bluuebunny/crossref_metadata_2025 huggingface dataset:
Future ecosystem changes in the Northeast Atlantic: a comparison between a global and a regional model system
Authors: Skogen Morten D , Hjøllo Solfrid S , Sandø Anne Britt , Tjiputra Jerry
Published: June 2018

The biogeochemistry from a global climate model (Norwegian Earth System Model) has been compared with results from a regional model (NORWECOM.E2E), where the regional model is forced by downscaled physics from the global model. The study should both be regarded as a direct comparison between a regional and its driving global model to investigate at what extent a global climate model can be used for regional studies, and a study of the future climate change in the Nordic and Barents Seas. The study concludes that the global and regional model compare well on trends, but many details are lost when a coarse resolution global model is used to assess climate impact on regional scale. The main difference between the two models is the timing of the spring bloom, and a non-exhaustive nutrient consumption in the global model in summer. The global model has a cold (in summer) and saline bias compared with climatology. This is both due to poorly resolved physical processes and oversimplified ecosystem parameterization. Through the downscaling the regional model is to some extent able to alleviate the bias in the physical fields, and the timing of the spring bloom is close to observations. The summer nutrient minimum is one month early. There is no trend in future primary production in any of the models, and the trends in modelled pH and ΩAr are also the same in both models. The largest discrepancy in the future projection is in the development of the CO2 uptake, where the regional suggests a slightly reduced uptake in the future.
Political Context and Citizen Information: Propaganda Effects in China
Authors: Chen Dan
Published: June 2018

Propaganda is integral to authoritarian rule. Yet, questions remain regarding what propaganda content is effective at influencing which opinions and to whom. Using an original online survey experiment conducted in China, this study finds that although propaganda is ineffective with average Internet users, it persuades highly informed participants when reality validates its messages. The propaganda treatments enhance opinions on government performance in several issue areas, including anticorruption and the economy, for participants who are politically informed. Propaganda thus sways opinions when real-world changes lend support, which necessitates a certain level of acquired information. These results suggest the limits of propaganda while specifying conditions for its effects.
An Outsider’s View from Inside
Authors: Devresse Marie-Sophie , Scalia Damien
Published: June 2018

Acquittal in international criminal law has long been disregarded by the governing bodies of international criminal courts. However, the acquittal exposes constitutive (and constituent) components of this very body of law. The authors draw conclusions from semi-directive interviews with (acquitted and condemned) people tried by the ad hoc tribunals. Their approach creates an opportunity to highlight and comprehend — from the perspective of the acquitted individual — the failures of the functioning of international criminal justice, which is focused on the idea of guilt. Moreover, this research shows how the position of tried individuals affects their perception and acceptance of international criminal law.
Geographic Variability in Discharge Setting and Outpatient Postacute Physical Therapy After Total Knee Arthroplasty: A Retrospective Cohort Study
Authors: Warren Meghan , Shireman Theresa I
Published: June 2018

Background

Despite the frequency of total knee arthroplasty (TKA) in the Medicare population, little is known about the use of postacute physical therapy among those discharged to home.

Objective

The objectives of this study were to explore factors associated with geographic variability in discharge disposition and outpatient physical therapy utilization for Medicare patients after TKA discharged to home/self-care.

Design

The design of the study was a retrospective cohort study.

Methods

Medicare patients with TKA discharged alive from July 1, 2010, to June 30, 2011, with discharge disposition to home/self-care (HSC), home health agency (HHA), inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF) were selected. Geography was measured with Census region. Outpatient physical therapy utilization was calculated from Medicare Part B claims. Odds ratios for discharge disposition and adjusted means for physical therapy utilization variables by Census region were calculated, accounting for county-clustered data and adjusting for demographics, clinical, and environmental characteristics.

Results

There was significant variation with discharge destination by Census region among 18,278 patients. With discharge disposition analysis, the patients from the West region who were discharged home were the referent group. The patients from the South and Northeast regions had higher odds for discharge to HHAs (adjusted odds ratio [95% CI = 1.80 [1.48–2.19] and 2.20 [1.70–2.84]), SNFs (1.34 [1.08–1.66] and 4.42 [3.38–5.79]), and IRFs (2.36 [1.80–3.09] and 8.83 [6.41–12.18]). For those discharged to HSC, 40.4% received outpatient physical therapy within 4 weeks. Significant differences were found with time to first physical therapy visit (Midwest <South <[West = Northeast]) and length of therapy episode, but not with the number of therapy visits by geographic region.

