bluuebunny/crossref_metadata_2025 huggingface dataset:
The Dialectical Dilemmas of Implementation
Authors: Best Helen , Lyng Jim
Published: July 2018

Implementing a behavioural health programme involves more than simply providing training to healthcare providers. System-wide behavioural change is necessary, often including prevailing attitudes, values, and mindsets. This process frequently involves multi-faceted, deliberate activity across an organization’s many levels (clinicians, teams, administrators, managers, etc.). As a complex, multi-modal treatment for severe and life-threatening problems, implementing DBT presents unique challenges. A dialectical stance which finds a synthesis between opposing, but true, ideas helps resolve the inevitable tensions associated with introducing and sustaining DBT. This chapter identifies three dialectical dilemmas which commonly occur when implementing DBT, and offers examples of each from real-world projects. It discusses the tension between adopting DBT with full fidelity and adapting it in response to the context in which it is delivered; the tension between short-term risk management decisions and persisting with DBT delivery and maintaining a long-term view; and the tension between meeting both the organizational system’s needs and the needs of people delivering the treatment. Finally, it offers practical suggestions for those considering implementing a DBT programme.
Lighting the Good Life
Authors: Carrié Jean-Philippe
Published: July 2018

During late antiquity, the aristocratic house worked as an architectural social filtering system. Many structures of the private residence were used and combined to create, or to strengthen, an impression of social superiority. Ancient sources and archaeological evidence show clearly that light played a key role as an aesthetic element within this aristocratic housing scheme. The function of many key architectural and ornamental features were dependent on lighting. Hence the crucial importance of taking into consideration the ‘variable light’ in any attempt of architectural restitution of domus or villas. This chapter proposes to go deeper into the analysis, attempting to determine whether light should be regarded as a simple variable of aesthetic enhancement or whether, like any other ‘hard’ structures of the house, it should be considered as a fully structuring feature of the aristocratic residential space.
Lighting in Reconstructed Contexts
Authors: Gheorghiu Dragoş
Published: July 2018

Light in the context of experimental and experiential archaeology can offer valuable information on the ergonomics of work and sensoriality, especially in cases where visual interpretation of variations in intensity and colour of flame light are a determining factor in the use of technologies of fire, called pyrotechnologies. For studying the relationship of the operator with light during the technological process, one experimental approach is the reconstruction of the original context of work, where the natural and artificial illumination conditions could be restored. This chapter discusses the visual ergonomics and the sensorial experience of ceramic and glass technologists during the different stages of diurnal and nocturnal illumination in the reconstructed context of a Roman workshop.
Light and Shadow Effects in Megalithic Monuments in the Iberian Peninsula
Authors: González-García A. César
Published: July 2018

Atlantic Europe and the Mediterranean, especially the Iberian Peninsula, contain thousands of Megalithic monuments, such as dolmens and passage graves, built at the end of the Neolithic and Bronze Age. These are funereal monuments normally built with large bolders that define a space usually kept in darkness except for a period of time when light may enter the inner parts. These light and shadow displays were used in all likelihood to highlight differences between the realms of the dead and the living, and also incorporated other meanings related to the surrounding landscape and the social concept of time. How direct, indirect or penumbral light is incorporated into the otherwise dark inner parts of a dolmen are investigated. The interplay of light with the inner parts of these monuments, for instance decoration, is scrutinized. This chapter reviews these issues and outlines an interpretation in which the location, orientation, architecture, and perhaps even the shape of megalithic monuments were considered at the moment of their construction in order to incorporate light and shadow into the realm of the dead.
Bodily Experience and its Disorders
Authors: Cutting John
Published: July 2018

This chapter discusses bodily experience and its disorders, showing that bodily psychopathology is pervasive and that the different terms can be reduced to a number of general phenomenological principles. It first looks at some examples of bodily psychopathology in terms of body size, shape, color, composition, integrity, function, belongingness, etc., before analyzing the incidence of bodily psychopathology in psychiatric and neurological disorders such as schizophrenia, depressive psychosis, mania, epilepsy, and brain damage. It then examines descriptive bodily psychopathology, nosological specificity of bodily psychopathology, and psychological and neuropsychological accounts of bodily psychopathology. It also considers extant phenomenological analysis of bodily psychopathology by focusing on the insights of K. Goldstein, W. Blankenburg, and T. Fuchs. Finally, it describes the philosophical phenomenology of bodily psychopathology.
Phenomenological Psychopathology and Clinical Decision-Making
Authors: Iacoponi Eduardo , Wickham Harvey
Published: July 2018

This chapter examines how the phenomenological approach to psychopathology contributes to clinical decision making in psychiatry. It first considers competing forces in psychiatric clinical decision making, focusing in particular on the barriers that patients face in their search for a clinician to make their stories real. It then discusses factors that have contributed to the decline of phenomenological psychopathology, including the increase in importance of diagnostic classifications in psychiatry such as the Diagnostic and Statistical Manual, 3rd edition (American Psychiatric Association 1980); changes in the delivery of public mental health services; and increased attention to risk assessment for severe mental illness. It also describes clinical encounters with two patients that illustrate how phenomenological psychiatry can still contribute to sound clinical decision making.
Plays 1598–1603
Authors: Lowe Eleanor
Published: July 2018

