bluuebunny/crossref_metadata_2025 huggingface dataset:
Practice Variation Among Hospitals in Revascularization Therapy and Its Association With Procedure-related Mortality
Authors: Dalton Jarrod E. , Zidar David A. , Udeh Belinda L. , Patel Manesh R. , Schold Jesse D. , Dawson Neal V.
Published: April 2016

Background:

While substantial practice variation in coronary revascularization has been described and deviation from clinical practice guidelines has been associated with worse outcomes, the degree to which this is driven by flawed decision making and/or appropriate deviation associated with comorbid conditions is unknown. We evaluated heterogeneity in procedure use, and the extent to which hospital-level practice variation is related to surgical mortality.

Methods:

We analyzed data on 554,563 inpatients undergoing either percutaneous coronary intervention or coronary artery bypass grafting at 391 centers in 6 states. Procedure-specific risk models were developed based on demographics and comorbidities, allowing for differential effects of comorbidities for each sex. For each patient, the revascularization procedure that minimized predicted probability of inhospital mortality was designated as the model-preferred procedure.

Hospital-level discordance rates—the proportion of cases in each hospital for which the opposite from the model-preferred procedure was performed—were calculated. Hierarchical linear models were used to analyze the relationship between HDRs and hospital-level risk-standardized mortality ratios (RSMRs).

Results:

Comorbidities and demographics alone explained between 68% and 86% of overall variation in inhospital mortality (corresponding C-statistics of 0.84–0.93). The mean (SD) HDR was 26.3% (9.6%). There was a positive independent association between HDRs and inhospital mortality, with a 10% increase in HDR associated with an 11% increase in RSMR (P<0.001).

Conclusions:

Variance in procedure use according to model preference was strongly associated with worse outcomes. A systematic approach to incorporating comorbidity as part of the decision-making process for coronary revascularization is needed.
Microenvironmental regulation of hematopoietic stem cells and its implications in leukemogenesis
Authors: Seshadri Madhav , Qu Cheng-Kui
Published: April 2016

Purpose of review

Hematopoietic stem cells (HSCs) are a population of cells in the bone marrow which can self-renew, differentiate into late lineage progenitors, or remain quiescent. HSCs exist alongside several cell types in the bone marrow microenvironment that comprise the stem cell niche. These cells regulate HSC function and can contribute to leukemogenesis. In this review we will discuss recent advances in this field.

Recent findings

In the vascular niche, arteriolar and sinusoidal zones appear to play distinct roles in HSC function. Endothelial cells modulate HSC function via Notch and other signaling pathways. In the endosteal niche multiple cell types regulate HSCs. Osteoblasts promote HSC quiescence via secreted factors and possibly physical interactions, whereas adipocytes may oppose HSC quiescence. The balance of these opposing factors depends on metabolic cues. Feedback from HSC-derived cells, including macrophages and megakaryocytes also appears to regulate HSC quiescence. Dysfunction of the bone marrow microenvironment, including mesenchymal stem cell-derived stromal cells and the sympathetic nervous system can induce or alter the progression of hematologic malignancies.

Many cell types in the bone marrow microenvironment affect HSC function and contribute to malignancy. Further understanding how HSCs are regulated by the microenvironment has clinical implications for stem cell transplantation and other therapies for hematologic malignancies.
Spanish and English Language Symposia to Enhance Activation in Pediatric Inflammatory Bowel Disease
Authors: Martin Melissa , Garcia Manuel , Christofferson Megan , Bensen Rachel , Yeh Ann Ming , Park K.T.
Published: April 2016

Objectives:

Patient activation is an important consideration for improved health outcomes in the management of chronic diseases. Limited English proficiency among patients and primary care providers has been shown to be a predictor for worse health across disease states. We aimed to determine the baseline patient activation measure (PAM) among Spanish‐speaking (SP) and English‐speaking (ES) pediatric patients with IBD and parents, and to describe the feasibility and efficacy of a novel peer‐group education symposium designed to enhance patient activation as measured with the PAM.

Methods:

Two separate half‐day educational symposia in either Spanish or English were presented and moderated by 2 native SP physicians. Content for each of the presentations were highly standardized and interactive, designed to address each of the activation domains (self‐management, collaboration with a health care provider, maintenance of function and prevention of disease exacerbation, and appropriate access to high‐quality care). Descriptive statistics were used to describe changes between pre‐ and postsymposium PAM trends.

Results:

Eleven primarily SP and 21 ES families participated in their respective symposium. Paired pre‐ and post‐PAM scores were available from 24 pediatric patients with IBD (8 SP, 16 ES) and 41 parents (15 SP, 26 ES). The mean age for SP and ES patients was 11.6 and 12.0 years, and female sex in 80% and 62%, respectively. Paired pre‐ and post‐PAM scores for all participants (n = 65) were analyzed. PAM scores uniformly increased in all 4 groups after the symposia (SP patients 59.1–70.3, P = 0.05; SP parents 69.8–75.2, P = 0.2; ES patients 59.9–64.0, P = 0.08; ES parents 61.9–69.1, P = 0.002), although only the ES‐parents group had sufficient sample size (n = 26) to achieve statistical significance. The overall cohort had an aggregate increase from pre‐PAM of 62.9 (SD 14.5) to post‐PAM of 69.4 (SD 13.9) (<0.001).

