bluuebunny/crossref_metadata_2025 huggingface dataset:
Establishment of a Rapid Detection Method for Rice Blast Fungus Based on One-Step Loop-Mediated Isothermal Amplification (LAMP)
Authors: Li Ling , Zhang Shu Ya , Zhang Chuan-Qing
Published: March 2019

Rice blast is one of the most serious diseases for rice, and controlling the filamentous fungus Magnaporthe oryzae that causes rice blast is crucial for global food security. Typically, early infected rice does not show symptoms. Therefore, the early diagnosis of rice blast is particularly important to avoid uncontrollable propagation of rice blast fungus. In the present work, a rapid and efficient loop-mediated isothermal amplification (LAMP) method was developed to detect the pathogen at the early infected stage of rice. The Alb1 superfamily hypothetical protein MGG_04322, a nuclear shuttling factor involved in ribosome and melanin biogenesis, was chosen as the target for designing the LAMP primers. The LAMP assay enabled rapid detection of as little as 10 pg of pure genomic DNA of M. oryzae. In addition, we established the quantitative LAMP (q-LAMP) detection system to quantify the conidia of rice blast fungus. The q-LAMP assay enabled rapid detection (within 35 min) of the fungal spores at a sensitivity of 3.2 spores/ml. In addition, the assay sets up the linearization formula of the standard curve as y = 0.3066 + 15.33x (where x = amplification of time), inferring that spore number = 100.60y. In addition, the q-LAMP assay was successfully used to detect the presence of the virulence strains of M. oryzae (wild type) in comparison with that of the two mutant strains by quantifying the biomass within host tissue. These results provide a useful and convenient tool for detecting M. oryzae that could be applied in the incubation period of rice blast before symptoms appear.
Anthracnose Fruit and Root Necrosis of Strawberry Are Caused by a Dominant Species Within the Colletotrichum acutatum Species Complex in the United States
Authors: Wang Nan-Yi , Forcelini Bruna B. , Peres Natalia A.
Published: March 2019

Strawberry anthracnose fruit rot and root necrosis, caused by Colletotrichum acutatum, are primary limiting factors in fruit production fields in the United States. Recent research focusing on the phenotypic and genetic characteristics of this species has shed light on the diversity of the C. acutatum species complex. In this study, we performed multilocus sequence analysis of four genetic loci to characterize 217 C. acutatum isolates collected over a 23-year period from symptomatic plant tissues of strawberry from six different states. The results revealed two Colletotrichum spp. (C. nymphaeae and C. fioriniae), with 97.7% of the isolate collection (212 of 217) belonging to C. nymphaeae as a dominant clonal linage, regardless of the isolation source. No correlation between species groups and geographical origins of the isolates was observed. Further sequence comparison between historical and contemporary isolates showed the same populations being widely distributed throughout the strawberry nurseries and production fields in the United States and Canada. Subsequently, a subset of 12 isolates representing different quinone-outside inhibitor fungicide resistance profiles from root or fruit tissue of strawberry was selected for comparison of pathogenicity on strawberry. In this test, isolates of different resistance groups or different isolation sources exhibited a similar degree of aggressiveness and caused indistinguishable symptoms on strawberry crowns (P = 0.9555 and 0.7873, respectively) and fruit (P = 0.1638 and 0.1141, respectively), although a significant difference among individual isolates was observed in detached-fruit assays (P = 0.0123). Separate pathogenicity tests using isolates of the two species revealed C. nymphaeae being more aggressive than C. fioriniae in infecting strawberry roots and crowns (P = 0.0073). Therefore, given the occurrence and pathogenicity of C. nymphaeae, this species is likely the sole cause responsible for strawberry anthracnose in the United States.
Urinary Tract Infection After Hysterectomy for Benign Gynecologic Conditions or Pelvic Reconstructive Surgery
Authors: El-Nashar Sherif A. , Singh Ruchira , Schmitt Jennifer J. , Leon Daniel Carranza , Arora Chetna , Gebhart John B. , Occhino John A.
Published: March 2019

(Abstracted from Obstet Gynecol 2018;132:1347–1357)

About half of all women will experience at least 1 urinary tract infection (UTI) in their lifetimes, and the infection will recur in more than 10% of postmenopausal women. Pelvic surgery increases risk of UTI.
Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia: A Randomized Clinical Trial
Authors: Cahill Alison G. , Srinivas Sindhu K. , Tita Alan T. N. , Caughey Aaron B. , Richter Holly E. , Gregory W. Thomas , Liu Jingxia , Woolfolk Candice , Weinstein David L. , Mathur Amit M. , Macones George A. , Tuuli Methodius G.
Published: March 2019

(Abstracted from JAMA 2018;320(14):1444–1454)

Despite the frequency of childbirth, many aspects of labor management lack an evidence-based approach. The second stage of labor, defined as the interval from complete cervical dilation through delivery of the fetus, is the most physiologically demanding period of labor for both the mother and the fetus.
An Evaluation of Fetal Heart Rate Characteristics Associated With Neonatal Encephalopathy: A Case-Control Study
Authors: Frey H. A. , Liu X. , Lynch C. D. , Musindi W. , Samuels P. , Rood K. M. , Thung S. F. , Bakk J. M. , Cheng W. , Landon M. B.
Published: March 2019