The chapter begins by marking out the boundaries of ‘early Jonson’ with reference to theatre history and bibliography, before providing recorded responses to Jonson in the contemporary theatre. It identifies 1597 as a key year in his dramatic development, particularly pointing to the influence of George Chapman on Jonson’s playwriting and on popular London theatre more generally. The Case Is Altered, Jonson’s first extant performed play, is analysed in detail, with special attention paid to his presentation of households on the stage (the carefully delineated status of the steward, his lord, and other servants), and integral use of properties, costume and objects in stage business. The conclusion points to Jonson’s skill in crafting little worlds within the theatre, and in bringing London onto the stage.
Introduction to Ecclesiology
Authors: Avis Paul
Published: July 2018

The purpose of this introductory chapter is to provide the reader with an overview of the theological discipline of ecclesiology and a basic orientation to its questions and methods. Noting the boost that ecclesiology received from Karl Barth’s Church Dogmatics, Vatican II, and the Ecumenical Movement, the chapter proceeds to explain the etymology of ‘ecclesiology’ and then to define it as the discipline that is concerned with comparative, critical, and constructive reflection on the dominant paradigms of the identity of the church. It then mentions the primary sources of ecclesiology and charts its late arrival on the theological scene. It explores why ecclesiology is inherently problematic—because the church is a divine mystery. Recent developments within ecclesiology are introduced: missiological, ecumenical, feminist, practical, and ethnographical. Four questions to wrestle with are briefly discussed and the chapter ends by raising the possibility of ecclesiology as a vocation.
Liberation Ecclesiologies with Special Reference to Latin America
Authors: Maldonado Michelle Gonzales
Published: July 2018

This chapter starts by reflecting on the historic European and North American dominance of theology, including ecclesiology, and by noting that in recent decades minority voices from the global South have begun to make themselves heard, salient among them liberation theologians. Liberation theology, emanating from—but not confined to—Latin America, is introduced. It has developed a new theological method, with radical implications for ecclesiology. In liberation theology the principal subjects of the church are not the members of the ecclesiastical hierarchy, but the poor or otherwise marginalized, gathered in ‘base communities’ to read the Bible in the light of their experience of oppression. The gospel message is not primarily concerned with individual salvation but with social and economic justice and the sustaining of communities of mutual support. The targets of Liberation Theology also include colonialism, racism and ethnocentrism, gender discrimination, and oppression on grounds of sexual orientation.
The Metaphysics of Reasons
Authors: Olson Jonas
Published: July 2018

This chapter focuses exclusively on normative reasons. Normative reasons count in favor of actions and attitudes like beliefs, desires, feelings, and emotions. Section 11.2 explores the common ground concerning the metaphysics of reasons. We shall see that the really controversial metaphysical issues in metanormative theorizing about reasons arise with respect to the metaphysics of the reason relation. The two subsequent sections therefore go beyond the common ground and consider competing accounts of the reason relation. Robust and quietist versions of non-naturalism are considered in section 11.3 and naturalism is considered in section 11.4. Section 11.5 summarizes and gives a brief comparative assessment of the accounts considered.
Constructivism About Reasons
Authors: Southwood Nicholas
Published: July 2018

Given constructivism’s enduring popularity and appeal, it is perhaps something of a surprise that there remains considerable uncertainty among many philosophers about what constructivism is even supposed to be. My aim in this chapter is to make some progress on the question of how constructivism should be understood. I begin by saying something about what kind of theory constructivism is supposed to be. Next, I consider and reject both the standard proceduralist characterization of constructivism and Sharon Street’s ingenious standpoint characterization. I then suggest an alternative characterization according to which what is central is the role played by certain standards of correct reasoning. I conclude by considering the implications of this account for evaluating the success of constructivism. I suggest that certain challenges raised against constructivist theories are based on dubious understandings of constructivism, whereas other challenges only properly come into focus once a proper understanding is achieved.
Reasons, Choices, and Responsibility
Authors: Kearns Stephen
Published: July 2018

This chapter is divided broadly into two parts. The first part examines the idea that agents choose for (motivating) reasons. After an investigation of what this idea amounts to, arguments for the claim the agent always chooses for reasons and for the claim that agents never choose for reasons are set out and critiqued. It is concluded that, at the very least, there are deep problems with the idea that agents choose for reasons. The second part examines what light the relationship between (normative) reasons and responsibility can shed on the nature of reasons. Roughly, it is argued that, given reasons-responsive accounts of responsibility, reasons are best cashed out as being evidence of the normative or evaluative status of actions.
The Unity of Reasons
Authors: Schroeder Mark
Published: July 2018

This chapter is concerned with the question of what unifies reasons for action and reasons for belief, sometimes called practical and epistemic reasons. According to some views, reasons for belief are a special case of reasons to do something, and so epistemic reasons are a special case, very broadly speaking, of practical reasons. According to other views, reasons for action are a special case of reasons to draw some conclusion, and so practical reasons are a special case of epistemic reasons. This chapter considers some of the evidence that bears on whether either of these claims is correct, or whether instead practical and epistemic reasons have something else in common.
Subjective and Objective Reasons
Authors: Sepielli Andrew
Published: July 2018