Conclusions:

We describe a novel peer‐group educational symposium presented in Spanish and English languages to increase patient and parent activation in pediatric patients with IBD and their caregiving parents. The use of PAM to assess levels of activation appears to be feasible and effective in these groups.
Transitions in Pediatric Gastroenterology
Authors: Bensen Rachel , McKenzie Rebecca B. , Fernandes Susan M. , Fishman Laurie N.
Published: April 2016

Objectives:

Transition and transfer to adult‐oriented health care is an important yet challenging task for adolescents and young adults with chronic medical conditions. Transition practices vary widely, but a paucity of data makes determination of best practices difficult. We described North American pediatric gastroenterologists’ preferences and present transition practice patterns and explored whether experience affected providers’ perspectives.

Methods:

An online survey was distributed via e‐mail to members of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition. Participation was voluntary and answers were anonymous. Quantitative and qualitative analysis was performed.

Results:

Almost three quarters of the 175 respondents describe providing transition or self‐care management education, but only 23% use structured readiness assessments. Most respondents (88%) report having age cutoffs above which they no longer accept new referrals, with the most common age being 18 years (57%). One third report the ability to provide age‐appropriate care to patients older than 21 years. Only 6% indicate that their practice or institution should provide care for individuals older than 25 years. Many (63%) indicate that their practice or institution has a policy regarding age of transfer, but most (79%) are flexible. Provider preferences for triggers to transfer to adult care diverge widely between age, milestones, and comorbidities. Overall, parent (81%) and patient (74%) attachment to pediatric health care providers are cited as the most common barriers to transition.

Conclusions:

Preferences and practices surrounding transition preparation and transfer to adult care vary widely, reflecting continued uncertainty regarding optimal transition strategies.
Ascites in Children
Authors: Karnsakul Wikrom , Ingviya Thammasin , Seaberg Eric , Laengvejkal Pavis , Imteyaz Hejab , Vasilescu Alexandra , Schwarz Kathleen B. , Scheimann Ann O.
Published: April 2016

Objectives:

The aim of our study was to describe the changing prevalence, demographic features, etiologies, and treatment of ascites in children hospitalized during a 27‐year period at the Johns Hopkins Hospital (Baltimore, MD).

Methods:

We retrospectively reviewed discharges from 1983 to 2010 to select patients whose records included a diagnosis of ascites. We assessed the etiologies and degrees of ascites (ascites grade 1 detectable only by radiologic tests; ascites grades 2 and 3 recognized by moderate and marked abdominal distension by physical examinations).

Results:

We classified 518 children into 9 etiology groups: intrahepatic disease (IH) (105), hepatic vein outflow obstruction (HVOO) (45), congestive heart disease (CH) (33), nephrotic syndrome (NS) (36), pancreatitis (26), inflammatory and infectious diseases (77), malignancy (49), idiopathic (71), and miscellaneous (76). IH and CH were predominant in the younger age group (0–5 years) versus HVOO, pancreatitis, and malignancy in the older age group (13–21 years) (P < 0.001). The prevalence of ascites increased over time from 1983 to 2006 and declined thereafter. Ascites grade 1 was more common than ascites grades 2 and 3 in all the groups (P = 0.048). IH and NS were more likely to have ascites grade 2 and 3 (P = 0.02). Although spironolactone was more frequently used in the IH group versus other etiologies, furosemide was used more frequently in NS and CH versus other etiologies (P < 0.001).

Conclusions:

The increased prevalence of ascites during the initial study period could reflect improved detection radiologic detection. The proportion of severe ascites and the various medical treatments differed among the etiologic groups.
IBD‐Like Features in Syndromic Diarrhea/Trichohepatoenteric Syndrome
Authors: Busoni Veronica B. , Lemale Julie , Dubern Beatrice , Frangi Fernando , Bourgeois Patrice , Orsi Marina , Badens Catherine , Fabre Alexandre
Published: April 2016

Background:

Very early onset inflammatory bowel disease (VEOIBD) (inflammatory bowel disease [IBD] before 6 years of age) may manifest as a monogenic disease affecting the gastrointestinal tract. Syndromic diarrhea/trichohepatoenteric syndrome (SD/THE), a rare disorder caused by alteration of a complex involved in RNA degradation, has been reported to present with some degree of colitis and in some cases an IBD‐like presentation.

Methods:

We reviewed clinical and biological data of 4 previously published cases and added detailed data of 2 new cases of SD/THE with an IBD‐like presentation.

Results:

All the 6 patients presented with typical intractable diarrhea and hair abnormalities. The colon was affected in all of the patients: 1 had ileitis, 2 had panenteritis, and 2 presented with perianal disease. Fecal calprotectin level and erythrosedimentation rate were elevated in 2 cases each. All the therapeutic classes of IBD treatment (mesalazine, steroids, immunomodulators, and biological therapy) were used in the 6 cases. In 2 patients, treatment had no effect. Three showed a partial effect, and 1 patient sustained only a transient effect.

