. The short-term rebleeding rate (intention to treat) was about 36% in E-BRTO for this subset of patients.

Conclusions:

BRTO during endoscopic cyanoacrylate injection is an alternative selection for cirrhotic patients with portovenous shunts. The procedure is feasible and procedurally safe, but the associated high rebleeding rate may require a multimodality approach.
Central Lymph Node Dissection by Endoscopic Bilateral Areola Versus Open Thyroidectomy
Authors: Zhang Daqi , Wang Tie , Dionigi Gianlorenzo , Zhang Jiao , Xue Gaofeng , Sun Hui
Published: September 2018

Background:

Endoscopic thyroidectomy by bilateral areola approach (ETBAA) potentially expose a technical limitation for anatomize the central compartment lymph nodes located in its most caudal portion because of visual obstruction and instrument interference of clavicles and sternum. We provide a comparative analysis of ETBAA versus open thyroidectomy approach (OTA) for central compartment dissection (CND).

Methods:

From October 2013 to August 2017, 400 patients with papillary thyroid cancer (PTC) underwent CND; 200 patients were enrolled in each group. For the endoscopic group, a 10-mm curved incision is made along the margin of the right areola at 2 to 4’oclock for the 30 degrees endoscope. Bilaterally 5-mm incisions are on the edges of the areola at 11 to 12’oclock as accessory operating ports. Supplementary video (Supplemental Digital Content 1, http://links.lww.com/SLE/A180) depicts steps of ETBAA with CND.

Results:

In ETBAA group, a total of 1049 lymph nodes were removed, nodes excision ranged from 1 to 19 (mean, 5.25), the ratio positive/metastatic rate was 18.6%. In OTA group, 916 lymph nodes were excised, nodes removal amplitude was 1 to 20 (average, 4.58), 12.1% were metastatic. Compared with the open group, significantly more lymph nodes were extracted during ETBAA (P<0.05). There was no significant difference between the 2 groups per resected side or surgical morbidity (P>0.05). Periodic monitoring of PTC patients revealed no clinical or US recurrence, undetectable serum Tg in both groups.

Conclusions:

Our results show the feasibility of CND in ETBAA.
Opioid Pain Medication Use in New Urogynecology Patients
Authors: Dwarica Denicia S. , Rubenstein Abby R. , Boccaccio Robert B. , Motwani Anita K. , Peck Jennifer D. , LeClaire Edgar L. , Quiroz Lieschen H.
Published: September 2018

Objectives

The aim of this study was to determine the prevalence of opioid pain medication use among patients presenting for a new visit to the urogynecology clinic compared with those presenting to general gynecology.

Methods

We identified all patients who presented for new patient visits to the urogynecology and gynecology clinics between January 1, 2016, and December 31, 2016. Any previous or current opioid use was extracted from the electronic medical record medication list. Statistical analysis was performed using χ2 and Fisher exact tests for comparisons of categorical variables. Modified Poisson regression models were used to estimate prevalence proportion ratios (PPRs).

Results

There were 1835 (955 gynecology, 880 urogynecology) patients included. Median age was 47 years (interquartile range, 29 years), and median body mass index was 28.15 kg/m2 (interquartile range, 9.96 kg/m2). Prevalence of opioid use was lowest among women who identified as Asian or other race and highest among black and Native American women; however, when compared by ethnicity, use was lowest among Hispanic women (P = 0.01). Among new urogynecology patients, 14% had self-reported opioid pain medication usage. Opioid use was almost twice as likely in the urogynecology group (PPR, 1.86; 95% confidence interval, 1.4–2.4). When adjusted for confounders, the urogynecology group was 1.3 times as likely to report opioid use (PPR 1.29; 95% confidence interval, 1.0–1.8), with this result approaching statistical significance.