We sometimes treat right and wrong as subjective—that is, as necessarily dependent on things like our beliefs and evidence. Think of “subjective utilitarianism.” Sometimes we treat these as objective—that is, as perhaps dependent on the way things really are, independently of our beliefs and evidence. Think of “objective utilitarianism.” Are these just different but equally acceptable ways of thinking and talking, or is one somehow privileged over the other? The philosophers I call “Dividers” take the former view; those I call “Debaters” take the latter. While lots of ink has been spilled on the topic of “subjective and objective reasons” by philosophers in both the Divider and Debater camps, no one has thus far attempted to adjudicate between the two positions. That is the task of this chapter.
Prudential and Moral Reasons
Authors: Crisp Roger
Published: July 2018

This chapter concerns the relation between prudential (“self-regarding” or “self-interested”) reasons and moral reasons. It begins with definitions of these types of reasons, arguing that moral reasons be understood as those described in ineliminably moral terminology, before moving on to central current views on reasons, well-being, and what makes actions right or wrong. Forms of egoism are distinguished and some objections to normative egoism answered. Views egoists might take on morality are then discussed, including that of Thrasymachus in Plato’s Republic. The following section covers impartial views, including the extreme form found in utilitarianism. The chapter then outlines the range of “dualistic” positions available, in which reasons are grounded both in the good of the agent and in morality. It concludes with discussion of some recent work on the relation of prudential and moral reasons.
Reasons and Emotions
Authors: Tappolet Christine
Published: July 2018

Because there are different kinds of emotions and different kinds of reasons, the question of the relation between emotions and reasons splits into several ones. This chapter focuses on whether emotions can inform us about normative reasons for actions. It starts with a brief defense of the claim that the Perceptual Theory, according to which emotions are perceptual experiences of values, is better placed than its main competitors, Feeling Theories and Conative Theories. On the basis of this, the chapter argues for two claims: that when things go well, emotions allow us to track our practical reasons, and that under certain conditions, which involve a kind of “standby control,” we are able not only to track reason, but to manifest reason-responsiveness when we act on our emotions. The upshot is that an agent can manifest reason-responsiveness even if she acts akratically, that is, against her better judgment.
Normativity and Concepts
Authors: Ginsborg Hannah
Published: July 2018

A number of philosophers, including Kant, Kripke, Boghossian, Gibbard and Brandom, can be read as endorsing the view that concepts are normative. I distinguish two versions of that view: a strong, non-naturalistic version which identifies concepts with norms or rules (Kant, Kripke), and a weaker version, compatible with naturalism, on which the normativity of concepts amounts only to their application’s being governed by norms or rules (Boghossian, Gibbard, Brandom). I consider a problem for the strong version: grasp of a rule seems to require grasp of the concepts which constitute the content of that rule, so how can we explain concept acquisition without falling into regress? I offer a Kantian response, on which grasp of a rule does not require antecedent grasp of concepts, but still involves the recognition of normativity in one’s rule-governed behavior. I distinguish the normativity of concepts, so understood, from the normativity associated with truth or warrant.
Internalism and Externalism about Reasons
Authors: Paakkunainen Hille
Published: July 2018

Internalism about normative reasons for action, in its broadest characterization, holds that each agent A’s reasons to act are constrained by some motivational fact, M, about A. Different versions of internalism differ on what M is. This chapter examines Bernard Williams’s (1981) influential version of, and argument for, internalism, in a broadly sympathetic vein. I isolate the key assumptions driving Williams’s argument, tracing their influence on Williams’s views and on the literature he sparked; and arguing that each assumption, when properly understood, is more plausible than some recent critics think. The upshot is that Williams’s internalism, and the assumptions that generate it, remain serious contenders on the contemporary scene.
Peer Mentoring as a Successful Retention Strategy for a Baccalaureate Nursing Program in a Historically Black College and University
Authors: Igbo Immaculata N. , Sule Ejim N.
Published: July 2018

A university-based, student-run nursing organization improved cultural awareness, academic environment, and performance for members of the organization. The International Student Nursing Organization sponsored cultural events and a peer mentoring program. Members who participated in the peer mentoring program were randomly matched as mentors (seniors) or mentees (juniors); mentors were awarded service hours. Statistical data was tracked over two semesters for the first cohort of students. Mentors had a higher aggregate score on their comprehensive exit and nursing licensure exams when compared to their graduating class as a whole. A collegial and learning environment was created that promoted students’ professional and leadership skills.
Failing to Fail in Undergraduate Nursing: Understanding the Phenomenon
Authors: Docherty Angie
Published: July 2018

AIM

The aim of the study was to explore and understand the phenomenon of “failing to fail.”

BACKGROUND

Phase 1 of a mixed-methods study suggested faculty in clinical settings instructed students that should not have passed preceding placements; students in didactic settings also passed exams that merited a fail. Phase 2 explored this phenomenon.

METHOD

A multisite qualitative case study targeted baccalaureate and community college faculty to support analysis using replication logic. Data collection was conducted via semistructured interview.

