bluuebunny/crossref_metadata_2025 huggingface dataset:
Non-mobile Adjacent Level Cervical Spondylolisthesis Does Not Always Require Fusion in Patients Undergoing ACDF
Authors: Segar Anand H. , Divi Srikanth N. , Tarazona Daniel , Fried Tristan , Sandhu Hanna , Kaye Ian D. , Kepler Christopher K. , Kurd Mark F. , Woods Barrett I. , Hilibrand Alan S. , Radcliff Kristen E. , Rihn Jeffrey A. , Anderson D. Greg , Vaccaro Alexander R. , Schroeder Gregory D.
Published: July 2019

Study Design.

Retrospective review of a prospectively maintained database.

Objective.

Compare outcomes following anterior cervical decompression and fusion (ACDF) between patients with no adjacent level spondylolisthesis (NAS) and adjacent level spondylolisthesis (AS).

Summary of Background Data.

There are no prior studies evaluating the effect of preoperative adjacent-level cervical spondylolisthesis on outcomes following anterior cervical discectomy and fusion (ACDF).

Methods.

A retrospective review of consecutive patients who underwent ACDF for degenerative cervical disease was performed. Adjacent level spondylolisthesis was defined on radiographs as anterior displacement (> 1 mm) of the vertebra in relation to an adjacent “to be fused” level. Patients were categorized as either AS or NAS. Preoperative and 1-year postoperative outcomes including Short Form-12 Physical and Mental Component Scores, Neck Disability Index, Visual Analog Score for arm and neck pain, and rate of revision surgery were compared between the two groups. Radiographic changes were also analyzed for patients with AS.

Results.

A total of 264 patients met the inclusion criteria. There were 53 patients (20.1%) with AS and 211 patients (79.9%) with NAS. Both groups improved significantly from baseline with respect to all patient outcomes and there were no significant differences between the two groups. After accounting for confounding variables, the presence of an AS was not a predictor of any postoperative outcome. Revision rates did not differ between the two groups.

Conclusion.

Patients with an AS had similar postoperative clinical outcomes compared with NAS. Furthermore, the presence of an AS was not a predictor of poorer clinical outcomes. This is the first study to investigate the effect of AS in patients undergoing ACDF and suggests that an adjacent-level spondylolisthesis does not need to be included in a fusion construct if it is not part of the primary symptom generating pathology.

Level of Evidence: 3
Risk, Recovery, and Clinical Impact of Neurological Complications in Adult Spinal Deformity Surgery
Authors: Yagi Mitsuru , Michikawa Takehiro , Hosogane Naobumi , Fujita Nobuyuki , Okada Eijiro , Suzuki Satoshi , Tsuji Osahiko , Nagoshi Narihito , Asazuma Takashi , Tsuji Takashi , Nakamura Masaya , Matsumoto Morio , Watanabe Kota
Published: July 2019

Study Design.

Multicenter retrospective case series.

Objective.

To report the risks, recovery, and clinical impact of neurological complications (NCs) in adult spinal deformity (ASD) surgery.

Summary of Background Data.

Although recent studies have reported the incidence of NCs in ASD surgery, few have addressed the recovery from and clinical impacts of NC.

Methods.

We reviewed records from a multicenter database for 285 consecutive surgically treated ASD patients who had reached a 2-year follow-up. NCs were categorized as sensory only or motor deficit (MD). Recovery was noted as none, partial, or complete, during hospitalization and at every postoperation visit. Uni- and multivariate risk analyses were performed to identify risk factors for MD.

Results.

NC developed in 29 (10%) patients within 30 days of surgery, of which 11 were permanent deficits (seven no recovery, and four partial recovery). MD developed in 14 (5%) patients, including one spinal cord injury. Seven MD patients required physical assistance at the latest follow-up. While NC patients experienced significant improvements in health-related quality of life at the 2-year follow-up, the health-related quality of life was significantly worse for the NC versus no-NC group at this time point. Univariate analyses revealed that Schwab-SRS types N and L, pelvic tilt, modified frailty index physical function, and an inferior SRS22 function domain at baseline were risk factors for MD. Among them, modified frailty index physical function, which represented a preoperative decline in activities of daily living, was identified as an independent risk factor for MD (OR: 4.0, 95% CI: 1.2–13.5, P = 0.03).

Conclusions.

NC developed in 10% of ASD surgery patients, with permanent deficits occurring in 4%. Half of the patients who developed MD required physical assistance, which contributed to the inferior clinical outcomes. Surgical intervention should be considered before severe activities of daily living decline to prevent NCs.

Level of Evidence: 4
Low-Pressure Lumbar Provocation Discography According to Spine Intervention Society/International Association for the Study of Pain Standards Does Not Cause Acceleration of Disc Degeneration in Patients With Symptomatic Low Back Pain
Authors: McCormick Zachary L. , Lehman Vance T. , Plastaras Christopher T. , Walega David R. , Huddleston Paul , Moussallem Charbel , Geske Jennifer R. , Verdoorn Jared T. , Kennedy David J. , Maus Timothy P. , Carr Carrie M.
Published: July 2019

Study Design.

Retrospective matched cohort study.

Objective.

To determine if low-pressure lumbar provocation discography (PD) results in long-term accelerated disc degeneration, internal disc disruption, or disc herniation in patients with symptomatic low back pain (LBP).

Summary of Background Data.

Study of subjects without clinically-significant LBP suggests that high-pressure PD may accelerate disc degeneration.

Methods.