(Abstracted from BJOG 2018;125:1480–1487)

Neonatal encephalopathy is a clinical condition identified shortly after birth in term or near-term infants that is characterized by abnormal neurological function. Affected infants often present with a decreased level of consciousness or seizures, as well as difficulty initiating and maintaining respirations and abnormal reflexes or tone.
Maternal Mortality After Cesarean Section in the Netherlands
Authors: Kallianidis Athanasios F. , Schutte Joke M. , van Roosmalen Jos , van den Akker Thomas
Published: March 2019

(Abstracted from Eur J Obstet Gynecol Reprod Biol 2018;229:148–152)

Cesarean delivery rates have increased worldwide, despite several recommendations by the World Health Organization to curb this increase. A World Health Organization ecological study found that rates above 10% are not associated with improved maternal and perinatal outcomes.
Pregnancy Outcome of Autosomal Aneuploidies Other Than Common Trisomies Detected by Noninvasive Prenatal Testing in Routine Clinical Practice
Authors: Wan Junhui , Li Ru , Zhang Yongling , Jing Xiangyi , Yu Qiuxia , Li Fatao , Li Yan , Zhang Lina , Yi Cuixing , Li Jian , Li Dongzhi , Liao Can
Published: March 2019

(Abstracted from Prenat Diagn 2018;38:849–857)

The discovery of cell-free fetal DNA in maternal plasma and the invention of massively parallel sequencing have made noninvasive prenatal testing (NIPT) for fetal common aneuploidies (trisomies 13, 18, and 21) a clinical reality. Noninvasive prenatal testing has been recommended as a first-tier or second-tier screening test for common fetal trisomies, with lower false-positive rates and higher positive predictive values than serum biochemical screening.
Evidence-Based Guidelines for Vaginal Hysterectomy of the International Society for Gynecologic Endoscopy (ISGE)
Authors: Chrysostomou Andreas , Djokovic Dusan , Edridge William , van Herendael Bruno J.
Published: March 2019

(Abstracted from Eur J Obstet Gynecol Reprod Biol 2018;231:262–267)

Hysterectomy can be performed abdominally, vaginally, or laparoscopically, with or without robotic assistance. Abdominal hysterectomy (AH) for benign uterine conditions is the most commonly chosen route worldwide.
Neoadjuvant Chemotherapy Versus Debulking Surgery in Advanced Tubo-Ovarian Cancers: Pooled Analysis of Individual Patient Data From the EORTC 55971 and CHORUS Trials
Authors: Vergote Ignace , Coens Corneel , Nankivell Matthew , Kristensen Gunnar B. , Parmar Mahesh K. B. , Ehlen Tom , Jayson Gordon C. , Johnson Nick , Swart Ann Marie , Verheijen René , McCluggage W. Glenn , Perren Tim , Panici Pierluigi Benedetti , Kenter Gemma , Casado Antonio , Mendiola Cesar , Stuart Gavin , Reed Nick S. , Kehoe Sean
Published: March 2019

(Abstracted from Lancet Oncol 2018;19:1680–1687)

Most women with carcinoma of the ovary, fallopian tube, or peritoneum (tubo-ovarian cancer) present with advanced disease and have a very poor prognosis. An essential therapeutic strategy in these women has been primary debulking surgery (PDS), but no randomized controlled trials have demonstrated an improved prognosis of patients with this strategy.
Using Electronic Health Record Data to Assess Residents’ Clinical Performance in the Workplace: The Good, the Bad, and the Unthinkable
Authors: Sebok-Syer Stefanie S. , Goldszmidt Mark , Watling Christopher J. , Chahine Saad , Venance Shannon L. , Lingard Lorelei
Published: March 2019

Purpose

Novel approaches are required to meet assessment demands and cultivate authentic feedback in competency-based medical education. One potential source of data to help meet these demands is the electronic health record (EHR). However, the literature offers limited guidance regarding how EHR data could be used to support workplace teaching and learning. Furthermore, given its sheer volume and availability, there exists a risk of exploiting the educational potential of EHR data. This qualitative study examined how EHR data might be effectively integrated and used to support meaningful assessments of residents’ clinical performance.

Method

Following constructivist grounded theory, using both purposive and theoretical sampling, in 2016–2017 the authors conducted individual interviews with 11 clinical teaching faculty and 10 senior residents across 12 postgraduate specialties within the Schulich School of Medicine and Dentistry at Western University. Constant comparative inductive analysis was conducted.

Results

Analysis identified key issues related to affordances and challenges of using EHRs to assess resident performance. These include the nature of EHR data; the potential of using EHR data for assessment; and the dangers of using EHR data for assessment. Findings offer considerations for using EHR data to assess resident performance in appropriate and meaningful ways.