Conclusions

Opioid use is greater in patients presenting to the urogynecology clinic compared with general gynecology. Urogynecologists need to know this information for planning and optimizing pain management in this population.
Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism
Authors: Myers Sara P. , Kutcher Matthew E. , Rosengart Matthew R. , Sperry Jason L. , Peitzman Andrew B. , Brown Joshua B. , Neal Matthew D.
Published: September 2018

BACKGROUND

Tranexamic acid (TXA) is used as a hemostatic adjunct for hemorrhage control in the injured patient and reduces early preventable death. However, the risk of venous thromboembolism (VTE) has been incompletely explored. Previous studies investigating the effect of TXA on VTE vary in their findings. We performed a propensity matched analysis to investigate the association between TXA and VTE following trauma, hypothesizing that TXA is an independent risk factor for VTE.

METHODS

This retrospective study queried trauma patients presenting to a single Level I trauma center from 2012 to 2016. Our primary outcome was composite pulmonary embolism or deep vein thrombosis. Mortality, transfusion, intensive care unit and hospital lengths of stay were secondary outcomes. Propensity matched mixed effects multivariate logistic regression was used to determine adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) of TXA on outcomes of interest, adjusting for prespecified confounders. Competing risks regression assessed subdistribution hazard ratio of VTE after accounting for mortality.

RESULTS

Of 21,931 patients, 189 pairs were well matched across propensity score variables (standardized differences <0.2). Median Injury Severity Score was 19 (interquartile range, 12–27) and 14 (interquartile range, 8–22) in TXA and non-TXA groups, respectively (p = 0.19). Tranexamic acid was associated with more than threefold increase in the odds of VTE (aOR, 3.3; 95% CI, 1.3–9.1; p = 0.02). Tranexamic acid was not significantly associated with survival (aOR, 0.86; 95% CI, 0.23–3.25; p = 0.83). Risk of VTE remained elevated in the TXA cohort despite accounting for mortality (subdistribution hazard ratio, 2.42; 95% CI, 1.11–5.29; p = 0.03).

CONCLUSION

Tranexamic acid may be an independent risk factor for VTE. Future investigation is needed to identify which patients benefit most from TXA, especially given the risks of this intervention to allow a more individualized treatment approach that maximizes benefits and mitigates potential harms.

LEVEL OF EVIDENCE

Therapeutic, level III.
Trauma and emergency general surgery patients should be extubated with an open abdomen
Authors: Taveras Luis R. , Imran Jonathan B. , Cunningham Holly B. , Madni Tarik D. , Taarea Roberto , Tompeck Allison , Clark Audra T. , Provenzale Natalie , Adeyemi Folarin M. , Minshall Christian T. , Eastman Alexander L. , Cripps Michael W.
Published: September 2018

BACKGROUND

Open abdomen (OA) and temporary abdominal closure (TAC) are common techniques to manage several surgical problems in trauma and emergency general surgery (EGS). Patients with an OA are subjected to prolonged mechanical ventilation. This can lead to increased rates of ventilator-associated pneumonia (VAP). We hypothesized that patients who were extubated with an OA would have a decrease in ventilator hours and as a result would have a lower rate of VAP without an increase in extubation failures.

METHODS

A retrospective review was performed of all trauma and EGS patients managed at our institution with OA and TAC from January 2014 to February 2016. Patients were divided into cohorts consisting of those who were successfully extubated with an OA and those who were not. The number of extubation events and ventilator-free hours were calculated for each patient. Adverse events such as the need for reintubation with an OA and VAP were collected.

RESULTS

Fifty-two patients (20 trauma, 32 EGS) were managed with an OA and TAC during the study period. Twenty-five patients (6 trauma, 19 EGS) had at least one extubation event with an OA. Median extubation events per patient was 3 (interquartile range, 1–5). The median ventilator-free hours for patients who were extubated was 101 hours (interquartile range, 39.42–260.46). Patients that were never extubated with an OA had higher rates of VAP (30.8% vs. 3.8%, p = 0.01).

CONCLUSION

This study provides much needed data regarding the feasibility of extubation in trauma and EGS patients managed with an OA and TAC. Benefits of early extubation may include lower VAP rates in this population. Plans for reexploration hinder the decision to extubate in these patients.