Conclusions:

SD/THE can have a similar presentation as VEOIBD, often as pancolitis. IBD treatments appear to have little efficacy for SD/THE, suggesting a different pathogenesis for the IBD‐like features in SD/THE compared with classical IBD.
Preschoolers With Allergic Diseases Have an Increased Risk of Irritable Bowel Syndrome When Reaching School Age
Authors: Tan Teck‐King , Chen An‐Chyi , Lin Cheng‐Li , Shen Te‐Chun , Li Tsai‐Chung , Wei Chang‐Ching
Published: April 2016

Objectives:

The aim of the study was to systemically investigate the risk of subsequent irritable bowel syndrome (IBS) in children with antecedent allergic diseases in a population‐based case‐control study in Taiwan.

Methods:

We evaluated 11,242 children (age range: 7–18 years) with IBS and 44,968 age‐ and sex‐matched control subjects who had been examined between 2000 and 2008. IBS odds ratios were calculated for children with antecedent allergic diseases, including allergic conjunctivitis, allergic rhinitis, asthma, atopic dermatitis, urticaria, and food allergy.

Results:

Children with antecedent allergic diseases had a greater risk of IBS than did control subjects (P < 0.001). Among the 6 evaluated diseases, the highest adjusted odds ratio of 1.78 was observed with allergic rhinitis (95% confidence interval [CI], 1.69–1.87). With 2 or more allergic diseases, the adjusted odds ratios increased to 2.06 (95% CI, 1.93–2.19) for all subjects, 2.07 (95% CI, 1.88–2.28) for girls, and 2.18 (95% CI, 2.02–2.35) for children 12 years or older.

Conclusions:

Preschoolers with a history of allergic disease had an increased risk of subsequent IBS development upon reaching school age. This risk increased in the presence of concurrent allergic disease and a higher clinical allergy burden.
Experiences of working from a freestanding position as a case manager when supporting clients in the Swedish welfare system
Authors: Klockmo Carolina , Marnetoft Sven-Uno
Published: April 2016

The Swedish state uses a case management function known as Personligt Ombud (PO). The role as PO differs from the traditional professional roles. It has a freestanding position in the welfare system. The aim of this study was to investigate POs’ experiences of working from a freestanding position when supporting clients. Telephone interviews were conducted with 22 POs across Sweden. The interviews were recorded, transcribed, and analyzed by latent qualitative content analysis. The findings were reflected in three categories – freedom-promoted flexibility, surfing through a complex welfare system, and working for legitimacy. POs developed a holistic view to both the client as well as to the welfare system. POs experienced solely representing the client, which is a positive feature because part of the POs’ role is advocating for the clients rights. The PO service differs from the PO service from other existing case management models and may need to develop strategies for decision-making and support in their own role. For example, they may use group supervision teams or ‘reflective teams’. The freestanding position may also entail problems in terms of lack of legitimacy. It is important for POs to develop good platforms with the surrounding actors among others things to improve the co-ordination process. It could be interesting if the PO model would be tested in other countries that have a fragmented welfare system. The PO model may also be useful to other ‘target groups’ who are in need of co-ordinated rehabilitation services.
Childhood Precursors of Adult Borderline Personality Disorder Features
Authors: Cramer Phebe
Published: April 2016

This study identifies childhood personality traits that are precursors of adult Borderline Personality Disorder (BPD) features. In a longitudinal study, childhood personality traits were assessed at age 11 (N = 100) using the California Child Q-set (CCQ: Block and Block, 1980). A number of these Q-items were found to be significantly correlated (p < 0.001) with a prototype-based measure of BPD features at age 23. Factor analysis of these Q-items suggested that they could be characterized by two underlying personality dimensions: Impulsivity and Nonconformity/Aggression. The findings thus provide evidence that childhood personality traits predict adult BPD features. Identifying such childhood precursors provides an opportunity for early intervention.
Effects of Intensive Short-Term Dynamic Psychotherapy on Depressive Symptoms and Executive Functioning in Major Depression
Authors: Ajilchi Bita , Nejati Vahid , Town Joel M. , Wilson Ryan , Abbass Allan
Published: April 2016

This study examined the efficacy of intensive short-term dynamic psychotherapy (ISTDP) on depressive symptoms and executive functioning in patients with major depression. We examined pretest, posttest, and follow-up depression scores as well as pretest–posttest executive functioning scores between 16 participants receiving ISTDP and 16 allocated to wait-list control. Participants in each group were matched according to age, sex, and educational level. Mixed-models analyses demonstrated significant interaction effects of group and time on depression scores when the group ISTDP was compared with the wait-list control group; participants receiving ISTDP had significantly reduced depression severity both after treatment and at follow-up. Next, a series of hierarchical regression models demonstrated modest improvements on most tests of executive functioning in participants receiving ISTDP. Depressed patients receiving ISTDP show a sustained reduction in depression severity after treatment and after 12-month follow-up and improvements in executive functioning after treatment compared with a wait-list control.
Relationship between Reduced Accommodative Lag and Myopia Progression
Authors: Koomson Nana Yaa , Amedo Angela Ofeibea , Opoku-Baah Collins , Ampeh Percy Boateng , Ankamah Emmanuel , Bonsu Kwaku
Published: April 2016

Purpose

To determine the relationship between accommodative lag and rate of myopia progression when Ghanaian myopic school children are either undercorrected or fully corrected with single vision lenses.