Conclusions

EHR data have potential to support formative assessment practices and guide feedback discussions with residents, but evaluators must take context into account. The EHR was not designed with the purpose of assessing resident performance; therefore, adoption and use of these data for educational purposes require careful thought, consideration, and care.
Examining the Educational Commission for Foreign Medical Graduates Announcement Requiring Medical School Accreditation Beginning in 2023
Authors: Tackett Sean
Published: March 2019

In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG, Philadelphia, Pennsylvania) announced that, beginning in 2023, graduation from a formally accredited medical school would be necessary for an international medical graduate (IMG) to be eligible for ECFMG certification. The announcement is notable because ECFMG certification is required for graduate medical training and practice in the United States. Graduating from a school accredited by an agency formally recognized by the World Federation for Medical Education (WFME), which has been formally evaluating and recognizing accrediting agencies since 2012, would fulfill the new ECFMG requirement. In 2015, ECFMG applicants came from 1,141 medical schools located in 139 countries or territories. As of December 2018, the WFME had formally recognized 14 accrediting agencies, which would cover only approximately a third of these recent ECFMG-certified IMGs. In this Perspective, the author compares the context of the ECFMG announcement to the beginning of accreditation in the United States so as to provide insight into the challenges the WFME faces as it seeks to evaluate and recognize what could ultimately be over 100 more accrediting authorities. The author then explores the possible effects of the requirement—specifically, its potential to restrict the ECFMG applicant pool—on the quantity and quality of the U.S. physician workforce. The author ends the Perspective by considering the implications of three broad policy options that the ECFMG could consider starting in 2023: implementation as announced, maintenance of the status quo, or a policy modified from the original announcement.
Can a Woman of Color Trust Medical Education?
Authors: Marte Denise
Published: March 2019

In this Invited Commentary, the author—a second-generation immigrant, a first-generation college graduate, and a woman of color—reflects on the experiences during medical school that shaped her trust in the medical education system. She describes her reasons for entering medicine—to become the kind of doctor she wished she had had growing up. Then she considers how the words physicians use with patients and to talk about patients, which can reinforce problematic narratives and indicate complicity with structural injustices, negatively affect the care they provide. Trainees learn what is acceptable behavior from this hidden curriculum, perpetuating these harmful practices. The author challenges readers to consider how leaders in medical education can work to change this culture to create an education system that trains a physician workforce that keeps patients’ voices and experiences at the center of their care and serves the needs of all patients, regardless of their identities.
Competency-Based Curriculum Development to Meet the Needs of People With Disabilities: A Call to Action
Authors: Ankam Nethra S. , Bosques Glendaliz , Sauter Carley , Stiens Steven , Therattil Maya , Williams Faren H. , Atkins Caleb C. , Mayer R. Samuel
Published: March 2019

People with disabilities constitute 22.2% of the population in the United States, and virtually all physicians have people with disabilities in their clinical practice across a wide range of diagnostic groups. However, studies demonstrate that people with disabilities are inadequately served by the health care system, leading to high costs and poor outcomes. The authors argue that one cause of this discrepancy is that medical students receive limited training in the care of people with disabilities and may therefore not be able to adequately meet the competencies that underlie the Core Entrustable Professional Activities for Entering Residency. To address these gaps, the authors present practical examples of integrating concepts of disability into the curriculum with minimal additional time requirements. A comprehensive disability curriculum is suggested to include active classroom learning, clinical, and community-based experiences. At institutions that do not have a comprehensive curriculum, the authors recommend adding disability-related knowledge and skill acquisition to existing curricula through modifications to current case-based learning, simulated patients, and objective structured clinical examinations. To facilitate curriculum development, they recommend that the World Health Organization International Classification of Functioning, Disability, and Health be used as a tool to build disability concepts into active learning. The goal of these recommended curricular changes is to enhance student performance in the clinical management of people with disabilities and to better train all future physicians in the care of this population.
Envisioning a True Continuum of Competency-Based Medical Education, Training, and Practice
Authors: Cate Olle ten , Carraccio Carol
Published: March 2019

The existing structure of physician education has developed in siloed stages, with consecutive degrees and certifications and progressively longer training programs. As further fragmentation of health care and training systems will not improve the quality of care and education, the authors argue that a new vision of education, training, and practice as a continuum is needed.

They advocate for a model of competency-based medical education that merges with competency-based medical practice. In this system, education and training will result in individual, dynamic portfolios of valid entrustable professional activities (EPAs) for which physicians are certified. Physicians can maintain and renew that entrustment as long as the EPAs remain within their scope of practice. Entrustment occurs initially during training but is then granted for new activities as physicians’ careers evolve.

This model accounts for the need to keep pace with changes in population health needs and expectations of competence over time. It de-emphasizes the divides between the stages of training and views the continuum from undergraduate medical education until retirement as a whole. Key obligations of self-regulating medical professionals include both the reception and the provision of supervision from and for others, respectively. Learning must be embedded in practice to address expectations regarding new knowledge and skills as they evolve with scientific and technological advances.

Entrusting physicians to deliver effective and safe care, based on their performance of the requisite EPAs without supervision, should ensure that they provide high-value, quality care to patients.
Attitudes and Habits of Highly Humanistic Surgeons: A Single-Institution, Mixed-Methods Study
Authors: Swendiman Robert A. , Marcaccio Christina L. , Han Jason , Hoffman Daniel I. , Weiner Timothy M. , Nance Michael L. , Chou Carol M.
Published: March 2019

Purpose

Humanism in medicine is associated with increased patient satisfaction, trust of patients in their doctors, and better outcomes. The authors sought to identify attitudes, habits, and other factors that sustain humanism in academic surgical faculty, and compare these with attributes determined from a previous study of internal medicine faculty.