Consecutive patients with symptomatic LBP who underwent magnetic resonance imaging (MRI), PD, and repeat MRI more than 7 years later, but did not undergo subsequent spinal fusion surgery, were included. Punctured discs were matched (1:2 to 1:4) to corresponding discs in a control cohort by age, BMI, Pfirrmann score (±2), and presence of disc herniation; control cohort inclusion required MRIs for symptomatic LBP, separated by more than 7 years. The primary outcome of the study was a progression in Pfirrmann score category (I–II, III–IV, V). MRI disc-to-CSF T2 signal-intensity ratio, disc height, disc herniations, high intensity zones (HIZs), and Modic changes were assessed.

Results.

Baseline and follow-up MRIs were available for 77 discs exposed to PD, and for 260 discs in the matched control cohort. There was no difference in the proportion of punctured discs that advanced in Pfirrmann score category in the PD group (17%, 95% CI 9–27%) compared with corresponding discs in the Control group (21%, 95% CI 17–27%), P = 0.3578, or in non-punctured discs in the PD group (35%, 95% CI 21–51%) compared with corresponding discs in the Control group (34%, 95% CI 27–42%), P = 0.1169. There were no differences in disc-to-CSF T2 signal-intensity ratio, presence of disc herniations, HIZs, or Modic changes following puncture in the PD versus matched cohort discs or in the non-punctured PD cohort discs versus corresponding control cohort discs (P > 0.05).

Conclusion.

Patients with symptomatic LBP who underwent low-pressure PD, but who did not undergo a subsequent spinal fusion surgery, developed disc degeneration and new disc herniations at a similar rate to corresponding discs in matched control patients.

Level of Evidence: 3
Improving Tracheostomy Decannulation Rate in Trauma Patients
Authors: Farrell Michael S. , Gillin Thomas M. , Emberger John S. , Getchell John , Caplan Richard J. , Cipolle Mark D. , Bradley Kevin M.
Published: July 2019

Objectives:

Identify the effect of a multidisciplinary tracheostomy decannulation protocol in the trauma population.

Design:

Single-center retrospective review.

Setting:

American College of Surgeons level 1 trauma center; large academic associated community hospital.

Patients:

Adult trauma patients who required a tracheostomy.

Interventions:

A tracheostomy decannulation protocol empowering respiratory therapists to move patients toward tracheostomy decannulation.

Measurements Main Results:

Tracheostomy decannulation rate, time to tracheostomy decannulation, length of stay, and reintubation and recannulation rates. A total of 252 patients met inclusion criteria during the study period with 134 presenting after the tracheostomy decannulation protocol was available. Since the tracheostomy decannulation protocol was implemented, patients managed by the tracheostomy decannulation protocol had a 50% higher chance of tracheostomy decannulation during the hospital stay (p < 0.001). The time to tracheostomy decannulation was 1 day shorter with the tracheostomy decannulation protocol (p = 0.54). There was no difference in time to discharge after ventilator liberation (p = 0.91) or in discharge disposition (p = 0.66). When comparing all patients, the development of a tracheostomy decannulation protocol, regardless if a patient was managed by the tracheostomy decannulation protocol, resulted in an 18% higher chance of tracheostomy decannulation (p = 0.003). Time to tracheostomy decannulation was 5 days shorter in the postintervention period (p = 0.07). There was no difference in discharge disposition (p = 0.88) but the time to discharge after ventilator liberation was shorter post protocol initiation (p = 0.04).

Conclusions:

In a trauma population, implementation of a tracheostomy decannulation protocol significantly improves tracheostomy decannulation rates during the same hospital stay. A larger population will be required to identify patient predictive factors for earlier successful tracheostomy decannulation.
Thymic malignancies: emerging systemic therapies
Authors: Girard Nicolas
Published: July 2019

Purpose of review

The management of thymic malignancies is based on multidisciplinary collaboration. Systemic agents may be administered as an exclusive treatment if local treatment is not achievable. Novel and innovative agents are needed. Integrated genomic analyses reported the activation of targetable signaling pathways in thymomas and thymic carcinomas.

Recent findings

Phase II trials reported the antitumor activity of phosphatidylinositol 3-kinase/mechanistic target of rapamycin kinase inhibitors, cyclin dependent kinase inhibitors, and antiangiogenic agents in advanced, refractory thymic malignancies. Meanwhile, a major challenge is the use of immune checkpoint inhibitors, given the frequent association of those tumors with autoimmune disorders.

Although those innovative agents were assessed in phase II trials reporting on variable antitumor efficacy in terms of response and survival, in selected and limited cohorts of patients, a better understanding of systemic treatment sequences in a real-life setting is mandatory to analyze the actual efficacy of each line of treatment one after another, define the best clinical–pathological selection of patients for the administration of chemotherapy, targeted agents, and immunotherapy, and develop individualized decision-making to optimize the survival of patients with advanced thymic malignancies.
The Effect of Time to Postoperative Radiation Therapy on Survival in Resected Merkel Cell Carcinoma
Authors: Shinde Ashwin , Verma Vivek , Jones Bernard L. , Li Richard , Glaser Scott , Freeman Morganna , Melstrom Laleh , Kang Robert , Parvathaneni Upendra , Modi Badri , Amini Arya
Published: July 2019

Objectives:

Delays from surgery to adjuvant radiation therapy (aRT) are associated with poorer prognosis in multiple neoplasms. Presently, no data exist for Merkel cell carcinoma (MCC). The authors sought to assess the time interval from surgery to aRT and effect on outcomes in MCC.