Conclusions

Geographic region was associated with discharge setting, postacute physical therapy, and outpatient therapy utilization in Medicare beneficiaries after TKA. Differences in outcomes of outpatient therapy should be assessed to better describe the impact of geographic variation in care.
Risk Factors for Early Reoperation After Operative Treatment of Acetabular Fractures
Authors: Ding Anthony , O'Toole Robert V. , Castillo Renan , Reahl Brad , Montalvo Ryan , Nascone Jason W. , Sciadini Marcus F. , Carlini Anthony R. , Manson Theodore T.
Published: June 2018

Objectives:

To identify the risk factors for early reoperation after operative fixation of acetabular fractures.

Design:

Retrospective evaluation.

Setting:

Level I Trauma Center.

Patients:

Seven hundred ninety-one patients with displaced acetabular fractures treated with open reduction and internal fixation (ORIF) from 2006 to 2015. Average follow-up was 52 weeks.

Main Outcome Measures:

Early reoperation after acetabular ORIF, defined as secondary procedure for infection or revision within 3 years of initial operation.

Results:

Fifty-six (7%) patients underwent irrigation and debridement for infection and wound complications. Four associated risk factors identified were length of stay in the intensive care unit, pelvic embolization, operative time, and time delay between injury and surgical fixation. Sixty-two (8%) patients underwent early revision, including 45 conversions to total hip arthroplasty, 10 revision ORIF, 6 fixation device removals because of concern for joint penetration (2 acutely and 4 > 6 months after surgery), and 1 stabilization procedure. Three risk factors associated with early revision were hip dislocation, articular comminution, and concomitant femoral head or neck injury. Combined injuries to the pelvic ring and acetabulum, fracture pattern, marginal impaction, and body mass index had no significant effect on early revision surgery.

Conclusions:

Risk factors for early reoperation after operative fixation of acetabular fractures differed based on the reason for return to the operating room. Infection was more likely to occur in patients who had prolonged stays in the intensive care unit, had prolonged operative times, were embolized, or experienced delay in time to fixation. Revision was more likely with hip dislocation, articular comminution, femoral head or neck fracture, and advancing age.

Level of Evidence:

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Cost-effectiveness of a Bone-anchored Annular Closure Device Versus Conventional Lumbar Discectomy in Treating Lumbar Disc Herniations
Authors: Ament Jared , Thaci Bart , Yang Zhuo , Kulubya Edwin , Hsu Wellington , Bouma Gerrit , Kim Kee D.
Published: June 2018

Study Design.

Cost-utility analysis of an annular closure device (ACD) based on data from a prospective, multicenter randomized controlled trial (RCT)

Objective.

The aim of this study was to determine the cost-effectiveness of a novel ACD in a patient population at high risk for recurrent herniation following discectomy.

Summary of Background Data.

Lumbar disc herniation patients with annular defect widths ≥6 mm are at high risk for recurrent herniation following limited discectomy. Recurrent herniation is associated with worse clinical outcomes and greater healthcare costs. A novel ACD may reduce the incidence of recurrent herniation and the associated burdens.

Methods.

A decision analytical modeling approach with a Markov method was used to evaluate the cost-effectiveness of the ACD versus conventional discectomy. Health states were created by projecting visual analogue scale (VAS) onto Oswestry Disability Index (ODI). Direct costs were calculated based on Humana and Medicare 2014 claims to represent private and public payer data, respectively. Indirect costs were calculated for lost work days using 2016 US average annual wages. The incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life year (QALY) was compared to willingness-to-pay thresholds. Sensitivity analyses were also conducted.

Results.

Patients with the ACD had less symptomatic reherniations, reoperations, and complications and gained 0.0328 QALYs within the first 2 years. Total direct medical costs for the ACD group were similar to control. When productivity loss was considered, using the ACD became $2076 cheaper, per patient, than conventional discectomy. Based on direct costs alone, the ICER comparing ACD to control equaled $6030 per QALY. When indirect costs are included, the ICER became negative, which indicates that superior quality of life was attained at less cost.

Conclusion.

For lumbar disc herniations patients with annular defects ≥6 mm, the ACD was, at 2 years, a highly cost-effective surgical modality compared to conventional lumbar discectomy.

Level of Evidence: 1
Preoperative Sagittal Spinal Profile of Adolescent Idiopathic Scoliosis Lenke Types and Non-Scoliotic Adolescents
Authors: Pasha Saba , Baldwin Keith
Published: June 2018

Study Design.

Systematic review and meta-analysis.

Objective.