Method

A mixed-methods study design at University of Pennsylvania Health System was employed from 2016 to 2018 using a survey instrument and semistructured interviews. Surgical residents nominated faculty who exemplified humanism. In-depth interviews were then conducted with surgeons receiving the most nominations. The interviews were transcribed, and common themes were identified using the grounded theory method. These were compared with findings from a previous internal medicine study.

Results

Ten faculty described three strongly shared attitudes: humility, responsibility, and a desire to live up to a high standard of professional behavior. Five habits were found important to sustaining these attitudes and their practice: self-reflection, finding deep connections with patients, maintaining personal and professional relationships, “having fun” at work, and paying it forward to surgical trainees. Surgeons also cited the importance of past role models in developing humanistic attitudes and sustaining practice. Responses were compared with previously documented attitudes and habits of humanistic internal medicine faculty at the institution.

Conclusions

This study identified recurring attitudes and habits that characterize humanistic behaviors in a cohort of academic surgeons. Learning from these exemplary humanistic surgeons may inform the development of future educational programs for residents and faculty in sustaining humanism.
Strengthening Teachers’ Professional Identities Through Faculty Development
Authors: Steinert Yvonne , O’Sullivan Patricia S. , Irby David M.
Published: March 2019

Although medical schools espouse a commitment to the educational mission, faculty members often struggle to develop and maintain their identities as teachers. Teacher identity is important because it can exert a powerful influence on career choice, academic roles and responsibilities, and professional development opportunities. However, most faculty development initiatives focus on knowledge and skill acquisition rather than the awakening or strengthening of professional identity. The goal of this Perspective is to highlight the importance of faculty members’ professional identities as teachers, explore how faculty development programs and activities can support teachers’ identities, and describe specific strategies that can be used in professional development. These strategies include the embedding of identity and identity formation into existing offerings by asking questions related to identity, incorporating identity in longitudinal programs, building opportunities for community building and networking, promoting reflection, and capitalizing on mentorship. Stand-alone faculty development activities focusing on teachers’ identities can also be helpful, as can a variety of approaches that advocate for organizational change and institutional support. To achieve excellence in teaching and learning, faculty members need to embrace their identities as teachers and be supported in doing so by their institutions and by faculty development.
Hurricane Harvey: Firsthand Perspectives for Disaster Preparedness in Graduate Medical Education
Authors: Newman Brian , Gallion Courtney
Published: March 2019

When disasters strike, hospitals are challenged to continue the delivery of health care, much of which is dependent on trainees. Fortunately, disasters are infrequent; however, that infrequency leads to an absence of training in how to plan and execute a disaster response, and leaves medical professionals and trainees unprepared to handle the burden of a disaster when it strikes. In August 2017, Hurricane Harvey tested the efficacy of the graduate medical education (GME) disaster plan at Corpus Christi Medical Center (CCMC) and provided an opportunity to evaluate residents’ performance in a disaster situation in the inpatient setting. In this Invited Commentary, the authors recall their experience at CCMC during Hurricane Harvey and its aftermath. They describe the challenges that resulted from a disaster plan that proved to be inadequate. Based on their own lessons learned, the authors offer several recommendations for more effective disaster planning for GME programs: adequate staffing, adequate resources, optimal team structure, effective communication, safe evacuation, and thorough planning. This evaluation of how the residents prepared for and responded to an actual natural disaster provides perspective into organizational and institutional processes that could benefit from further development and implementation.
Eat, Sleep, Console Approach
Authors: Grisham Lisa M. , Stephen Meryl M. , Coykendall Mary R. , Kane Maureen F. , Maurer Jocelyn A. , Bader Mohammed Y.
Published: March 2019

Background:

The opioid epidemic in the United States has resulted in an increased number of drug-exposed infants who are at risk for developing neonatal abstinence syndrome (NAS). Historically, these infants have been treated with the introduction and slow weaning of pharmaceuticals. Recently, a new model called Eat, Sleep, Console (ESC) has been developed that focuses on the comfort and care of these infants by maximizing nonpharmacologic methods, increasing family involvement in the treatment of their infant, and prn or “as needed” use of morphine.

Purpose:

The purpose of this evidenced-based practice brief was to summarize and critically review emerging research on the ESC method of managing NAS and develop a recommendation for implementing an ESC model.

Methods:

A literature review was conducted using PubMed, Cochrane, and Google Scholar with a focus on ESC programs developed for treating infants with NAS.

Finding/Results:

Several studies were found with successful development and implementation of the ESC model. Studies supported the use of ESC to decrease length of stay, exposure to pharmacologic agents, and overall cost of treatment.