Materials and Methods:

The National Cancer Database was queried for histologically confirmed nonmetastatic MCC status post resection and aRT diagnosed between 2004 and 2015 who received aRT within 24 weeks of surgery. Kaplan-Meier analysis assessed univariate overall survival (OS); multivariable Cox proportional hazards modeling assessed multivariate OS; χ2 and logistic regression assessed differences in baseline characteristics and predictors of delayed aRT.

Results:

Of 5952 patients meeting criteria, 13% commenced aRT within 4 weeks, 48% between 4 and 7 weeks, 23% between 8 and 11 weeks, 11% between 12 and 15 weeks, and 6% between 16 and 24 weeks. There were no differences in OS on the basis of the surgery-aRT interval (P=0.99). Predictors of worse OS on the multivariate analysis included advanced age, greater comorbidities, male sex, lower regional income, earlier year of diagnosis, more advanced tumor and nodal staging, positive margins, head and neck location, and treatment at community facilities (P<0.05 for all). Factors predictive of delayed aRT were identified. Subset analyses on these factors, such as receipt of chemotherapy or positive lymph nodes, did not demonstrate that the timing of aRT affected survival (P≥0.37).

Conclusion:

This study of a contemporary national database revealed that delays from resection to aRT were not associated with survival in MCC, somewhat discordant from other malignancies such as squamous cell carcinoma.
Unique Uses of SPY: An Approach to Groin Lymphatic Complications
Authors: Lu Karen B. , Erickson Cameron , Sanniec Kyle , Amirlak Bardia
Published: July 2019

Femoral artery reconstructive operations pose the risk of damage to the lymphatic system and leakage of lymph fluid into the groin. This leakage establishes a stagnant reservoir of protein-rich fluid, further placing the patient at risk for complications, especially a higher infection rate. The use of SPY technology (Stryker Corp/Novadaq Technologies, Kalamazoo, Mich) for lymphatic leaks have been described in previous studies. However, the management of persistent high-output lymphatic leaks addressed secondarily with SPY lymphangiography have yet to be reported. This case report describes a young male who underwent thrombectomy in the left common femoral artery, who presented several days later with a high-output chylous leak. The lymphatic leak was initially managed and failed conventional muscle flaps, and SPY lymphangiography was performed to manage the lymphatic leak during the secondary surgery. The lymphatic vessels were ligated and confirmed with SPY lymphangiography. The management of lymphatic groin complications aided by the use of SPY lymphangiography provided valuable data and allowed for better intraoperative visualization. Utilization of SPY technology allowed the surgeons to properly address all sites of leakage in an otherwise persistent lymphatic leak. Resolution of lymphatic leak was further confirmed with SPY. Lymphatic complications, particularly those in the groin area, are of significant concern to physicians. Any suspected chylous leak should be followed with SPY lymphangiography to ensure proper treatment and resolution. Prophylactic use of SPY technology in high-risk patients during lymphatic surgery of the groin may also be considered.
Infantile Hemangiomas of the Lip: Complications and Need for Surgical Intervention
Authors: Cawthorn Thomas R. , Fraulin Frankie O.G. , Harrop Alan Robertson
Published: July 2019

Background:

Infantile lip hemangiomas are challenging to manage due to the functional and aesthetic importance of the lips. Hemangiomas in this region may lead to significant complications including ulceration, feeding difficulties, and lip contour distortion requiring surgical intervention.

Methods:

A retrospective chart review of children with focal lip hemangiomas treated at our institution between January 2000 and December 2016 was conducted. Patient demographics, lesion characteristics, complications, treatments, and outcomes were collected. Lesions were classified based on depth (superficial, deep, or mixed depth), vermillion border involvement, and location.

Results:

One hundred and two patients with focal lip hemangiomas were identified; 45.1% were managed expectantly, 43.1% were treated medically, and 18.6% required surgery. Residual lip contour deformity following involution was the most common complication (26.5% of patients). Ulceration during the proliferation phase was reported in 14.7% of patients, leading to significant feeding difficulties in 9.8% of patients. All ulcerations occurred in lesions with a superficial component. None of the patients with superficial lesions underwent surgery; 27.1% of patients with deep or mixed depth hemangiomas required surgical treatment to restore lip contour.

Conclusions:

Lip hemangiomas have high rates of complications that seem to be related to lesion morphology and phase of growth. Ulceration occurs during the early proliferative phase and is most frequently associated with mixed depth hemangiomas. Residual lip contour deformities are identified in the involution phase; presence of a deep component is the primary factor in predicting the need for surgical intervention in these patients.
Prediction of Best-Corrected Visual Acuity With Swept-Source Optical Coherence Tomography Parameters in Keratoconus
Authors: Esaka Yuri , Kojima Takashi , Dogru Murat , Hasegawa Asato , Tamaoki Akeno , Uno Yunako , Nishida Tomoya , Nakamura Tomoaki , Hara Syuya , Ichikawa Kazuo
Published: July 2019

Purpose:

This study aimed to predict the best-corrected visual acuity (BCVA) based on swept-source optical coherence tomography (SS-OCT) parameters in eyes with keratoconus.

Methods:

We retrospectively reviewed 135 eyes of 135 patients with keratoconus (mean age: 31.9 ± 12.4 years). The average keratometry value and BCVA (logarithm of the minimal angle of resolution [Snellen]) were 48.68 ± 5.44 diopter and 0.20 ± 0.36 (20/25), respectively. Eleven parameters were calculated using SS-OCT. Apart from the corneal height and elevation, all the other parameters were calculated from both anterior and posterior corneal OCT data. The patients were divided into 2 groups, 1 for creating the prediction equation (prediction group, 86 eyes) and another for verifying the equation (verification group, 49 eyes). In the former, individual correlations between the BCVA and SS-OCT parameters were analyzed. A stepwise multiple regression analysis was performed with the BCVA as a dependent variable and SS-OCT parameters as independent variables. After its creation, the accuracy of the prediction equation was verified in the verification group.