LEVEL OF EVIDENCE

Therapeutic study, level IV.
Effects of Exendin-4 on pancreatic islets function in treating hyperglycemia post severe scald injury in rats
Authors: Li Dawei , Shang Yuru , Shen Chuanan , Li Longzhu , Zhao Dongxu , Ma Li , Yu Yongming
Published: September 2018

BACKGROUND

It has been established that glucagon-like peptide 1 (GLP 1) inhibits pancreatic β-cell apoptosis, increases insulin secretion, and improves glucose tolerance in scald injury. However, the effects of Exendin-4, a long-acting incretin similar to GLP 1, remained unclear in severe scald injury. Hence, this study attempted to investigate whether Exendin-4 had similar effects by protecting the histology of pancreas in severely scalded rats.

METHODS

One hundred sixty-two adult Wistar rats were equally randomized to sham burn group, burn group and burn with Exendin-4 treatment group. Rats were subjected to full skin thickness scald injuries (total body surface area: 50%) and were injected subcutaneously with Exendin-4 (4 μg/kg) twice daily. The histological changes of islets, the apoptosis of β cells, the amount of glucagon and insulin, and the concentration of plasma glucagon and insulin were observed; and the intraperitoneal glucose tolerance test was performed as well.

RESULTS

The islets and β cells were injured and the number of secretory granules decreased in the scalded rats, but less histopathological changes were seen in the rats treated with Exendin-4. The apoptosis index of treated rats was significantly lower than that of the scalded rats (p < 0.05). There was significant difference in β-cell density postinjury between the two groups (p < 0.05). More insulin and less glucagon in islets and plasma were found in the treated rats (p < 0.05), suggesting improved intraperitoneal glucose tolerance (p < 0.05) and fasting blood glucose (p < 0.05) in this group.

CONCLUSION

Based on our previous finding that GLP-1 could control hyperglycemia by increasing insulin secretion and inhibiting β-cell apoptosis in severe scald injuries, this study further confirmed that Exendin-4 could increase glycemic control following severe scald by preserving the histology of β cells in pancreatic islets and inhibiting their apoptosis.
Impact of licensed federal firearm suppliers on firearm-related mortality
Authors: Chao Stephanie D. , Kastenberg Zachary J. , Madhavan Sriraman , Staudenmayer Kristan
Published: September 2018

BACKGROUND

Legal firearm sales occur largely through suppliers that have Federal Firearm Licensees (FFLs). Since FFL density might reflect ease-of-access to firearm purchases, we hypothesized that the number of FFL dealers would be associated with firearm-related deaths. We further hypothesized that licensee-type subsets would be associated with differential risks for gun-related deaths.

METHODS

We used data from the National Center for Health Statistics National Vital Statistics System (2008–2014) and national data on Federal Firearms Licensees for 2014. Correlation analysis and linear regression analysis were performed to determine the relationship between different licensee types and firearm-related deaths. We controlled for population, number of statewide registered firearms, and the density of other types of FFLs.

RESULTS

We identified a total of 65,297 FFLs. There was a moderate correlation (R = 0.53, ρ = 0.48) between total FFL density and firearm-related death rates. Further analysis by type of firearm-related death showed a strong correlation (R = 0.81, ρ = 0.76) between total FFL density and firearm-related suicide rates. No correlation was found between total FFL density and firearm-related homicide rate. Among individual FFL types, FFL02 (firearm dealing pawnshop) density was the only FFL-type found to be correlated with firearm-related death rates. We found a strong correlation between FFL02 density and overall firearm-related death rate (R = 0.69, ρ = 0.78) and firearm-related suicide rate (R = 0.72, ρ = 0.78). Linear regression analysis showed that even while controlling for number of registered firearms and population, the number of firearm-dealing pawnshops remained significantly associated with overall firearm-related deaths and firearm-related suicides.

CONCLUSION

Access to legally distributed firearms is associated with firearm-related death rates, particularly firearm-related suicides. Specifically, firearm-dealing pawnshops were associated with suicide-related deaths. These findings suggest that deeper exploration of legal firearm access and firearm-related injuries would benefit discussion of preventative measures.