Methods

A 2-year single masked randomized control trial was conducted using 150 Ghanaian myopic children aged 10 to 15 years with mean baseline myopia of −1.98 ± 0.50D. The children were randomly assigned to wear either a full correction (n = 75) or +0.50D undercorrection (UC) (n = 75) single vision lenses. Repeated measurements which included refractive error and accommodative response at 33 and 28.6 cm for FC and UC, respectively, were performed using Open-Field Autorefractor whereas ocular biometry results were obtained using A-Scan ultrasonography. Results were based on the right eye and analyzed using STATA 11.

Results

After 24 months, the mean myopia progression of children in the FC group (−0.54 ± 0.26D) was not significantly different from that of the children in the UC group (−0.5 ± 0.22D) (p = 0.31). There was no significant difference between the mean values of the initial near lag and the average lag measured 24 months later in both groups (FC: initial lag −0.74 ± 0.17D, average lag −0.72 ± 0.15D, p = 0.44; UC: initial lag −0.57 ± 0.14D, average lag −0.58 ± 0.15D; p = 0.67). Also, there was no significant correlation between refractive change seen in 24 months and either the first near lag for both FC (r = −0.05, p = 0.43) and UC (r = −0.08, p = 0.43) or the average near lag of accommodation for both FC (r = −0.02, p = 0.49) and UC (r = −0.04, p = 0.49).

Conclusions

This study showed no relationship between lag of accommodation and rate of myopia progression in children with progressing myopia. Different ethnic groups may respond differently to the same size of hyperopic blur.
EBV-associated Peripheral T-Cell Lymphoma of Gastrointestinal Tract Presented With Widespread Chronic Inflammation: A Case Report
Authors: Uppal Guldeep , Chodoff Alaina , Wang Zi-Xuan , Baliff Jeffrey P. , Domingo-Vidal Marina , Martinez-Outschoorn Ubaldo E. , O’Malley Dennis P. , Gong Jerald Z.
Published: April 2016

We report a case of Epstein-Barr virus (EBV)-associated T-cell lymphoma of gastrointestinal (GI) tract from a 70-year-old white woman who initially presented with a widespread GI inflammation and gastric obstruction. Initial biopsies of the GI tract showed severe chronic inflammation in the esophagus, stomach, and the small intestine. Celiac disease and inflammatory bowel disease were ruled out. The patient was treated with partial gastrectomy. Histology showed gastric wall thickening with EBV-positive, mixed lymphocytic and plasma cell infiltration in the mucosa, and thickening and fibrosis of the submucosa. She developed EBV-associated T-cell lymphoma of the GI tract one and a half years later and expired due to multiorgan failure. The T-cell lymphoma diffusely infiltrated the GI wall without forming a mass lesion. The lymphoma expressed EBV and cytotoxic molecules but lacked common features of extranodal natural killer/T-cell lymphoma nasal type, such as angioinvasion/angiodestruction, necrosis, or CD56 expression. Immunoglobulin heavy chain (IGH) gene and T-cell receptor-γ gene rearrangements and EBV-positive cells were detected at the early stage of the disease. While IGH clones were transient, T-cell clones and EBV-positive cells progressively increased over the disease course. We conclude that this case is best classified as EBV-associated peripheral T-cell lymphoma of GI tract. Age-related immune senescence may have contributed to the uncontrolled GI inflammation and subsequent transformation to T-cell lymphoma.
New MYC IHC Classifier Integrating Quantitative Architecture Parameters to Predict MYC Gene Translocation in Diffuse Large B-Cell Lymphoma
Authors: Bigras Gilbert , Dong Wei-Feng , Canil Sarah , Lai Raymond , Morel Didier , Swanson Paul E. , Izevbaye Iyare
Published: April 2016

A new automated MYC IHC classifier based on bivariate logistic regression is presented. The predictor relies on image analysis developed with the open-source ImageJ platform. From a histologic section immunostained for MYC protein, 2 dimensionless quantitative variables are extracted: (a) relative distance between nuclei positive for MYC IHC based on euclidean minimum spanning tree graph and (b) coefficient of variation of the MYC IHC stain intensity among MYC IHC-positive nuclei. Distance between positive nuclei is suggested to inversely correlateMYCgene rearrangement status, whereas coefficient of variation is suggested to inversely correlate physiological regulation of MYC protein expression. The bivariate classifier was compared with 2 other MYC IHC classifiers (based on percentage of MYC IHC positive nuclei), all tested on 113 lymphomas including mostly diffuse large B-cell lymphomas with knownMYCfluorescent in situ hybridization (FISH) status. The bivariate classifier strongly outperformed the “percentage of MYC IHC-positive nuclei” methods to predictMYC+ FISH status with 100% sensitivity (95% confidence interval, 94-100) associated with 80% specificity. The test is rapidly performed and might at a minimum provide primary IHC screening forMYCgene rearrangement status in diffuse large B-cell lymphomas. Furthermore, as this bivariate classifier actually predicts “permanent overexpressed MYC protein status,” it might identify nontranslocation-related chromosomal anomalies missed by FISH.
Cancer Antigen 125 (CA125, MUC16) Protein Expression in the Diagnosis and Progression of Pancreatic Ductal Adenocarcinoma
Authors: Jiang Kun , Tan Elaine , Sayegh Zena , Centeno Barbara , Malafa Mokenge , Coppola Domenico
Published: April 2016