RESULTS

Eighteen demographically diverse cases were recruited (including age, experience, and full-/part-time status). Factors supporting failing to fail included being good enough, clinical/didactic dichotomy, team grading, and being the bad guy.

CONCLUSION

The consistency of enabling factors suggests a collective approach is required to address failing to fail, including pedagogical preparation and cross-school mechanisms for ensuring grading parity. Effort must address integrity and teaching excellence in all aspects of nursing education.
Budget Friendly Simulation for Clinical Nursing Education: Putting It All Together
Authors: Zamora Zelne , Shedd Joanna , Kittipha Panicha
Published: July 2018

Clinical simulation in nursing has become increasingly valuable in helping students learn tasks and assessments in a nonthreatening environment. Evaluating student assessments can promote collegiality among faculty. This article focuses on three tips for faculty used by one university to objectively capture a clinical snapshot in a cost-effective manner: 1) write one’s own scenarios, 2) create assessment forms using Word, and 3) employ bar scanning with quick response code readers.
Competencies, Milestones, and a Level of Supervision Scale for Entrustable Professional Activities for Scholarship
Authors: Mink Richard B. , Myers Angela L. , Turner David A. , Carraccio Carol L.
Published: July 2018

Problem

Scholarship is an important element of both undergraduate and graduate medical education, and scholarly activity is required for all pediatric fellows. However, despite the creation of entrustable professional activities (EPAs) for scholarship, the specific progressive levels of performance and the appropriate level of supervision for a given performance level have not been defined. The authors developed competencies and milestones for the scholarship EPA to provide a framework for assessment across the continuum; a level of supervision scale was also developed.

Approach

The Vitae Researcher Development Framework served as a template to create the competencies and milestones for the scholarship EPA. Beginning in September 2015 and using a modified Delphi approach, three drafts were circulated to individuals with expertise in various types of scholarship until broad agreement was achieved. Then, in October 2016, the Steering Committee of the Subspecialty Pediatrics Investigator Network created a level of supervision scale, modeled after one it had previously developed.

Outcomes

Eight competencies were identified as important in making entrustment decisions related to scholarship. For each competency, five milestone levels that span the continuum from novice to expert were created. A supervision scale with five progressive levels of entrustment was also created.

Next Steps

Next steps include a study to obtain validity evidence for the supervision scale and determine the correlation between milestone and supervision levels. These competencies, milestones, and supervision levels can potentially serve as a road map for trainees and junior faculty and also play a role in the assessment of physician–scientists.
Massachusetts Child Psychiatry Access Program for Moms
Authors: Byatt Nancy , Straus John , Stopa Arielle , Biebel Kathleen , Mittal Leena , Moore Simas Tiffany A.
Published: July 2018

OBJECTIVE:

To describe the utilization and quality assessment of a population-based program to help health care providers address mental health and substance use disorders among pregnant and postpartum women, the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms).

METHODS:

The Massachusetts Child Psychiatry Access Program for Moms builds health care providers' capacity to address perinatal mental health and substance use disorders through 1) trainings and toolkits, 2) telephonic access to perinatal psychiatric consultation, and 3) facilitating referral to community resources. Clinical encounter data were collected during telephone consultations. Focus groups were conducted with health care providers and staff from enrolled practices. In-depth interviews were conducted with patients served by the practices that participated in the focus groups. Transcribed interviews were analyzed by two researchers using an iterative, interpretive process with a grounded theory framework.

RESULTS:

In the first 3.5 years, MCPAP for Moms enrolled 145 obstetric practices, conducted 145 trainings for 1,174 health care providers, and served 3,699 women. Of telephone consultations provided, 42% were with obstetric care providers–midwives and 16% with psychiatrists. Health care providers perceived that MCPAP for Moms facilitates health care providers detecting and addressing depression and women disclosing symptoms, seeking help, and initiating treatment. Obstetric practices reported that they need additional support to more proactively address and further improve depression care.

CONCLUSION:

The high volume of encounters, sustained utilization over 3.5 years, and qualitative themes identified from health care providers and patients demonstrate that MCPAP for Moms is a feasible, acceptable, and sustainable approach to increasing access to evidence-based treatments for perinatal mental health and substance use disorders on a population-based level.
Cumulative Financial Burden of Readmissions for Biliary Pancreatitis in Pregnant Women
Authors: Juo Yen-Yi , Khrucharoen Usah , Sanaiha Yas , Seo Young-Ji , Dutson Erik , Benharash Peyman
Published: July 2018

OBJECTIVE:

To evaluate the cumulative hospitalization cost differences between routine cholecystectomy and an observational approach during index hospitalization for pregnant patients.

METHODS:

A retrospective cohort study of 1,245 pregnant women with biliary pancreatitis across the United States between 2010 and 2014 was performed using the Nationwide Readmissions Database. Cumulative costs and complications were compared between patients with and without cholecystectomy during both initial and subsequent hospitalizations.