Video Abstract Available at
https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=32&autoPlay=true.
A nationwide analysis of failed irrigation and debridement for pediatric septic arthritis of the hip
Authors: Sabour Andrew F. , Alluri Ram K. , Heckmann Nathanael , Heidari Keemia S. , Rick Hatch George F. , VandenBerg Curtis
Published: March 2019

Irrigation and debridement (I&D) is the gold standard for treatment of pediatric septic arthritis of the hip. If the index surgery fails, subsequent surgery may be required to eradicate the infection, resulting in substantial increases in morbidity, healthcare costs, and psychosocial burden. The purpose of this study was to identify the incidence of failed I&D for pediatric septic arthritis of the hip, defined by the need for at least one subsequent surgical intervention, and potential risk factors for failed initial I&D. The Kids’ Inpatient Database was used to extract data for pediatric patients diagnosed with septic arthritis of the hip from 1997 to 2012. Factors such as patient demographics, preoperative comorbidities, inpatient variables, and hospitals variables were assessed for associations with successful versus failed I&Ds. During the period examined, 3341 (94.3%) children were successfully treated with a single I&D, whereas 203 (5.7%) children required at least one additional surgery during the same hospitalization. Univariate analysis found anemia, coagulopathy, and electrolyte disorders to be associated with repeat surgery. Patients who required multiple surgeries had significantly longer lengths of stay (11.3 vs. 6.9 days), higher likelihood of being discharged with home health (39 vs. 25%), and higher total overall inpatient costs ($58 400 vs. $31 900). On the basis of the results of this study, the nationwide incidence of patients requiring multiple I&Ds was 5.7%. Patient preoperative comorbidities such as coagulopathy, and hospital characteristics such as government ownership and teaching status were significantly associated with failed initial I&D for septic arthritis of the hip. We believe this data can be useful in guiding future research efforts and providing clearer anticipatory guidance to patients and guardians. Level of evidence: Level III: Retrospective comparative study.
Occipitocervical or C1–C2 fusion using allograft bone in pediatric patients with Down syndrome 8 years of age or younger
Authors: Ando Kei , Kobayashi Kazuyoshi , Ito Kenyu , Tsushima Mikito , Morozumi Masayoshi , Tanaka Satoshi , Machino Masaaki , Ota Kyotaro , Ishiguro Naoki , Imagama Shiro
Published: March 2019

Sufficient internal fixation for occipitocervical (OC) or C1–C2 instability in pediatric patients with Down syndrome is difficult owing to small osseous structures, congenital deformities, and immature ossification. The purpose of this study was to evaluate the clinical outcomes of patients aged 8 years or younger with Down syndrome who underwent OC or C1–C2 fusion using freeze-dried allograft as bone graft substitute. The participants included seven consecutive patients aged 8 years or younger with Down syndrome who were treated for upper cervical disorders with posterior OC or C1–C2 fusion using freeze-dried allografts at our hospital between 2007 and 2016 and had a minimum follow-up of 1 year. Postoperative flexion/extension cervical radiography and computed tomography were repeated at 3 months after surgery before removal of the collar. The modified McCormick scale was used to grade functional status. The seven patients had an age range of 5–8 years (mean: 5.9 years). The mean follow-up period was 36 months (12–120 months). Six patients had os odontoideum and one had basilar invagination. Three patients underwent C1–C2 fusion, and in all cases, bilateral C1 lateral mass screws and bilateral C2 pedicle screws were used. Four patients underwent OC fusion, and in three of these cases, occipital and bilateral pedicle screws were used. One patient underwent reoperation because of occipital screw back-out with autograft; therefore, C2 lamina screws were added to pedicle screws. Solid bony fusion was achieved, and stable constructs were maintained on radiography in all patients, without infection or implant failure. In this study, we used freeze-dried allograft as a bone graft substitute, and we were able to detect bony trabeculae at the graft–recipient interface on lateral cervical radiographs and on reconstructed sagittal computed tomographic images in all patients. These results suggest that use of allograft is effective for treatment of upper cervical spine abnormalities in pediatric patients with Down syndrome.
Pediatric navicular dorsal osteochondroma: a rare case of navicular–cuneiform impingement
Authors: Turati Marco , Bigoni Marco , Omeljaniuk Robert J. , Griffet Jacques , Zatti Giovanni , Courvoisier Aurélien
Published: March 2019

Osteochondroma is one of the most common benign bone tumors; however, as it rarely affects any bones in feet, it may easily escape detection without rigorous examination. We present an exceptionally rare case of tarsal navicular dorsal osteochondroma diagnosed in an 11-year-old female child affected by chronic foot pain. Radiographs, MRI, and computed tomography scan revealed bony excrescences extending outward from the navicular bone. After conservative treatment failed, the navicular dorsal exostosis was excised in open surgery with complete resolution of symptoms. Navicular–cuneiform impingement was diagnosed by instrumental and intraoperative techniques. Histological analysis confirmed the diagnosis of navicular dorsal osteochondroma. This case report illustrates the necessity of particularly rigorous evaluation of the substrates of pediatric chronic foot pain.
Treatment of early-onset scoliosis with growing rods in patients with neurofibromatosis-1
Authors: Carbone Marco , Vittoria Francesca , Del Sal Alice
Published: March 2019

This study aimed at verifying the efficacy of growing rod treatment in patients affected by neurofibromatosis with early-onset scoliosis. The authors present a retrospective case study of seven children treated between 2001 and 2017. Mean age at initial surgery was 7.2 years. Mean Cobb angle was 82.7°. Lengthening was performed once a year. Mean Cobb angle at last follow-up was 50.1°. Mean spinal growth was 13.6 mm/year, with regular gain during lengthening procedures. Mean follow-up period was 7 years after the first surgery. Three patients underwent final fusion. Complications were one proximal junctional kyphosis, nine rod breakages, and one hook dislocation.
Excision of Physeal Bars of the Distal Femur, Proximal and Distal Tibia Followed to Maturity
Authors: Yuan Brandon J. , Stans Anthony A. , Larson Dirk R. , Peterson Hamlet A.
Published: March 2019

Objective:

In the 50 years since a premature partial physeal arrest (a physeal bar) was first excised from an epiphysis there have been no large in-depth studies reporting the results in patients followed to skeletal maturity. This paper reports the results of physeal bar resection surgery in a group of patients followed to skeletal maturity, documenting the restored growth of the affected physis, the affected bone, and the final limb-length discrepancy.