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive carcinoma, with most patients diagnosed at an advanced stage, with a 5-year survival rate of around 5%. An urgent need exists for identifying better diagnostic, prognostic, and therapeutic markers for this lethal disease. Recently, CA125 has been identified in PDAC, and the aim of this research is to study the changes in CA125 expression during the progression of benign pancreatic tissue (BPT) to PDAC and to assess its value as a biomarker of tumor growth. To address these questions, the cellular levels of CA125 in BPT and PDAC were measured using immunohistochemistry and compared on the basis of tumor staging, and the tissue microarray technology were constructed using resected pancreatic tissues. The staining reactions for each case were evaluated semiquantitatively using the histologic score system. Our investigation demonstrates a consistent and significant upregulation of CA125 during the transition from BPT to PDAC. We also found a direct correlation between CA125 immunohistochemistry score and tumor stage (P=0.02). In conclusion, our data indicate that CA125 plays a direct role in pancreatic carcinogenesis and suggests that it may eventually be used as a diagnostic and/or prognostic biomarker of pancreatic cancer. Prospective studies are recommended to evaluate further the diagnostic and prognostic capabilities of CA125 in PDAC, and further studies are warranted to assess the use of CA125 as a therapeutic marker.
New Robust and Reproducible Stereological IHC Ki67 Breast Cancer Proliferative Assessment to Replace Traditional Biased Labeling Index
Authors: Bigras Gilbert , Dong Wei-Feng , Canil Sarah , Hugh Judith , Berendt Richard , Wood George , Yang Hua
Published: April 2016

There is a pressing need for an objective decision tool to guide therapy for breast cancer patients that are estrogen receptor positive and HER2/neu negative. This subset of patients contains a mixture of luminal A and B tumors with good and bad outcomes, respectively. The 2 main current tools are on the basis of immunohistochemistry (IHC) or gene expression, both of which rely on the expression of distinct molecular groups that reflect hormone receptors, HER2/neu status, and most importantly, proliferation. Despite the success of a proprietary molecular test, definitive superiority of any method has not yet been demonstrated. Ki67 IHC scoring assessments have been shown to be poorly reproducible, whereas molecular testing is costly with a longer turnaround time. This work proposes an objective Ki67 index using image analysis that addresses the existing methodological issues of Ki67 quantitation using IHC on paraffin-embedded tissue. Intrinsic bias related to numerical assessment performed on IHC is discussed as well as the sampling issue related to the “peel effect” of tiny objects within a thin section. A new nonbiased stereological parameter (VV) based on the Cavalieri method is suggested for use on a double-stained Ki67/cytokeratin IHC slide. The assessment is performed with open-source ImageJ software with interobserver concordance between 3 pathologists being high at 93.5%. Furthermore, VVwas found to be a superior method to predict an outcome in a small subset of breast cancer patients when compared with other image analysis methods being used to determine the Ki67 labeling index. Calibration methodology is also discussed to further this IHC approach.
Evaluation of Disseminated Intravascular Coagulation Scores in Critically Ill Pediatric Patients
Authors: Jhang Won Kyoung , Ha Eun Ju , Park Seong Jong
Published: April 2016

Objectives:

Disseminated intravascular coagulation is a complex systemic thrombohemorrahgic disorder, which may contribute to organ failure. We aimed to compare the detection rate of the disseminated intravascular coagulation, early in the course of ICU admission, of the two disseminated intravascular coagulation scoring systems defined by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria and the prognostic value of disseminated intravascular coagulation scores in critically ill pediatric patients.

Design:

Single-center retrospective observational study.

Setting:

PICU in a tertiary care children’s hospital.

Patients:

Pediatric patients admitted in the PICU between January 2013 and December 2014.

Interventions:

None.

Measurements and Main Results:

A total of 191 patients were included. Among them, 15.7% and 29.8% of the patients were diagnosed with disseminated intravascular coagulation by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria, respectively. The diagnostic concordance rate between the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems was 52.6%. As the Pediatric Risk of Mortality III, the modified Sequential Organ Failure Assessment, and the Pediatric Multiple Organ Dysfunction Syndrome scores increased, the percentage of patients with disseminated intravascular coagulation increased stepwise. The disseminated intravascular coagulation scores correlated well with these severity scores. Overall, the 28-day mortality was 9.9%. There were significant differences in most variables consisting of the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems between survivor and nonsurvivors. Patients detected to have disseminated intravascular coagulation by the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems showed higher mortality than patients without disseminated intravascular coagulation. The areas under the receiver operating characteristic curve of the Japanese Association for Acute Medicine score and International Society on Thrombosis and Hemostasis score were 0.788 (95% CI, 0.675–0.900) and 0.716 (95% CI, 0.598–0.834), respectively.