Results:

All the parameters, except for age and total corneal cylinder, showed statistically significant correlations with BCVA (P < 0.0001). Using the stepwise multiple regression analysis, we selected 2 explanatory variables: root mean square of anterior corneal elevation (standardized regression coefficient: 1.221; P < 0.0001) and total coma aberration (standardized regression coefficient: −0.575; P = 0.001; adjusted R2 = 0.546). The prediction was correct in 84.6% of the eyes within ±1 line of Snellen BCVA.

Conclusions:

Using the equation we derived from SS-OCT parameters is a promising method to predict visual function in patients with keratoconus.
Excluding Clinically Significant Bacteremia by 24 Hours in Otherwise Well Febrile Children Younger Than 16 Years
Authors: Theodosiou Anastasia A. , Mashumba Fari , Flatt Andrew
Published: July 2019

Background:

In febrile children given empiric parenteral antibiotics, guidelines advise provisional reporting of negative blood cultures and antibiotic review after 36 hours incubation for neonates and 48 hours for older children. Following improvements in culture processing and childhood vaccination, we revisited this important clinical topic, assessing time to exclude clinically significant bacteremia in well-appearing febrile children with no comorbidities or features of sepsis.

Methods:

We analyzed the results of all 53,276 pediatric blood cultures taken during an 8-year period at a UK hospital.

Results:

1308 (2.5%) cultures were positive, of which 333 (25.5%) grew pathogens typically associated with clinically significant bacteremia. The remaining 975 (74.5%) grew organisms associated with contaminated culture, or with opportunistic infection only in children with relevant risk factors. Time to positivity (TTP) from incubation was significantly shorter for the 333 definite pathogens than the 975 contaminating/opportunistic organisms, with 92% of definite pathogens identified by 24 hours incubation. Only 3 of all definite pathogens were identified after 24 hours in children otherwise eligible for discharge at 24 hours. There was no significant difference in TTP for definite pathogens between neonates and older children. Median time from specimen collection to incubation was 3 hours.

Conclusions:

Clinically significant bacteremia can be excluded by 24 hours incubation in well-appearing febrile children with no comorbidities or features of sepsis. This is the largest dataset of its kind, and the second to compare neonates and older children. Our findings may inform future guidelines, facilitating earlier antibiotic review and discharge.
Recommendations for photoprotection in pediatric rheumatology patients
Authors: Dayrit-Castro Carmela , Tantuco Kimberly , Lara-Corrales Irene
Published: July 2019

Purpose of review

Patients seen at pediatric rheumatology are at increased risk of immediate and long-term consequences from sun exposure. The objective of this review is to build awareness of the need of sun protection in pediatric rheumatology patients.

Recent findings

Sun exposure can lead to disease exacerbations in many rheumatic diseases. There is well documented literature linking the chronic use of immunosuppressants with long-term risk of skin cancer. Although there is a lack of literature in pediatric rheumatology addressing the need of sun protection in this patient population, the young age of patients, the nature of their disease and the treatments they receive, make them a high-risk population for the effects of the sun.

Sun protection recommendations are outlined in the following manuscript, backed up by the rationale and biology of why it is important for pediatric rheumatology patients to be protected from the sun. The information reviewed in this article should be part of the education that all pediatric rheumatology patients should receive as part of their care.
Experiences of Women with Postpartum Depression Participating in a Support Group Led by Mental Health Providers
Authors: Cook Carolyn , Goyal Deepika , Allen Monica
Published: July 2019

Purpose:

The purpose of this study was to explore experiences of women currently with or at high risk for developing postpartum depression (PPD) who were participating in a postpartum support group facilitated by mental health providers.

Study Design and Methods:

Using a qualitative design, women ≥18 years of age, who had given birth within the past 2 years, and who were currently attending, or had attended the PPD support group within the past year were invited to participate. The women provided demographic data and participated in a semistructured face-to-face interview. Data were analyzed using qualitative content analysis.

Results:

Seven women between 27 and 38 years of age participated. Most were married and college educated. At time of the interviews, participants were between 5 months and 2 years postpartum and all reported taking antidepressant medications for their symptoms. Qualitative content analysis revealed three overall themes: attendance, impact, and medication adherence, with associated subthemes.

Clinical Implications:

Women attending a PPD support group facilitated by mental health providers felt supported, were more likely to disclose their symptoms to other women in the same situation, and were able to share their feelings without fear of judgment. Having concerns about antidepressant medication addressed at each meeting promoted medication adherence. Nurses working with childbearing women should be aware of community support services available for women at risk for developing PPD.
Chemotherapy supply chain safety: current data from public oncology centers in Morocco
Authors: Ouasrhir Abdelali , Rahhali Rabie , Boukhatem Noureddine
Published: July 2019

Introduction:

Since 2006, Morocco has been involved in care development for cancer patients, through regionalization of oncology centers, setting up of a program for cancer prevention, control, and treatment, finally by ensuring the quality of treatment. Chemotherapy is a risk-complexed process because of involving many health professionals. Our objective is to focus on the current state of public oncology hospitals and evaluate the chemotherapy process.