LEVEL OF EVIDENCE

Therapeutic, Level V.
Relative Yield of MEG and EEG Spikes in Simultaneous Recordings
Authors: Ebersole John S. , Wagner Michael
Published: September 2018

Purpose:

Most clinical magnetoencephalography (MEG) centers record both MEG and EEG, but model only MEG sources. This may be related to the belief that MEG spikes are more prevalent, MEG is more sensitive, or to proprietary software limitations. Biophysics would contend, however, that EEG, being sensitive to radial and tangential source orientations, would provide complementary data for analysis.

Methods:

We recorded 306 channels of MEG and 25 channels of EEG simultaneously in 297 consecutive patients over 3 years. We inspected the MEG and EEG recordings separately, identified spikes in both, determined whether their voltage and/or magnetometer magnetic fields were dipolar and thus model-worthy, and segregated them into types based on similar and distinct field topography. We placed for each patient their spike types into categories, including those with both a recognizable MEG and EEG signal and those with only an MEG and only an EEG signal.

Results:

Eighty-three percent of patients had spikes recorded, and these patients had an average of 2.7 spike types each. Fifty-six percent of spike types were present in both MEG and EEG. However, 36% of spike types were only evident in EEG, whereas 8% were noted in MEG alone. In 49% of patients with spikes, MEG review missed at least one spike type, whereas in 17% of patients, EEG review missed at least one spike type.

Conclusions:

To obtain an optimal yield of diagnostic information, EEG should also be subjected to source analysis in any clinical MEG study. EEG and MEG data are indeed complementary.
A Waves in Diabetic Neuropathy: Pathophysiology and Neurographic Images
Authors: Rampello Liborio , Rampello Luigi , Arcidiacono Antonio
Published: September 2018

Purpose:

To evaluate the presence of A waves in diabetic neuropathy, we designed a retrospective observational study recruiting patients with type II diabetes and chronic diabetic distal sensorimotor polyneuropathy.

Methods:

We recruited 238 patients of both sexes aged between 41 and 89 years. Neurography was undertaken on two bilateral upper (median and ulnar) and lower (peroneal and tibial) limb nerves. As controls, we considered that neurographs performed bilaterally on the same nerves of 40 healthy subjects.

Results:

In addition to neurographic changes typical of chronic distal sensorimotor neuropathy, patients had a 32.77% incidence of A waves, mostly found in the tibial (16.38%) and peroneal (8.8%) nerves. Among controls, A waves were found only in the tibial nerve of a single subject (2.5%). Chi-square test with Yates correction to compare the two percentages (32.77% of patients and 2.5% of healthy subjects): 13.98, P = 0.0002, highly significant.

Conclusions:

We postulate that demyelination may be the site of backfiring or slowing of nerve conduction velocity, explaining the appearance of A waves in their different varieties. Implementing the search for A waves in routine neurographic examination can be a useful option for the diagnosis of neuropathy and the prediction of possible latent neuropathic processes.
Reducing adverse medication events in mental health: Australian National Survey
Authors: Gadzhanova Svetla , Roughead Elizabeth , Lowy Helen , O’Connor Daniel
Published: September 2018

Aim:

To determine the extent to which evidence-based medication safety practices have been implemented in public and private mental health inpatient units across Australia.

Methods:

The Reducing Adverse Medication Events in Mental Health survey was piloted in Victoria, Australia, in 2015, and rolled out nationally in 2016. In total, 235 mental health inpatient units from all States and Territories in Australia were invited to participate. The survey included questions about the demographics of the mental health unit, evidence-based strategies to improve prescription writing, the administration and dispensing of medicines and pharmacy-led interventions, and also questions relating to consumer engagement in medication management and shared decision-making.

Results:

The response rate was 45% (N = 106 units). Overall, the survey found that 57% of the mental health units had fully or partially implemented evidence-based medication safety practices. High levels of implementation (80%) were reported for the use of standardized medication charts such as the National Inpatient Medication Chart as a way to improve medication prescription writing. Most (71%) of the units were using standardized forms for recording medication histories, and 56% were using designated forms for Medication Management Plans. However, less than one-fifth of the units had implemented electronic medication management systems, and the majority of units still relied on paper-based documentation systems.