Conclusions:

Both the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine scoring systems are useful for detection of the disseminated intravascular coagulation in critically ill pediatric patients. These scores correlate well with other severity scores, including Pediatric Risk of Mortality III, modified Sequential Organ Failure Assessment, and Pediatric Multiple Organ Dysfunction Syndrome. Disseminated intravascular coagulation scores are also significantly associated with 28-day mortality, suggesting that these could be promising prognostic factors.
Application of Sepsis Definitions to Pediatric Patients Admitted With Suspected Infections in Uganda*
Authors: Wiens Matthew O. , Larson Charles P. , Kumbakumba Elias , Kissoon Niranjan , Ansermino J. Mark , Singer Joel , Wong Hubert , Ndamira Andrew , Kabakyenga Jerome , Moschovis Peter , Kiwanuka Julius
Published: April 2016

Objectives:

Acute infectious diseases are the most common cause of under-5 mortality. However, the hospital burden of nonneonatal pediatric sepsis has not previously been described in the resource poor setting. The objective of this study was to determine the prevalence of sepsis among children 6 months to 5 years old admitted with proven or suspected infection and to evaluate the presence of sepsis as a predictive tool for mortality during admission.

Design:

In this prospective cohort study, we used the pediatric International Consensus Conference definition of sepsis to determine the prevalence of sepsis among children admitted to the pediatric ward with a proven or suspected infection. The diagnosis of sepsis, as well as each individual component of the sepsis definition, was evaluated for capturing in-hospital mortality.

Setting:

The pediatric ward of two hospitals in Mbarara, Uganda.

Patients:

Admitted children between 6 months and 5 years with a confirmed or suspected infection.

Interventions:

None.

Measurements and Main Results:

One thousand three hundred seven (1,307) subjects with a confirmed or suspected infection were enrolled, and 65 children died (5.0%) during their admission. One thousand one hundred twenty-one (85.9%) met the systemic inflammatory response syndrome criteria, and therefore, they were defined as having sepsis. The sepsis criteria captured 61 deaths, demonstrating a sensitivity and a specificity of 95% (95% CI, 90–100%) and 15% (95% CI, 13–17%), respectively. The most discriminatory individual component of the systemic inflammatory response syndrome criteria was the leukocyte count, which alone had a sensitivity of 72% and a specificity of 56% for the identification of mortality in hospital.

Conclusions:

This study is among the first to quantify the burden of nonneonatal pediatric sepsis in children with suspected infection, using the international consensus sepsis definition, in a typical resource-constrained setting in Africa. This definition was found to be highly sensitive in identifying those who died but had very low specificity as most children who were admitted with infections had sepsis. The systemic inflammatory response syndrome–based sepsis definition offers little value in identification of children at high risk of in-hospital mortality in this setting.
Parent Satisfaction With Communication Is Associated With Physician’s Patient-Centered Communication Patterns During Family Conferences*
Authors: October Tessie W. , Hinds Pamela S. , Wang Jichuan , Dizon Zoelle B. , Cheng Yao I. , Roter Debra L.
Published: April 2016

Objectives:

To evaluate the association between physician’s patient-centered communication patterns and parental satisfaction during decision-making family conferences in the PICU.

Design:

Single-site, cross-sectional study.

Setting:

Forty-four–bed PICUs in a free-standing children’s hospital.

Participants:

Sixty-seven English-speaking parents of 39 children who participated in an audiorecorded family conference with 11 critical care attending physicians.

Measurements and Main Results:

Thirty-nine family conferences were audiorecorded. Sixty-seven of 77 (92%) eligible parents were enrolled. The conference recordings were coded using the Roter Interaction Analysis System and a Roter Interaction Analysis System–based patient-centeredness score, which quantitatively evaluates the conversations for physician verbal dominance and discussion of psychosocial elements, such as a family’s goals and preferences. Higher patient-centeredness scores reflect higher proportionate dialogue focused on psychosocial, lifestyle, and socioemotional topics relative to medically focused talk. Parents completed satisfaction surveys within 24 hours of the conference. Conferences averaged 45 minutes in length (sd, 19 min), during which the medical team contributed 73% of the dialogue compared with parental contribution of 27%. Physicians dominated the medical team, contributing 89% of the team contribution to the dialogue. The majority of physician speech was medically focused (79%). A patient-centeredness score more than 0.75 predicted parental satisfaction (β = 12.05; p < 0.0001), controlling for the length of conference, child severity of illness, parent race, and socioeconomic status. Parent satisfaction was negatively influenced by severity of illness of the patient (β = –4.34; p = 0.0003), controlling for previously mentioned factors in the model.

Conclusions:

Parent-physician interactions with more patient-centered elements, such as increased proportions of empathetic statements, question asking, and emotional talk, positively influence parent satisfaction despite the child’s severity of illness.
Early Electroencephalographic Background Features Predict Outcomes in Children Resuscitated From Cardiac Arrest*
Authors: Topjian Alexis A. , Sánchez Sarah M. , Shults Justine , Berg Robert A. , Dlugos Dennis J. , Abend Nicholas S.
Published: April 2016

Objectives:

To determine 1) whether early electroencephalographic background features were associated with survival and neurologic outcomes among children resuscitated from cardiac arrest and not treated with therapeutic hypothermia and 2) if addition of electroencephalographic background to commonly used clinical criteria is more predictive of outcome than clinical criteria alone.

Design:

Retrospective study.

Setting:

PICU and Cardiac ICUs of a tertiary children’s hospital.

Patients:

Patients resuscitated from in-hospital or out-of-hospital cardiac arrest who underwent clinically indicated electroencephalographic monitoring and were not treated with therapeutic hypothermia.

Interventions:

None.