Methods:

An anonymous questionnaire was sent to 12 public centers by e-mails. It contains 4 items that establish chemotherapy process starting by receiving and storage of anticancer drugs, pharmaceutical validation of therapeutic protocols, until the administration of chemotherapy as well as the management of medical waste and expired medications.

Results:

Results showed that public regional centers represent 58.4% of participating centers, and university hospital centers represent 41.6%. Three quarters (73.3%) of hospital pharmacies have enough and appropriate receiving space. Sixty percent of pharmacist did not do any training to receive anticancer drugs. Oncology treatment protocols received in 53.3% of hospitals are not computerized. Biological data for pharmaceutical validation are not available on chemotherapy protocol in 73% of cases. All participating centers in the study confirmed that they have subcontracting contracts with companies specialized in the management of expired anticancer drugs and chemotherapy waste.

Conclusion:

Our study has shown that much effort has been made concerning the provision of oncology centers in several regions of the kingdom, anticancer drugs compounding centralization, and establishment-quality procedures that accompanied the chemotherapy process.
Well-differentiated Pancreatic Neuroendocrine Tumor in a Patient With Familial Atypical Multiple Mole Melanoma Syndrome (FAMMM)
Authors: Noë Michaël , Hackeng Wenzel M. , de Leng Wendy W.J. , Vergeer Menno , Vleggaar Frank P. , Morsink Folkert H.M. , Wood Laura D. , Hruban Ralph H. , Offerhaus G. Johan A. , Brosens Lodewijk A.A.
Published: July 2019

Germline mutations in CDKN2A result in Familial Atypical Multiple Mole Melanoma Syndrome (FAMMM), which is associated with an increased risk for pancreatic ductal adenocarcinoma and melanoma. CDKN2A is somatically inactivated in multiple neoplasms, raising the possibility that, although the data are not conclusive, germline CDKN2A mutation may also impose an increased risk for other neoplasms. We present a patient with a CDKN2A germline mutation (p16-Leiden mutation) and mosaicism for neurofibromatosis type 2, who presented with a small asymptomatic pancreatic lesion, detected during endoscopic ultrasound screening of the pancreas. After resection, the lesion was found to be a well-differentiated pancreatic neuroendocrine tumor (PanNET). Molecular analysis of the tumor showed somatic loss of the second allele, supporting a causal relation of the PanNET to the underlying FAMMM syndrome. Recent data, showing the association between certain single-nucleotide polymorphisms in the CDKN2A gene and an increased incidence for PanNET, further support a role for germline CDKN2A alterations in PanNET risk. We conclude that PanNETs can be a phenotypic expression of FAMMM syndrome. This can have implications for screening and for the diagnosis of pancreatic neoplasms in carriers of germline CDKN2A mutations.
Atypical Lymphoid Proliferations and Clonality in Helicobacter-associated Inflammatory Infiltrates in Children
Authors: Ju Jennifer Y. , Stelow Edward B. , Mahadevan Mani S. , Fan Jinbo , Aguilera Nadine S.
Published: July 2019

Helicobacter infection is considered the major predisposing factor for gastric mucosa-associated lymphoid tissue (MALT) lymphoma with initial infection likely occurring in childhood. Primary gastric MALT lymphoma most commonly occurs in patients older than 50 years which is attributed to the lengthy chronic infection time required before the development of MALT lymphoma. Our study analyzes the histologic features and presence of immunoglobulin heavy chain (IGH) clonality in Helicobacter-associated chronic gastritis (62 cases) and Helicobacter-negative chronic gastritis (17 cases) biopsies within the pediatric population, diagnosed between 1996 and 2018. Helicobacter-associated gastritis was more likely to show active inflammation (P=0.01), with no significant difference in number of germinal centers or the strength, linear property, or depth of the inflammatory infiltrate. In total, 47% (29/62) of the Helicobacter-associated cases had at least 1 lymphoepithelial lesion, equivocal or definitive (a modified Wotherspoon score of 3 to 5), compared with 24% (4/17) of the Helicobacter-negative cases (P=0.5). All cases with lymphoepithelial lesions were assessed for IGH clonality, showing the presence of monoclonality in 27% (8/30) of evaluable cases. None of our patients were diagnosed with gastric lymphoma within available follow-up data. Although 4% of our cases could be considered MALT lymphoma in an adult patient based on prominent lymphoepithelial lesions and IGH monoclonality, caution is advised when diagnosing lymphoma in the pediatric population given the good prognosis of Helicobacter-associated gastritis in this age group. It is unclear if these monoclonal lymphoid proliferations require close follow-up.
Specific Viral Etiologies Are Associated With Outcomes in Pediatric Acute Respiratory Distress Syndrome*
Authors: Roberts Anna L. , Sammons Julia S. , Mourani Peter M. , Thomas Neal J. , Yehya Nadir
Published: July 2019

Objectives:

Infectious pneumonia is the most common cause of acute respiratory distress syndrome, with viruses frequently implicated as causative. However, the significance of viruses in pediatric acute respiratory distress syndrome is unknown. We aimed to characterize the epidemiology of viral pneumonia in pediatric acute respiratory distress syndrome and compare characteristics and outcomes between pneumonia subjects with and without viruses. Secondarily, we examined the association between specific viruses and outcomes.

Design:

We performed a secondary analysis of a prospectively enrolled pediatric acute respiratory distress syndrome cohort. Subjects with pneumonia acute respiratory distress syndrome underwent testing of respiratory secretions for viruses and culture for bacteria and fungi and were stratified according to presence or absence of a virus.

Setting:

Tertiary care children’s hospital.