Methods:

Forty-eight patients underwent physeal bar resection of the distal femur (21), proximal tibia (9), and distal tibia (18) by 1 surgeon (H.A.P.) from 1968 through 1996, and were followed prospectively to skeletal maturity with clinical and radiologic examinations. Factors such as sex, age at time of injury, etiology of the bar, physeal bar location and size, age at time of bar excision, interposition material, and additional surgical procedures were analyzed with respect to physis, bone, and limb growth following bar resection.

Results:

The mean growth for the entire bone following physeal bar excision was 7.6 cm for the distal femur, 4.7 cm for the proximal tibia, and 7.5 cm for the distal tibia, compared with growth in the contralateral control bone of 6.8 cm in the femur, 5.0 cm in the proximal tibia, and 7.8 cm in the distal tibia. The maximum bone growth following bar excision in a single patient was 21.3 cm for the distal femur, 10.3 cm for the proximal tibia, and 18.6 cm for the distal tibia. The mean limb-length discrepancy at maturity was −1.7 cm for the distal femur, −1.3 cm for the proximal tibia, and −1.1 cm for the distal tibia (all sites combined −1.4 cm). Fourteen patients (29%) had only the 1 bar excision with no other accompanying or subsequent surgery. Thirty-four patients (71%) had 1 to 4 accompanying or subsequent leg length or angular correcting procedures.

Conclusions:

Physeal bar excision to restore growth when applied to the appropriate patient is a useful, rewarding procedure, reducing the number of surgical limb length equalizing procedures. It is a demanding surgical procedure and requires diligent and careful follow-up until maturity. Additional limb length equalizing surgery is frequently needed.

Level of Evidence:

Case series, level IV.
Are Constant Pain, Night Pain, or Abnormal Neurological Examination Adequate Predictors of the Presence of a Significant Pathology Associated With Pediatric Back Pain?
Authors: Ramírez Norman , Olivella Gerardo , Valentín Pablo , Feneque José , Lugo Soniely , Iriarte Iván
Published: March 2019

Introduction:

Previous studies have suggested that most cases of pediatric back pain do not have an identifiable cause. No reliable sign or indication differentiates between a benign or serious cause of the symptom. Constant pain, night pain, and abnormal neurological examination have been suggested as adequate predictors of an identifiable cause, when plain radiographs could not explain the symptoms. The purpose of this study is to determine the sensitivity, specificity, and likelihood ratios of constant pain, night pain, and abnormal neurological examination to predict the presence of an underlying positive finding as a cause of back pain.

Method:

From 2010 to 2016, all patients who presented with a chief complaint of back pain were included in the study. Magnetic Resonance Image was performed to all patients presenting with back pain without identifiable cause lasting >4 weeks. Patients who presented with spondylolysis were treated accordingly base on radiographic findings and were excluded as study protocol.

Results:

A total of 388 patients were evaluated during the study period. The mean age of the subjects was 14.5 years; 69.7% being female. An underlying pathologic condition was identified in 56 of 132 (42%) of patients with constant pain, 61 of 162 (38%) with night pain, and 8 of 9 (89%) with abnormal neurological examination. Probability to have an underlying pathology correlated directly with the amount of clinical markers.

Discussion:

An abnormal neurological examination was found as a strong predictor for an underlying pathologic condition. Further imaging of a pediatric patient with back pain without clear explanation for their symptoms on plain radiographs should not be limited to constant pain, or night pain because clinicians could be missing important diagnosis. Therefore, the clinician cannot be assured by absence of these clinical markers, that there is no underlying spinal pathology.

Level of Evidence:

Level III.
Developmental Patterns of the Greater Trochanter in Skeletally Immature Patients
Authors: Knapik Derrick M. , McCarthy Conor , Liu Raymond W.
Published: March 2019

Background:

Trochanteric entry femoral nailing in immature patients is controversial. Although it has become increasingly accepted in pediatric patients aged 8 years and older, complications related to physeal violation have been reported. To date, the appropriate minimum age for safe antegrade nailing in skeletally immature patients remains to be unknown. The purpose of this investigation was to determine the degree of trochanteric bony and cartilage growth with increasing age to provide normative growth values.

Methods:

A total of 408 serial digitized radiographs of the left hip in 45 healthy children (n=26 female individuals, n=19 male individuals) between the ages of 6 and 14 were retrospectively reviewed by 2 independent authors. Radiographs were examined to measure the changing height of the bony greater trochanter with increasing age. Magnetic resonance imaging (MRI) scans of 55 (n=29 male individuals, n=26 female individuals) contemporary children between the ages of 6 and 14 were evaluated to measure bony greater trochanteric and the overlying cartilage cap height.