Measurements and Main Results:

One-hundred twenty-eight patients underwent electroencephalographic monitoring within 1 day of return of spontaneous circulation. Background category was normal in four subjects (3%), slow-disorganized in 58 subjects (45%), discontinuous-burst suppression in 24 subjects (19%) and attenuated-flat in 42 subjects (33%). Forty-six subjects (36%) had a reactive electroencephalography. Twenty subjects (15%) had a seizure during electroencephalographic monitoring. Absence of reactivity (p< 0.001) and seizures (p= 0.04) were associated with worse electroencephalographic background category. After controlling for covariates, for each incrementally worse background score, the odds of death was 3.63 (95% CI, 2.18–6.0;p< 0.001) and the odds of unfavorable neurologic outcome was 4.38 (95% CI, 2.51–7.17;p= 0.001).

Conclusions:

Worse electroencephalographic background early after resuscitation from both in-hospital and out-of-hospital cardiac arrest is associated with increased odds of death and unfavorable neurologic outcomes at hospital discharge. These electroencephalographic background patterns may be used in addition to clinical criteria to support prognostic decision making.
Listeria Meningitis in an Immunocompetent Child
Authors: Villa Giovanna , Diana Maria Cristina , Solari Nicoletta , Bandettini Roberto , Sorrentino Stefania , Loy Anna , Losurdo Giuseppe , Renna Salvatore
Published: April 2016

Listeria monocytogenes is a facultative anerobic, gram-positive bacillus that is isolated from the soil, vegetables, and wild or domestic animals. Listeria infection is usually found in the older adults, immunocompromised patients, pregnant women, and newborns, whereas it is rare in healthy infants and children. Listeria monocytogenes may cause meningitis, meningoencephalitis, brain abscess, pyogenic arthritis, osteomyelitis, and liver abscess in children. The course of meningoencephalitis by Listeria is often severe and even fatal. Complications such as acute hydrocephalus, brain abscess, and spine abscess can develop, and the mortality associated with listeriosis is significantly high. We present a case of a previously healthy 7-year-old boy who developed Listeria monocytogenes meningitis.
The Current Status of Development and Implementation of Medical Emergency Response Plan in Schools
Authors: Nishiuchi Tatsuya , Kinoshita Rie , Kubota Yoshie , Paul Moses , Hiraide Atsushi
Published: April 2016

Background

Automated external defibrillators (AEDs) have been widely distributed at schools in Japan. We have demonstrated that ventricular fibrillation accounted for 68% of nontraumatic sudden cardiac arrest (SCA) in schools, suggesting that a well-prepared medical emergency response plan (MERP) for schools would improve the outcomes of SCA patients. However, it is uncertain if the MERP has been well developed or implemented in Japanese schools.

Methods and Results

We conducted a cross-sectional study of schools in Osaka using a postal questionnaire. Survey items included type of school, number of students, school staff and teaching staff, number of AEDs used and the place of installation, cardiopulmonary resuscitation (CPR) training to school staff, MERP development and implementation, and the number of SCA cases they experienced. The response rate to this survey was 44% (764 of 1728 schools). Every school except for 4 have installed at least 1 AED. Thirty-six percent of schools, however, have not yet developed and implemented a MERP for SCA. Moreover, 49% of schools surveyed have not conducted a rehearsal training session for SCA in the previous 3 years, although 95% of schools provided CPR training courses to school staff. A total of 15 schools have experienced 16 presumed or actual SCA cases in the study period. Of the 15 schools, 6 schools reported that bystanders experienced psychological stress.

Conclusions

A MERP for SCA has not yet been fully developed and implemented in the schools surveyed in our study despite widely distributed AEDs and CPR training.
Current Situation of Treatment for Anaphylaxis in a Japanese Pediatric Emergency Center
Authors: Ninchoji Takeshi , Iwatani Sota , Nishiyama Masahiro , Kamiyoshi Naohiro , Taniguchi-Ikeda Mariko , Morisada Naoya , Ishibashi Kazuto , Iijima Kazumoto , Ishida Akihito , Morioka Ichiro
Published: April 2016

Objective

Anaphylaxis is a systemic allergic reaction that sometimes requires prompt treatment with intramuscular adrenaline. The aim of the study was to investigate the current situation regarding anaphylaxis treatment in a representative pediatric primary emergency facility in Japan.

Methods

We retrospectively examined the medical records dating from April 2011 through March 2014 from Kobe Children's Primary Emergency Medical Center, where general pediatricians work on a part-time basis. Clinical characteristics and current treatments for patients with anaphylaxis who presented to the facility were investigated. Furthermore, we compared the clinical characteristics between anaphylaxis patients given intramuscular adrenaline and those not given it.

Results

During the study period, 217 patients were diagnosed with anaphylaxis. The median Sampson grade at the time of visit was 2, and 90 patients (41%) were grade 4 or higher. No patients received self-intramuscular injected adrenaline before arrival at our emergency medical center because none of the patients had been prescribed it. Further treatment during the visit was provided to 128 patients (59%), with only 17 (8%) receiving intramuscular adrenaline. Patients given intramuscular adrenaline had significantly lower peripheral saturation of oxygen at the visit (P = 0.025) and more frequent transfer to a referral hospital (P < 0.001) than those not given intramuscular adrenaline.