Patients:

Children with acute respiratory distress syndrome.

Interventions:

None.

Measurements and Main Results:

Of 544 children with acute respiratory distress syndrome, 282 (52%) had pneumonia as their inciting etiology, of whom 212 were virus-positive. In 141 of 282 (50%) pneumonia acute respiratory distress syndrome cases, a virus was the sole pathogen identified. Virus-positive pneumonia had fewer organ failures but worse oxygenation, relative to virus-negative pneumonia, with no differences in antibiotic use, ventilator duration, or mortality. Subjects with respiratory syncytial virus-associated acute respiratory distress syndrome had lower mortality (0%), and subjects with influenza-associated acute respiratory distress syndrome had shorter ventilator duration, relative to other viral acute respiratory distress syndrome. Nonadeno herpesviruses, tested for exclusively in immunocompromised subjects, had greater than 80% mortality.

Conclusions:

Pneumonia was the most common cause of pediatric acute respiratory distress syndrome, and viruses were commonly isolated as the sole pathogen. Respiratory syncytial virus and influenza were associated with better outcomes relative to other viral etiologies. Viral pneumonias in immunocompromised subjects, particularly nonadeno herpesviruses, drove the mortality rate for pneumonia acute respiratory distress syndrome. Specific viral etiologies are associated with differential outcomes in pediatric acute respiratory distress syndrome and should be accounted for in future studies.
Acquired von Willebrand Syndrome in Pediatric Extracorporeal Membrane Oxygenation Patients: A Single Institution’s Experience*
Authors: Ruth Amanda , Meador Marcie , Hui Rocky , Loftis Laura , Teruya Jun
Published: July 2019

Objectives:

1) Describe the prevalence of acquired von Willebrand syndrome in pediatric patients undergoing extracorporeal membrane oxygenation deemed to be at increased risk for the disease in our institution, 2) discuss the challenges of testing for acquired von Willebrand syndrome diagnosis, 3) describe the characteristics of the patient population found to have acquired von Willebrand syndrome and their outcomes, and 4) discuss the potential implications of acquired von Willebrand syndrome on bleeding complications.

Design:

Retrospective chart review.

Setting:

PICU and cardiovascular ICU in a single institution.

Patients:

All PICU and cardiovascular ICU extracorporeal membrane oxygenation patients 0–18 years old who underwent screening for acquired von Willebrand syndrome between January 2014 and December 2016.

Interventions:

Humate P administration to a small subset of acquired von Willebrand syndrome positive subjects.

Measurements and Main Results:

Laboratory data of identified patients were analyzed. The diagnosis of acquired von Willebrand syndrome was made based on decreased ristocetin cofactor activity to von Willebrand factor antigen ratio and/or abnormal multimer analysis. Clinical data were extracted from the chart and through the Pediatric Extracorporeal Membrane Oxygenation Outcome Registry to describe the demographics, comorbidities, and outcomes of this patient population. In the 2 years, 29 patients had laboratory testing performed for surveillance and in cases of clinical bleeding. Of these, 23 (79%) were positive by criteria. No significant difference in mortality rate was found between patients with acquired von Willebrand syndrome versus without. We also did not find a significant difference in the blood product utilization or bleeding complications between patients with acquired von Willebrand syndrome versus without. Humate P was administered in 39% of patients (9/23) who were positive for acquired von Willebrand syndrome, but no significant difference was seen in blood product utilization or bleeding complications between acquired von Willebrand syndrome patients receiving Humate P versus those who did not.

Conclusions:

Acquired von Willebrand syndrome is a common but under recognized disorder in pediatric extracorporeal membrane oxygenation patients. The clinical implications of this disorder on bleeding and its potential treatments are still unclear.
Epidemiology of Clinically Relevant Bleeding in Critically Ill Adolescents*
Authors: Pinto Matthew G. , Shabanova Veronika , Li Simon , Trakas Erin , Miksa Michael , Gertz Shira , Polikoff Lee A. , Tala Joana A. , Faustino Edward Vincent S.
Published: July 2019

Objectives:

The epidemiology of clinically relevant bleeding in critically ill adolescents, particularly those who are at high risk of venous thromboembolism, is unclear. In preparation for a randomized clinical trial of pharmacologic prophylaxis against venous thromboembolism, we characterized the epidemiology of clinically relevant bleeding in critically ill adolescents.

Design:

Post hoc analysis of data from a pediatric multicenter observational study of venous thromboembolism.

Setting:

Six PICUs.

Patients:

Adolescents 13–17 years old who received cardiac or pulmonary support for at least 48 hours were eligible. Those admitted with venous thromboembolism or receiving therapeutic anticoagulation were excluded.

Interventions:

None.

Measurements and Main Results:

Adolescents (n = 88) were followed daily for the development of any bleeding event. The severity of the event was categorized based on the definitions by the International Society on Thrombosis and Haemostasis. The frequency of clinically relevant bleeding was 29.5% (95% CI, 20.3–40.2%) or 3.7 events (95% CI, 2.5–5.4 events) per 100 patient-days. Adolescents with venous thromboembolism were more likely to develop clinically relevant bleeding (hazard ratio, 2.06; 95% CI, 1.08–3.94). Age was negatively associated with clinically relevant bleeding (hazard ratio for every 1-year increase in age: 0.68; 95% CI, 0.58–0.79). In contrast, predicted risk of mortality (hazard ratio for every 0.10 increase in risk: 1.35; 95% CI, 1.05–1.74) and admission for trauma or surgery (hazard ratio: 2.04; 95% CI, 1.21–3.44) were positively associated with clinically relevant bleeding. The association of clinically relevant bleeding with medications, interventions, or laboratory tests, including mechanical ventilation and pharmacologic prophylaxis with anticoagulation, did not reach statistical significance. Adolescents with clinically relevant bleeding stayed in the hospital longer than those without clinically relevant bleeding.