Interventions to improve medicine administration and dispensing were not highly utilized. Individual patient-based medication distribution systems were fully implemented in only 9% of the units, with a high reliance (81%) on ward stock or imprest systems. Tall Man lettering for labelling was implemented in only one-third of the units.

Pharmacy services were well represented in mental health units, with 80% having access to onsite pharmacist services providing assessments of current medications and clinical review services, adverse drug reaction reporting and management services, patient and carer education and counselling, and medicines information services. However, pharmacists were involved in only half of medical reconciliations. Their involvement in post-discharge follow-up was limited to 4% of units.

Conclusions:

Gaps in medication safety practices included limited use of individual patient supply systems for medication distribution, a high reliance on ward stock systems and high reliance on paper-based systems for medication prescribing and administration. With regards to service provision, clinical pharmacist involvement in medical reconciliation services, therapeutic drug monitoring and interdisciplinary ward rounds should be increased. Discharge and post-discharge services were major gaps in service provision.
Dynamic regulation of dynein localization revealed by small molecule inhibitors of ubiquitination enzymes
Authors: Monda Julie K. , Cheeseman Iain M.
Published: September 2018

Cytoplasmic dynein is a minus-end-directed microtubule-based motor that acts at diverse subcellular sites. During mitosis, dynein localizes simultaneously to the mitotic spindle, spindle poles, kinetochores and the cell cortex. However, it is unclear what controls the relative targeting of dynein to these locations. As dynein is heavily post-translationally modified, we sought to test a role for these modifications in regulating dynein localization. We find that dynein rapidly and strongly accumulates at mitotic spindle poles following treatment with NSC697923, a small molecule that inhibits the ubiquitin E2 enzyme, Ubc13, or treatment with PYR-41, a ubiquitin E1 inhibitor. Subsets of dynein regulators such as Lis1, ZW10 and Spindly accumulate at the spindle poles, whereas others do not, suggesting that NSC697923 differentially affects specific dynein populations. We additionally find that dynein relocalization induced by NSC697923 or PYR-41 can be suppressed by simultaneous treatment with the non-selective deubiquitinase inhibitor, PR-619. However, we did not observe altered dynein localization following treatment with the selective E1 inhibitor, TAK-243. Although it is possible that off-target effects of NSC697923 and PYR-41 are responsible for the observed changes in dynein localization, the rapid relocalization upon drug treatment highlights the highly dynamic nature of dynein regulation during mitosis.
mmi1
and
rep2
mRNAs are novel RNA targets of the Mei2 RNA-binding protein during early meiosis in
Schizosaccharomyces pombe
Authors: Mukherjee Kaustav , Futcher Bruce , Leatherwood Janet
Published: September 2018

The RNA-binding protein Mei2 is crucial for meiosis in
Schizosaccharomyces pombe.
In
mei2
mutants, pre-meiotic S-phase is blocked, along with meiosis. Mei2 binds a long non-coding RNA (lncRNA) called meiRNA, which is a ‘sponge RNA’ for the meiotic inhibitor protein Mmi1. The interaction between Mei2, meiRNA and Mmi1 protein is essential for meiosis. But
mei2
mutants have stronger and different phenotypes than meiRNA mutants, since
mei2Δ
arrests before pre-meiotic S, while the meiRNA mutant arrests after pre-meiotic S but before meiosis. This suggests Mei2 may bind additional RNAs. To identify novel RNA targets of Mei2, which might explain how Mei2 regulates pre-meiotic S, we used RNA immunoprecipitation and cross-linking immunoprecipitation. In addition to meiRNA, we found the mRNAs for
mmi1
(which encodes Mmi1) and for the S-phase transcription factor
rep2
. There were also three other RNAs of uncertain relevance. We suggest that at meiotic initiation, Mei2 may sequester
rep2
mRNA to help allow pre-meiotic S, and then may bind both meiRNA and
mmi1
mRNA to inactivate Mmi1 at two levels, the protein level (as previously known), and also the mRNA level, allowing meiosis. We call Mei2–meiRNA a ‘double sponge’ (i.e. binding both an mRNA and its encoded protein).