RESULTS:

Cholecystectomy was performed at index hospitalization in 374 patients (374/1,245 [30.0%]). Those who did not undergo index cholecystectomy experienced higher 30-day readmissions (33.7% vs 5.3%, P<.01), and 24.5% eventually underwent interval cholecystectomy. Incidence of bile duct injury was exceedingly low for cholecystectomies performed during either index or subsequent hospitalizations (4/548 [0.7%] vs 12/213 [1.5%], P<.01). No significant difference in risk of premature delivery and abortion was observed (13.3% vs 13.2%, P=.98). Most common diagnoses during readmission included cholelithiasis (44.9%), acute pancreatitis (29.9%), cholecystitis (19.9%), choledocholithiasis (12.8%), chronic pancreatitis (4.2%), cholangitis (1.7%), and pancreatic pseudocyst (1.1%). Patients who underwent cholecystectomy during the index hospitalization had the lowest average cumulative hospitalization episodes, followed by patients undergoing nonoperative management; patients undergoing interval cholecystectomy experienced the highest average hospitalization episodes (1.4 vs 1.7 vs 2.9 hospitalizations, P<.01 for both comparisons). Although initial hospitalization cost was higher for patients who underwent cholecystectomy during index admission, the cumulative hospitalization cost became lower when costs for subsequent readmissions were factored in.

CONCLUSION:

Early cholecystectomy should be considered in pregnant patients with biliary pancreatitis to reduce readmission costs, because there were no differences in postoperative outcomes.
Prophylactic Negative Pressure Wound Therapy and Wound Complication After Cesarean Delivery in Women With Class II or III Obesity
Authors: Wihbey Kristina A. , Joyce Ellen M. , Spalding Zachary T. , Jones Hayley J. , MacKenzie Todd A. , Evans Rebecca H. , Fung June L. , Goldman Marlene B. , Erekson Elisabeth
Published: July 2018

OBJECTIVE:

To compare the occurrence of superficial surgical site infections in obese women using prophylactic negative pressure therapy with standard dressings after cesarean delivery.

Methods:

We conducted a randomized controlled, nonblinded, two-center study of prophylactic negative pressure therapy compared with standard surgical dressings placed at the time of primary closure at cesarean delivery in obese women with body mass indexes (BMI) of 35 or higher (ie, class II and III obesity). Our primary outcome was occurrence of a superficial surgical site infection. We assumed a superficial surgical site infection occurrence rate of 20% and intended to recruit 400 women. However, after low enrollment of 166 women over 24 months, an interim analysis for futility was conducted and the decision was made to halt the study.

RESULTS:

Women were recruited between January 5, 2015, and January 7, 2017, from two sites. The mean BMI on admission was 44.9 (±8) for the prophylactic negative wound therapy group and 43.4 (±7) for the standard dressing group. There were no differences in the occurrence of observed superficial surgical site infections between women using prophylactic negative pressure wound therapy (12/80 [15%]) compared with women who received the standard dressing (8/81 [10%], P=.35, relative risk 1.52, 95% CI 0.66–3.52). There were no differences in the occurrence of composite wound complications between women using prophylactic negative pressure wound therapy (25/80 [31%]) compared with women who received the standard dressing (24/81 [30%], P=.87).

CONCLUSION:

In this randomized controlled trial that did not achieve full anticipated enrollment, we did not observe a decrease in superficial surgical site infections after cesarean delivery in obese women with the use of prophylactic negative pressure wound therapy.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02390401.
Influence of Body Mass Index on Fetal Fraction Increase With Gestation and Cell-Free DNA Test Failure
Authors: Rolnik Daniel L. , Yong Yuanqi , Lee Timothy J. , Tse Cheryl , McLennan Andrew C. , da Silva Costa Fabricio
Published: July 2018

OBJECTIVE:

To assess the influence of body mass index (BMI) on fetal fraction increase with gestational age and on the rates of test failure.

METHODS:

We performed a cross-sectional study of consecutive singleton pregnancies in which cell-free DNA screening for fetal aneuploidies was performed from 10 weeks of gestation, between May 2013 and January 2018, at two fetal medicine clinics in Australia using one of two different platforms. Maternal characteristics, fetal fraction, and failure after a first attempt (“no-call”) and after resampling (“test failure”) were recorded. Body mass index was classified as normal (BMI less than 25.0), overweight (BMI 25.0–29.9), obesity class I (BMI 30.0–34.9), and obesity classes II and III (BMI 35.0 or greater). Fetal fraction and proportions of no-call results and test failure were compared between the groups.

RESULTS:

Of 14,223 singleton pregnancies included, 8,583 (60.3%) were screened with platform A and 5,640 (39.7%) with platform B. Median fetal fraction values were lower, and no-call and failure rates were higher in increased BMI groups across both platforms (P<.001 in both). When compared with women with normal BMIs, women with BMIs of 35 or greater had a significantly smaller increase in fetal fraction (0.1 vs 0.3 units/wk, P<.001, in both platforms). In this subgroup, when compared with women with normal BMIs, the odds ratios for a no-call result were 22.0 (95% CI 13.8–35.3, 16.6% vs 0.9%) and 8.0 (95% CI 4.1–15.6, 7.8% vs 1.0%) and for a failed test were 25.0 (95% CI 11.2–55.7, 6.4% vs 0.3%) and 5.8 (95% CI 2.0–17.3, 2.7% vs 0.5%) using platforms A and B, respectively.