Conclusions:

Clinically relevant bleeding is common in critically ill adolescents who are at high risk of venous thromboembolism. Admission for trauma or surgery can be used to stratify the risk of clinically relevant bleeding in these adolescents.
Risk Factors for Mortality in Critically Ill Children Requiring Renal Replacement Therapy*
Authors: Hames Daniel L. , Ferguson Michael A. , Salvin Joshua W.
Published: July 2019

Objectives:

There is an increased mortality risk in critically ill children who require renal replacement therapy for acute kidney injury and fluid overload. Nevertheless, renal replacement therapy is essential in managing these patients. The objective of this study was to identify risk factors for mortality in critically ill children requiring renal replacement therapy.

Design:

Single-center, retrospective cohort analysis.

Setting:

Tertiary care children’s hospital.

Patients:

All patients admitted to an ICU at Boston Children’s Hospital from January 2009 to December 2017 who required any form of renal replacement therapy.

Interventions:

None.

Measurements and Main Results:

Four-hundred sixty-three patients required inpatient renal replacement therapy over the study period. Of these, there were 98 patients who had 99 unique encounters for renal replacement therapy that met eligibility criteria for analysis. The most common diagnoses were respiratory failure, stem cell transplant, and sepsis. The overall mortality was 55.6%. Nonsurvivors had a lower ICU admission weight compared with survivors (30.0 kg vs 44.0 kg; p = 0.037) and a higher degree of fluid accumulation at the time of renal replacement therapy initiation (17.1% vs 8.1%; p = 0.021). In multivariable logistic regression analysis, invasive mechanical ventilation (odds ratio, 7.22; 95% CI, 1.88–27.7), a longer duration of stage 3 acute kidney injury (odds ratio, 1.08; 95% CI, 1.02–1.15), and higher fluid balance in the 72 hours after initiating renal replacement therapy (odds ratio, 1.12; 95% CI, 1.05–1.20) were associated with an increased odds of mortality.

Conclusions:

Earlier renal replacement therapy initiation with respect to the development of severe acute kidney injury was associated with lower mortality in this cohort of critically ill children. Additionally, invasive mechanical ventilation at the time of renal replacement therapy initiation and a higher degree of fluid accumulation after initiating renal replacement therapy were associated with increased mortality.
Endothelial-Dependent Vasomotor Dysfunction in Infants After Cardiopulmonary Bypass
Authors: Krispinsky Luke T. , Stark Ryan J. , Parra David A. , Luan Liming , Bichell David P. , Pietsch John B. , Lamb Fred S.
Published: July 2019

Objectives:

Cardiopulmonary bypass–induced endothelial dysfunction has been inferred by changes in pulmonary vascular resistance, alterations in circulating biomarkers, and postoperative capillary leak. Endothelial-dependent vasomotor dysfunction of the systemic vasculature has never been quantified in this setting. The objective of the present study was to quantify acute effects of cardiopulmonary bypass on endothelial vasomotor control and attempt to correlate these effects with postoperative cytokines, tissue edema, and clinical outcomes in infants.

Design:

Single-center prospective observational cohort pilot study.

Setting:

Pediatric cardiac ICU at a tertiary children’s hospital.

Patients:

Children less than 1 year old requiring cardiopulmonary bypass for repair of a congenital heart lesion.

Intervention:

None.

Measurements and Main Results:

Laser Doppler perfusion monitoring was coupled with local iontophoresis of acetylcholine (endothelium-dependent vasodilator) or sodium nitroprusside (endothelium-independent vasodilator) to quantify endothelial-dependent vasomotor function in the cutaneous microcirculation. Measurements were obtained preoperatively, 2–4 hours, and 24 hours after separation from cardiopulmonary bypass. Fifteen patients completed all laser Doppler perfusion monitor (Perimed, Järfälla, Sweden) measurements. Comparing prebypass with 2–4 hours postbypass responses, there was a decrease in both peak perfusion (p = 0.0006) and area under the dose-response curve (p = 0.005) following acetylcholine, but no change in responses to sodium nitroprusside. Twenty-four hours after bypass responsiveness to acetylcholine improved, but typically remained depressed from baseline. Conserved endothelial function was associated with higher urine output during the first 48 postoperative hours (R
2 = 0.43; p = 0.008).

Conclusions:

Cutaneous endothelial dysfunction is present in infants immediately following cardiopulmonary bypass and recovers significantly in some patients within 24 hours postoperatively. Confirmation of an association between persistent endothelial-dependent vasomotor dysfunction and decreased urine output could have important clinical implications. Ongoing research will explore the pattern of endothelial-dependent vasomotor dysfunction after cardiopulmonary bypass and its relationship with biochemical markers of inflammation and clinical outcomes.
Multiparametric Quantitative MRI for the Detection of IgA Nephropathy Using Tomoelastography, DWI, and BOLD Imaging
Authors: Lang Sophia Theresa , Guo Jing , Bruns Anne , Dürr Michael , Braun Jürgen , Hamm Bernd , Sack Ingolf , Marticorena Garcia Stephan Rodrigo
Published: July 2019

Objectives

The aim of this study was to noninvasively evaluate changes in renal stiffness, diffusion, and oxygenation in patients with chronic, advanced stage immunoglobulin A nephropathy (IgAN) by multiparametric magnetic resonance imaging using tomoelastography, diffusion-weighted imaging (DWI), and blood oxygen level–dependent (BOLD) imaging.