Conclusions

Education for Japanese pediatric practitioners and patients is warranted, because no patients used self-intramuscular injected adrenaline as a prehospital treatment for anaphylaxis, and only severely affected patients who needed oxygen therapy or hospitalization received intramuscular adrenaline in a pediatric primary emergency setting.
Marijuana Misadventures in Children
Authors: Heizer Justin W. , Borgelt Laura M. , Bashqoy Ferras , Wang George S. , Reiter Pamela D.
Published: April 2016

Objectives

This study aimed to explore a dose-response relationship of delta-9-tetrahydrocannabinol (THC) in THC-naïve children after unintentional acute exposure and compare clinical outcomes with non-naïve children.

Methods

A retrospective review was performed on children aged 31 days to 20 years who presented to Children's Hospital Colorado for care related to acute THC toxicity. The children were divided into groups based on exposure: group 1 (THC naïve) and group 2 (THC non-naïve).

Results

A total of 38 children (age, 3.5 [3] years) met inclusion for group 1 and an equal number of children (age, 15.1 [3.9] years) met the criteria for comparison in group 2. Eight naïve patients had documentation of estimated THC dose ingested (mean [SD], 7.13 [5.8] mg/kg; range, 2.9–19.5 mg/kg). A direct relationship between estimated oral THC dose, level of medical intervention required, and hospital disposition was observed. Lethargy/somnolence was more common in the naïve group (84% vs. 26%, P < 0.0001) whereas problems in cognition, perception, and behavior were more common in the non-naïve group (4% vs 11%, P = 0.01). The duration of clinical effect and length of hospital stay were longer in the naïve group (19.3 vs 5.0 hours, P < 0.0001) and (0.73 vs 0.19 days, P < 0.0001) respectively.

Conclusions

There seems to be a direct relationship between the estimated oral THC dose (mg/kg), hospital disposition, and level of medical intervention required. Symptoms and duration of effects after THC exposure varied based on the route of exposure, age of patient, and history of previous THC experience.
Acellular Dermal Matrix–Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience
Authors: Salzberg C. Andrew , Ashikari Andrew Y. , Berry Colleen , Hunsicker Lisa M.
Published: April 2016

Background:

Use of acellular dermal matrix for implant-based breast reconstruction appears to be associated with a lower incidence of capsular contracture compared with standard reconstruction. The majority of acellular dermal matrix studies were, however, of short duration; thus, long-term incidence of capsular contracture with acellular dermal matrix use is unknown.

Methods:

Patients undergoing acellular dermal matrix–assisted breast reconstruction from December of 2001 to May of 2014 at two institutions were evaluated. Cumulative incidence of capsular contracture was determined by the performing surgeon. A retrospective chart review was performed on prospectively gathered data on patient-, breast-, surgery-, and implant-related characteristics that were analyzed as potential risk factors for the development of capsular contracture.

Results:

A total of 1584 breast reconstructions in 863 patients were performed. Mean follow-up of patients was 4.7 years; 45 percent of patients had greater than or equal to 5 years of follow-up. The cumulative incidence of capsular contracture was 0.8 percent. Smaller implant size (<400 ml) and postoperative radiotherapy were significantly associated with an increased risk of capsular contracture, but the incidence of capsular contracture was 1.9 percent in irradiated breasts. All capsular contractures developed within the first 2 years, with no new events with longer follow-up.

Conclusions:

In this long-term study, the cumulative incidence of capsular contracture with acellular dermal matrix–assisted reconstruction remains low, even in irradiated breasts. Capsular contracture appears to be an early event, and longer follow-up does not appear to increase the incidence, suggesting that acellular dermal matrix may truly mitigate the development of capsular contracture as opposed to delaying its occurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Clinical Implications of the Extension of Platysmal Fibers on the Middle and Lower Face
Authors: Bae Jung-Hee , Youn Kwan-Hyun , Hu Kyung-Seok , Lee Joo-Heon , Tansatit Tanvaa , Kim Hee-Jin
Published: April 2016

Background:

Despite the area of insertion of the facial portion of the platysma being broad and highly variable, the details of its pattern of extension and morphology are not well described in the medical literature. The aim of this study was to clarify the extension patterns of the platysma on the middle and lower face by topographic examination and detailed dissection.

Methods:

A detailed dissection was performed in the cheek region of 34 cadaveric specimens. The anatomical aspects of the extent of the platysma were classified according to its area of coverage on the cheek.

Results:

The location of the posterior fibers of the platysma passing behind the mandibular angle were located 17.1 ± 8.8 mm (mean ± SD) from the mandibular angle. The platysma was classified into patterns (A, B-1, B-2, and C) according to its coverage area: in type A (8.8 percent), areas S1 to S2, M1 to M3, and I1 to I3 were partially covered by the platysma; in type B-1 (58.8 percent), areas M1 to M3 and I1 to I3 were partially covered; in type B-2 (26.5 percent), areas M1 to M2 and I1 to I3 were partially covered; and in type C (5.9 percent), areas I1 to I3 were partially covered.

Conclusion:

The description of the extent of the facial portion of the platysma presented in this article provides detailed anatomical knowledge regarding the midface, and represents fundamentally important knowledge for surgeons conducting rhytidectomy and other facial operations.