CONCLUSION:

The increase in fetal fraction throughout gestation in women with BMIs of 35 or above is minimal. Postponing the test is unlikely to reduce test failure rates in this population.
Gradual ulnar lengthening by an Ilizarov ring fixator for correction of Masada IIb forearm deformity without tumor excision in hereditary multiple exostosis: preliminary results
Authors: Ahmed Amin Abdel Razek Youssef
Published: July 2018

Bony exostoses are benign osteocartilaginous growths that start close to growth plates. Approximately 30–60% of patients have forearm deformities. The commonly encountered forearm deformities in these patients are bowing of the radius, with or without ulnar drift of the carpus, radial head dislocation, shortening of the ulna, and radial head dislocation. The current study reported on the results of management of radial head dislocation for type IIb Masada and Oho classification of forearm deformities by Ilizarov ulnar lengthening and without tumor excision. A series of 12 patients with Masada type IIb deformity were treated by Ilizarov lengthening at AlHadra University Hospital, Alexandria, Egypt, during the period from January 2008 to June 2014. There were eight males and four females; the right forearm was affected in seven patients. The mean age of the patients was 8.7 years (range: 7.5–10 years). All cases showed ulnar shortening with distal ulnar exostosis and radial head dislocation (Masada type IIb). All patients were operated on under general anesthesia, with application of the Ilizarov frame to the forearm. The frame used was assembled of two complete rings; the proximal one was fixed to the proximal ulna and the distal ring was fixed to both radius and ulna. Ulnar osteotomy was performed between the two rings, followed by ulnar lengthening 10 days postoperatively to lengthen the ulna and pull down the radius. Over a follow-up period of 33.2 months (24–48 months), all patients showed spontaneous reduction of the radial head and correction of the forearm deformity. The range of motion improved: flexion increased from 117.5° (110–130°) to 145° (130–160°) and extension increased to 4.6° (0–10°), whereas it was 13.8° (10–20°) preoperatively and the supination increased from 46.3° (40–50°) preoperatively to 73.6° (65–80°) postoperatively. Pronation improved from a preoperative average of 37.9° (30–40°) to 70.8° (60–80°) at the end of follow-up. The average amount of ulnar length was 27.9 mm (25–35) and the duration of external fixation was 103.3 days on average, with a range of 90–130. Thus, the average external fixation index was 3.7 days/mm (range: 3.6–4.0). Gradual lengthening of the ulna and pulling down the radius with an Ilizarov frame is an excellent method for correction of forearm deformity in patients with multiple hereditary exostosis (Masada IIb). Early intervention is the key to achieving spontaneous reduction of the radial head in all patients without the need for corrective osteotomy or tumor excision. Level of evidence: level IV.
Validation and Clinical Evaluation of a Method for Double-Blinded Blood Pressure Target Investigation in Intensive Care Medicine*
Authors: Grand Johannes , Meyer Anna Sina P. , Hassager Christian , Schmidt Henrik , Møller Jacob E. , Kjaergaard Jesper
Published: July 2018

Objectives:

No double-blinded clinical trials have investigated optimal mean arterial pressure targets in the ICU. The aim of this study was to develop and validate a method for blinded investigation of mean arterial pressure targets in patients monitored with arterial catheter in the ICU.

Design:

Prospective observational study (substudy A) and prospective, randomized, controlled clinical study (substudy B).

Setting:

ICU, Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark.

Patients:

Adult patients resuscitated from out-of-hospital cardiac arrest.

Interventions:

Standard blood pressure measuring modules were offset to display 10% lower or higher blood pressure values. We then: 1) confirmed this modification in vivo by comparing offset to standard modules in 22 patients admitted to the ICU. Thereafter we 2) verified the method in two randomized, clinical trials, each including 50 out-of-hospital cardiac arrest patients, where the offset of the blood pressure module was blinded to the treating staff.

Measurements and Main Results:

Substudy A showed that the expected separation of blood pressure measurements was achieved with an excellent correlation of the offset and standard modules (R
2 = 0.997). Bland-Altman plots showed no bias of modified modules over a clinically relevant range of mean arterial pressure. The primary endpoint of the clinical trials was between-group difference of norepinephrine dose needed to achieve target mean arterial pressure. Trial 1 aimed at a 10% difference between groups in mean arterial pressure (targets: 65 and 72 mm Hg, respectively) and demonstrated a separation of 5 ± 1 mm Hg (p < 0.001). The difference in norepinephrine dose was not significantly different (0.03 ± 0.03 µg/kg/min; p = 0.42). Trial 2 aimed at a 20% difference between groups in mean arterial pressure (targets: 63 and 77 mm Hg, respectively). Separation was 12 ± 1 mm Hg (p < 0.01) in mean arterial pressure and 0.07 ± 0.03 µg/kg/min (p < 0.01) in norepinephrine dose.