Materials and Methods

In this prospective study, 32 subjects (16 patients with biopsy-proven IgAN and 16 age- and sex-matched healthy controls) underwent multifrequency magnetic resonance elastography with tomoelastography postprocessing at 4 frequencies from 40 to 70 Hz to generate shear wave speed (meter per second) maps reflecting tissue stiffness. In addition, DWI and BOLD imaging were performed to determine the apparent diffusion coefficient in square millimeter per second and T2* relaxation time in milliseconds, respectively. Regions including the entire renal parenchyma of both kidneys were analyzed. Areas under the receiver operating characteristic (AUCs) curve were calculated to test diagnostic performance. Clinical parameters such as estimated glomerular filtration rate and protein-to-creatinine ratio were determined and correlated with imaging findings.

Results

Success rates of tomoelastography, DWI, and BOLD imaging regarding both kidneys were 100%, 91%, and 87%, respectively. Shear wave speed was decreased in IgAN (−21%, P < 0.0001), accompanied by lower apparent diffusion coefficient values (−12%, P = 0.004). BOLD imaging was not sensitive to IgAN (P = 0.12). Tomoelastography detected IgAN with higher diagnostic accuracy than DWI (area under the curve = 0.9 vs 0.8) and positively correlated with estimated glomerular filtration rate (r = 0.66, P = 0.006).

Conclusions

Chronic, advanced stage IgAN is associated with renal softening and restricted water diffusion. Tomoelastography is superior to DWI and BOLD imaging in detecting IgAN.
Perforator Flaps Based on the Terminal Perforators of the Pectoral Branch of Thoracoacromial Vessels Axis
Authors: Thalaivirithan Margabandu Balakrishnan , Dympep Badamutlang , J. Jaganmohan Janardhanan
Published: July 2019

Background

The purpose of this article is to develop a new method for elevating the pedicled terminal pectoral perforator flaps (PTPPFs) and to resolve the difficulties and controversies that shroud the anatomy of terminal pectoral perforators from the pectoral branch of the thoracoacromial axis.

Aim

Anatomical study was conducted to assess the feasibility of perforator flaps based on the terminal perforators of the pectoral branch of the thoracoacromial vessel axis. The knowledge that gleaned from this anatomical study was applied in the clinical scenario. A clinical retrospective study was conducted to evaluate the outcome of PTPPFs for the reconstruction of postexcisional head and neck defects.

Materials and Methods

Thirty cadaveric specimens were examined for the anatomy of the terminal musculocutaneous pectoral branch perforators. Thirty-two cases (22 males, 10 females) of various head and neck postexcision defects were reconstructed with the PTPPFs in a single-stage manner. Pectoralis major muscle with its innervation was spared in all cases. All the secondary defects were closed primarily.

Results

The maximum cutaneous paddle size was 156 cm2 harvested on a single best terminal pectoral branch perforator. The average size of the cutaneous paddle harvested was 73.47 cm2. The flap complications noted (9.3%) were trivial, and all the flaps survived well. The average institutional computed score for esthetic and functional recovery at the donor and reconstructed site done by 2 independent observers were 4.56 and 3.78, respectively.

Conclusions

The recruitment of the chest skin on the terminal pectoral branch perforators resulted in a long pedicle flap with adequate qualities like color match, texture match, and pliability. This flap shall serve as a primary option for pedicle and free flap head and neck reconstructions.
Resection of Septal Adenoid Cystic Carcinoma and Primary Reconstruction of the Surgical Defect via Open Rhinoplasty
Authors: Lee Dong Kyu , Yu Myeong Sang
Published: July 2019

Adenoid cystic carcinoma is one of the most common minor salivary gland malignancies of the head and neck region. However, adenoid cystic carcinoma of the nasal septum is extremely rare. The authors herein report a case of a septal adenoid cystic carcinoma in a 68-year-old man who complained of nasal bleeding and nasal obstruction for several months. Diagnostic nasal endoscopy revealed a protruding mass arising from the anterosuperior part of the nasal septum. The tumor was removed with a safety margin using the open rhinoplasty approach and primary reconstruction of the surgical defect was performed using septal cartilage. Histopathology indicated an adenoid cystic carcinoma with cribriform pattern. Two years postoperatively, there was no evidence of recurrence, the functional and cosmetic results were good, and the patient was satisfied with the treatment outcome.
Nasal Septal Abscess Developed After Radiofrequency Cauterization for Epistaxis
Authors: Kim Taehoon , Kim Jung Soo , Heo Sung Jae
Published: July 2019

Nasal septal abscesses are commonly caused by nasal trauma, infection, and nasal surgery. As delayed treatment of nasal septal abscesses can cause various complications, including saddle nose, a prompt diagnosis with the relevant intervention is important. However, the diagnosis of nasal septal abscesses is difficult when nasal pain occurs after cauterization because there have been no formal reports of nasal septal abscesses owing to cauterization for epistaxis. Here, the authors report the first case of a nasal septal abscess that developed after cauterization. A 48-year-old woman underwent radiofrequency cauterization as a treatment for epistaxis. She developed nasal pain 10 days following cauterization, and a computed tomography scan revealed a nasal septal abscess. Careful observation should be undertaken in patients who undergo cauterization of the nasal septum, especially in patients complaining of nasal pain.