Results:

Intraclass correlation coefficient values for both radiographic and MRI measurements were excellent. Longitudinal radiographs demonstrated that the bony growth was largely complete by age 11 in male and female individuals. MRI measurements demonstrated that bony trochanteric and overlying cartilage cap height was maximal by age 7 in female individuals and age 8 in male individuals, while no significant difference in bony and cartilage height was appreciated with increasing age in male, female individuals or male+female individuals.

Conclusions:

Combined bony and cartilaginous trochanteric growth is largely complete by age 7 in female individuals and age 8 in male individuals, with increases in the height of the trochanter beyond this age likely coming from ossification of the cartilaginous portions. As such, antegrade intramedullary nailing for closed femoral shaft fractures is reasonable in male and female individuals aged 8 years and older.

Level of Evidence:

Level II—retrospective study.
Obtaining Vitamin D Levels in Children With Fractures Improves Supplementation Compliance
Authors: Minkowitz Barbara , Nadel Leah , McDermott Meghan , Cherna Zachary , Ristic Jennifer , Chiu Stephanie
Published: March 2019

Background:

Obtaining ideal serum 25-vitamin D (25VitD) levels (>30 ng/mL) is imperative in childhood to achieve peak bone mass. Supplementation compliance in children recommended to take vitamin D postfracture was evaluated. The questions we sought to answer were: Is there (1) a compliance difference between patients with known versus unknown 25VitD levels; (2) an association between compliance and age; and (3) an association between fracture severity and initial 25VitD level.

Methods:

One physician analyzed compliance in 1818 fracture patients 2 to 18 years (42% female) with known (48%) and unknown 25VitD. Patient/caregiver’s self-reported adherence to supplementation as “yes” (4 d/wk minimum) or “no” defined compliance. Compliance relating to fracture severity via Abbreviated Injury Scale (AIS), 25VitD level, and age, was analyzed.

Results:

Patients with 25VitD levels were more compliant than patients without (61%, n=532/872; 21%, n=206/946; P<0.001). In total, 83% (n=104/125) of AIS 3 patients were compliant, compared with 49% (n=628/1292) of AIS 1/2 patients (P<0.001). Compliance increased with age (odds ratio: 1.09, 95% confidence interval: 1.061-1.120, P<0.001).

Conclusions:

Compliance increased when 25VitD levels were obtained, improving with fracture severity. Clinicians should order 25VitD levels on fracture patients to improve supplementation compliance.

Level of Evidence:

This is a level IV prognostic study which aims to investigate the effects of various patient characteristics on compliance.
Moderate-Intensity Insulin Therapy Is Associated With Reduced Length of Stay in Critically Ill Patients With Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State
Authors: Firestone Rachelle L. , Parker Patricia L. , Pandya Komal A. , Wilson Machelle D. , Duby Jeremiah J.
Published: March 2019

Objectives:

Insulin infusion therapy is commonly used in the hospital setting to manage diabetic ketoacidosis and hyperosmolar hyperglycemic state. Clinical evidence suggests both hypoglycemia and glycemic variability negatively impact patient outcomes. The hypothesis of this study was that moderate-intensity insulin therapy decreases hospital length of stay and prevalence of hypoglycemia in patients with diabetic ketoacidosis and hyperosmolar hyperglycemic state.

Design:

Pre-post study.

Setting:

Large academic medical center in the United States.

Patients:

Two-hundred one consecutive, nonpregnant, adult patients admitted for diabetic ketoacidosis and hyperosmolar hyperglycemic state between October 2010 and December 2014.

Interventions:

High-intensity insulin therapy versus moderate-intensity insulin therapy. High-intensity insulin therapy was designed to rapidly normalize blood glucose levels with bolus doses of insulin and rapid insulin titration. Moderate-intensity insulin therapy was designed to mitigate glycemic variability and hypoglycemia through avoidance of bolus dosing, a liberalized blood glucose target, and gradual insulin titration.

Measurements and Main Results:

Hospital and ICU length of stay were reduced by 23.6% and 38%, respectively. The relative risk of remaining in the hospital at day 7 (0.51; p = 0.022) and day 14 (0.28; p = 0.044) were significantly reduced by the moderate-intensity insulin therapy strategy. The relative risk of remaining in the ICU at 48 hours was significantly lower in the moderate-intensity insulin therapy cohort (0.34; p = 0.0048). The prevalence (35% vs 1%; p = 0.0003) and relative risk (0.028; p = 0.0004) of hypoglycemia were significantly lower in the moderate-intensity insulin therapy cohort. Glycemic variability decreased by 28.6% (p < 0.0001). There was no difference in the time to anion gap closure (p = 0.123).