Conclusions:

The present method is feasible and robust and provides a platform for double-blinded comparison of mean arterial pressure targets in critically ill patients.
The management of locally advanced cervical cancer
Authors: Naga CH Pushpa , Gurram Lavanya , Chopra Supriya , Mahantshetty Umesh
Published: July 2018

Purpose of review

Cervical cancer is still a major cause of morbidity and mortality among women worldwide. Surgery and chemoradiation are widely utilized treatments for cervical cancer. Despite the available standard treatment of choice, outcome is suboptimal among patients with LACC. It is vital to integrate the evidence generated from high-quality research work for effective management of these cases. This review intends to critically evaluate the latest evidence supporting the available treatment modalities and to provide a comprehensive overview of recent advances and ongoing research in the management of LACC.

Recent findings

Research advances in imaging and radiotherapy technologies, incorporating imaging into brachytherapy planning, use of newer targeted agents, chemotherapy intensification and immunotherapy are some of the new therapeutic options that have been in the forefront of research to improve the outcome of patients with LACC.

Advanced imaging modalities are increasingly being utilized to tailor treatments. Neoadjuvant chemotherapy followed by surgery does not improve outcomes in FIGO Stage IB2–IIB. Although cisplatin-based concurrent chemoradiation is the standard of care, more aggressive systemic therapies (neoadjuvant or adjuvant chemotherapy and chemoradiation) and use of newer agents, still remains investigational.
What Is the Survivorship of Revision Surgery Performed for the Chronically Dislocated THA?
Authors: Brown Timothy S. , McLaughlin Richard J. , Berry Daniel J. , Lewallen David G. , Trousdale Robert T. , Sierra Rafael J.
Published: July 2018

Background

Instability remains one of the most common indications for revision THA. However, little is known about the efficacy of surgery for and the complications associated with revision THA for patients with a chronically dislocated THA, which we define as a dislocation of more than 4 weeks.

Questions/purposes

For patients with a chronically dislocated THA undergoing revision THA, we asked (1) What is the survivorship free from additional revision for these procedures? (2) What complications are associated with revision THA in this setting? (3) What are the clinical outcomes as measured by the Harris hip score in these procedures?

Methods

From 1998 to 2014, 1084 patients who underwent revision THA for instability were reviewed and 33 patients (33 hips) were identified who had a hip that had been dislocated for more than 4 weeks. Median time dislocated was 4 months (range, 1–120 months), and the mean distance of the femoral head above hip center at presentation was 45 mm. Mean patient age was 67 ± 17 years, and 79% of patients (26 of 33) were women. During the period in question, we used four approaches: Treatment with acetabular component revision in 18 of 33 patients (55%), head and liner exchange in nine patients (27%), both-component revision in five patients (15%), and isolated femoral component revision in one patient (3%). A constrained liner was used in 17 patients (52%), including six of the patients treated with acetabular component revision, and three of those who had both-component revisions. During the period in question, our general indications were hip pain and/or unacceptable function with the chronically dislocated prosthesis. Our sample size was too small to evaluate the association of the procedure choice on survivorship or complication risk. We used Kaplan-Meier survivorship analysis to estimate survivorship free from complication, reoperation, or revision. Mean followup was 4.4 years (range, 2–10 years).

Results

Survivorship free from any revision, complication, or reoperation was 61% at 5 years (95% CI, 43–82). Survivorship free from revision was 83% at 5 years (95% CI, 67–98). Etiology for revision was aseptic loosening in three of 33 hips (9%), recurrent dislocation in two hips (6%), and deep periprosthetic joint infection in two hips (6%). Five complications (15%) did not result in a reoperation, including one dislocation and one incomplete peroneal nerve palsy in a patient after an anterolateral approach. The Harris hip score improved from mean 50 ± 17 preoperatively to mean 80 ± 11 at 5 years.

Conclusions

Chronically dislocated THAs can be successfully managed with revision THA. We recommend close evaluation of the components for aseptic loosening, performing revision surgery only on patients with pain and poor function, and thoroughly counseling patients that survivorship is modest and complications are common.

Level of Evidence

Level IV, therapeutic study.
The Obese Colorectal Surgery Patient: Surgical Site Infection and Outcomes
Authors: Wahl Tyler S. , Patel Fenil C. , Goss Lauren E. , Chu Daniel I. , Grams Jayleen , Morris Melanie S.
Published: July 2018

BACKGROUND:

Obese patients undergoing colorectal surgery are at increased risk for adverse outcomes. It remains unclear whether these risks can be further defined with more discriminatory stratifications of obesity.

OBJECTIVE:

The purpose of this study was to understand the association between BMI and 30-day postoperative outcomes, including surgical site infection, among patients undergoing colorectal surgery.

DESIGN:

This was a retrospective cohort study.

SETTINGS:

The 2011–2013 American College of Surgeons National Surgical Quality Improvement Program database was used.

PATIENTS:

Patients included those undergoing elective colorectal surgery in 2011–2013 who were assessed by the American College of Surgeons National Surgical Quality Improvement Program.

MAIN OUTCOME MEASURES:

BMI was categorized into World Health Organization categories. Primary outcome was 30-day postoperative surgical site infection. Secondary outcomes included all American College of Surgeons National Surgical Quality Improvement Program–assessed 30-day postoperative complications.