Conclusions:

Moderate-intensity insulin therapy for diabetic ketoacidosis and hyperosmolar hyperglycemic state resulted in improvements in hospital and ICU length of stay, which appeared to be associated with decreased glycemic variability.
Biomarkers, measured during therapy, for response of melanoma patients to immune checkpoint inhibitors: a systematic review
Authors: Ouwerkerk Wouter , van den Berg Mirjam , van der Niet Sanne , Limpens Jacqueline , Luiten Rosalie M.
Published: March 2019

Immune checkpoint inhibitors (ICIs), which target CTLA-4 or PD-(L)1 molecules, have shown impressive therapeutic results. Durable responses, however, are only observed in a segment of the patient population and must be offset against severe off-target immune toxicity and high costs. This calls for biomarkers that predict response during ICI treatment. Although many candidate biomarkers exist, as yet, there has been no systematic overview of biomarkers predictive during. Here, we provide a systematic review of the current literature of ICI treatment to establish an overview of candidate predictive biomarkers during ICI treatment in melanoma patients. We performed a systematic Medline search (2000–2018, 1 January) on biomarkers for survival or response to ICI treatment in melanoma patients. We retrieved 735 publications, of which 79 were finally included in this systematic review. Blood markers were largely studied for CTLA-4 ICI, whereas tumor tissue markers were analyzed for PD-(L)1 ICI. Blood cytology and soluble factors were more frequently correlated to overall survival (OS) than response, indicating their prognostic rather than predictive nature. An increase in tumor-infiltrating CD8 + T-cells and a decrease in regulatory T-cells were correlated to response, in addition to mutational load, neoantigen load, and immune-related gene expression. Immune-related adverse events were also associated frequently with a favorable response and OS. This review shows the great variety of potential biomarkers published to date, in an attempt to better understand response to ICI therapy; it also highlights the candidate markers for future research. The most promising biomarkers for response to ICI treatment are the occurrence of immune-related adverse events (especially vitiligo), lowering of lactate dehydrogenase, and increase in activated CD8 + and decrease in regulatory T-cells.
Acute progressive neuropathy–myositis–myasthenia-like syndrome associated with immune-checkpoint inhibitor therapy in patients with metastatic melanoma
Authors: Möhn Nora , Sühs Kurt-Wolfram , Gingele Stefan , Angela Yenny , Stangel Martin , Gutzmer Ralf , Satzger Imke , Skripuletz Thomas
Published: March 2019

Targeting immune cells instead of cancer cells is a new and successful therapeutic approach in patients with a variety of advanced cancers. Blocking antibodies bind to specific immune-checkpoint molecules namely cytotoxic T-lymphocyte-associated antigen 4, programmed cell death protein-1, and programmed cell death-ligand 1. However, their mechanism of action can lead to immune-related adverse events. In particular, neurological immune-related adverse events present, currently, a problem, as they are rare, difficult to diagnose, and are often high grade or even fatal. Here, we describe four cases with metastatic melanoma who developed symptoms of acute progressive weakness 3–9 weeks after therapy onset with immune-checkpoint inhibitors (ICIs) nivolumab and ipilimumab. Neurological examination and diagnostic procedures revealed results partly consistent with neurological disorders such as neuropathy, myositis, and myasthenia. This suggests an overlap of these known diseases indicating a new ICI-induced neuropathy–myositis–myasthenia-like syndrome. Here, we give recommendations for a structured and focused diagnostic assessment in patients presenting with neurological deficits during ICI therapy. This might improve the understanding, management, and ultimately the outcome of ICI-induced neurological adverse events.
How Patient Complexity and Surgical Approach Influence Episode-Based Payment Models for Colectomy
Authors: Sheetz Kyle H. , Dimick Justin B. , Regenbogen Scott E.
Published: March 2019

BACKGROUND:

Bundled payment programs broaden hospitals’ responsibility for spending to entire episodes of care. After demonstration programs in cardiac surgery and joint replacement, these payment reforms could soon extend to major operations like colectomy under Medicare’s Bundled Payments for Care Improvement – Advanced Model.

OBJECTIVE:

This study aims to evaluate how specific policies and surgical practice patterns would influence hospital reimbursement in a bundled payment program for colectomy.

DESIGN:

This was a population-based study.

SETTINGS:

We used national data from the 100% Medicare Provider Analysis and Review files for the years 2010 to 2014.

PATIENTS:

We identified patients undergoing colon resections by using diagnosis-related group codes and International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOME MEASURES:

We simulated per case reconciliation payments as the difference between actual price-standardized 90-day episode payments and estimated regional spending benchmarks among fee-for-service Medicare beneficiaries undergoing colectomy (2010–2014).We projected per patient and overall hospital-level reconciliation payments and the proportion of hospitals that would achieve shared savings under bundled payment conditions. We also assessed how variation in the use of laparoscopy could influence shared savings, using instrumental variable methods to account for selection bias between laparoscopic and open procedures.

RESULTS:

Under simulated bundled payment conditions, 51.8% of hospitals would achieve shared savings, but the average case would incur a reconciliation penalty of –$234 (95% CI, –$245 to –$223). Risk adjustment would increase the proportion of hospitals with shared savings to 54.3% (per case payment, +$237; 95% CI, $96–$379). Hospitals performing a greater proportion of cases laparoscopically would achieve higher per case reconciliation payments. For example, per case reconciliation penalties would be –$472 (95% CI, –$506 to –$438) for hospitals that performed 10% of their procedures laparoscopically, whereas those that performed 70% laparoscopically would receive payments of +$294 (95% CI, $262–$326).

LIMITATIONS:

Alternative payment models for colectomy have not yet been introduced.

CONCLUSIONS:

Surgical leaders must be prepared with strategies for optimizing episode efficiency. Inclusion of risk adjustment in bundled payment calculations and expanding utilization of laparoscopic surgery may represent approaches to achieve shared savings and improve surgeon engagement in alternative payment models for surgical care. See Video Abstract at http://links.lww.com/DCR/A928.