RESULTS:

Our cohort included 74,891 patients with 4.4% underweight (BMI <18.5), 29.0% normal weight (BMI 18.5–24.9), 33.0% overweight (BMI 25.0–29.9), 19.8% obesity class I (BMI 30.0–34.9), 8.4% obesity class II (BMI 35.0–39.9), and 5.5% obesity class III (BMI ≥40.0). Compared with normal-weight patients, obese patients experienced incremental odds of surgical site infection from class I to class III (I: OR = 1.5 (95% CI, 1.4–1.6); II: OR = 1.9 (95% CI, 1.7–2.0); III: OR = 2.1 (95% CI, 1.9–2.3)). Obesity class III patients were most likely to experience wound disruption, sepsis, respiratory or renal complication, and urinary tract infection. Mortality was highest among underweight patients (OR = 1.3 (95% CI, 1.0–1.8)) and lowest among overweight (OR = 0.8 (95% CI, 0.6–0.9)) and obesity class I patients (OR = 0.8 (95% CI, 0.6–1.0)).

LIMITATIONS:

Retrospective analysis of American College of Surgeons National Surgical Quality Improvement Program hospitals may not represent patients outside of the American College of Surgeons National Surgical Quality Improvement Program and cannot assign causation or account for interventions to improve surgical outcomes.

CONCLUSIONS:

Patients with increasing BMI showed an incremental and independent risk for adverse 30-day postoperative outcomes, especially surgical site infections. Strategies to address obesity preoperatively should be considered to improve surgical outcomes among this population. See Video Abstract at http://links.lww.com/DCR/A607.
A prospective study of inflammatory biomarker levels and risk of early menopause
Authors: Bertone-Johnson Elizabeth R. , Manson JoAnn E. , Purdue-Smithe Alexandra C. , Hankinson Susan E. , Rosner Bernard A. , Whitcomb Brian W.
Published: July 2018

Objective:

Early menopause, the cessation of ovarian function before age 45, has consequences for fertility and cardiovascular health. Evidence from studies of women with autoimmune conditions and genetic studies supports a role for inflammation in early menopause, but the association of inflammatory markers and risk has not been directly evaluated.

Methods:

We assessed the relation of the soluble fraction of tumor necrosis factor alpha receptor 2 (sTNFR2), C-reactive protein, interleukin-6 (IL6) levels with incident early menopause among Nurses’ Health Study II participants who provided a premenopausal blood sample in 1996 to 1999. Cases (n = 328) were women reporting natural menopause between blood collection and age 45.

Controls (n = 492) included (1) 328 women with menopause after age 47, matched 1:1 with cases on age at blood collection and other factors; and (2) 164 additional women with menopause after age 45.

Results:

In multivariable models comparing cases and n = 492 controls, we observed a significant association of sTNFR2 levels and risk of early menopause (P = 0.002). Compared with women with the lowest sTNFR2 levels, odds ratios (95% CIs) for quartiles 2 to 4 were 0.60 (0.38-0.95), 0.93 (0.61-1.43), and 1.40 (0.93-2.11). Results further adjusting for antimüllerian hormone levels were similar in magnitude, as were results from sensitivity analyses of matched cases and controls (n = 328 pairs), nonsmokers, and leaner women. C-reactive protein and IL6 levels were unrelated to risk.

Conclusions:

The observation of lower risk of early menopause among women with moderate sTNFR2 levels compared with women with lower and higher levels warrants further prospective study.
Enhanced Drug Delivery to the Skin Using Liposomes
Authors: Blueschke Gert , Boico Alina , Negussie Ayele H. , Yarmolenko Pavel , Wood Bradford J. , Spasojevic Ivan , Fan Ping , Erdmann Detlev , Schroeder Thies , Sauerbier Michael , Klitzman Bruce
Published: July 2018

Background:

Enhancing drug delivery to the skin has importance in many therapeutic strategies. In particular, the outcome in vascularized composite allotransplantation mainly depends on systemic immunosuppression to prevent and treat episodes of transplant rejection. However, the side effects of systemic immunosuppression may introduce substantial risk to the patient and are weighed against the expected benefits. Successful enhancement of delivery of immunosuppressive agents to the most immunogenic tissues would allow for a reduction in systemic doses, thereby minimizing side effects. Nanoparticle-assisted transport by low temperature–sensitive liposomes (LTSLs) has shown some benefit in anticancer therapy. Our goal was to test whether delivery of a marker agent to the skin could be selectively enhanced.

Methods:

In an in vivo model, LTSLs containing doxorubicin (dox) as a marker were administered intravenously to rats that were exposed locally to mild hyperthermia. Skin samples of the hyperthermia treated hind limb were compared with skin of the contralateral normothermia hind limb. Tissue content of dox was quantified both via high-performance liquid chromatography and via histology in skin and liver.

Results:

The concentration of dox in hyperthermia-treated skin was significantly elevated over both normothermic skin and liver. (P < 0.02).

Conclusions:

We show here that delivery of therapeutics to the skin can be targeted and enhanced using LTSLs. Targeting drug delivery with this method may reduce the systemic toxicity seen in a systemic free-drug administration. Development of more hydrophilic immunosuppressants in the future would increase the applicability of this system in the treatment of rejection reactions in vascularized composite allotransplantation. The treatment of other skin condition might be another potential application.