This study aims to determine the differences in sagittal spinopelvic parameters between adolescent idiopathic scoliosis (AIS) Lenke types and non-scoliotic controls through a systematic review and meta-analysis of the available literature.

Summary of Background Data.

AIS classification mainly focuses on frontal curve differences; however, the variations in the sagittal spinopelvic alignment in the current classification system is not fully established.

Methods.

Following preferred reporting items for systematic reviews and meta-analyses guidelines, searches were performed for sagittal spinal and pelvic parameters of Lenke types and non-scoliotic controls in PubMed, Scopus, EMBASE, and Cochrane databases. Selection criteria were: (1) age range 10 to 21 years; (2) Lenke types 1–6 (for AIS group) or non-scoliotic adolescents (for the control group); (3) preoperative data for T5–T12 thoracic kyphosis (TK), L1–S1 lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and sagittal vertical axis (SVA). (4) Written in English language. PI–LL mismatch was calculated from the weighted average of PI and LL. Publication bias between studies and within studies quality were assessed. A meta-regression compared each measured variable between groups. Thoracic (Lenke1 and 2) and thoracolumbar/lumbar (Lenke 5 and 6) scoliosis were combined and statistically compared with the control group.

Results.

Meta-analysis, including 81 AIS and 18 control studies, showed no significant differences in sagittal parameters between Lenke types and controls for LL, PI, PI–LL mismatch, SS, and SVA (P > 0.05). Publication bias was significant in Lenke 1 TK, Control LL, and Lenke 1, and 5 SVA. Stratification based on deformity region (thoracic vs. thoracolumbar/lumbar) showed no significant differences in sagittal spinopelvic parameters (P > 0.05).

Conclusion.

No definitive difference was found between non-scoliotic adolescents and Lenke types in sagittal spinal and pelvic parameters. Future studies on developing a sagittal classification specific to AIS patients with a goal to improve surgical planning and outcome prediction are highly encouraged.

Level of Evidence: 4
Hypertonic Lactate to Improve Cerebral Perfusion and Glucose Availability After Acute Brain Injury*
Authors: Carteron Laurent , Solari Daria , Patet Camille , Quintard Hervé , Miroz John-Paul , Bloch Jocelyne , Daniel Roy T. , Hirt Lorenz , Eckert Philippe , Magistretti Pierre J. , Oddo Mauro
Published: June 2018

Objectives:

Lactate promotes cerebral blood flow and is an efficient substrate for the brain, particularly at times of glucose shortage. Hypertonic lactate is neuroprotective after experimental brain injury; however, human data are limited.

Design:

Prospective study (clinicaltrials.gov NCT01573507).

Setting:

Academic ICU.

Patients:

Twenty-three brain-injured subjects (13 traumatic brain injury/10 subarachnoid hemorrhage; median age, 59 yr [41–65 yr]; median Glasgow Coma Scale, 6 [3–7]).

Interventions:

Three-hour IV infusion of hypertonic lactate (sodium lactate, 1,000 mmol/L; concentration, 30 µmol/kg/min) administered 39 hours (26–49 hr) from injury.

Measurements and Main Results:

We examined the effect of hypertonic lactate on cerebral perfusion (using transcranial Doppler) and brain energy metabolism (using cerebral microdialysis). The majority of subjects (13/23 = 57%) had reduced brain glucose availability (baseline pretreatment cerebral microdialysis glucose, < 1 mmol/L) despite normal baseline intracranial pressure (10 [7–15] mm Hg). Hypertonic lactate was associated with increased cerebral microdialysis lactate (+55% [31–80%]) that was paralleled by an increase in middle cerebral artery mean cerebral blood flow velocities (+36% [21–66%]) and a decrease in pulsatility index (–21% [13–26%]; all p < 0.001). Cerebral microdialysis glucose increased above normal range during hypertonic lactate (+42% [30–78%]; p < 0.05); reduced brain glucose availability correlated with a greater improvement of cerebral microdialysis glucose (Spearman r = –0.53; p = 0.009). No significant changes in cerebral perfusion pressure, mean arterial pressure, systemic carbon dioxide, and blood glucose were observed during hypertonic lactate (all p > 0.1).

Conclusions:

This is the first clinical demonstration that hypertonic lactate resuscitation improves both cerebral perfusion and brain glucose availability after brain injury. These cerebral vascular and metabolic effects appeared related to brain lactate supplementation rather than to systemic effects.
Comparative Pharmacokinetic and Electrocardiographic Effects of Intratracheal and Intravenous Administration of Flecainide in Anesthetized Pigs
Authors: Stocco Fernando G. , Evaristo Ederson , Silva Anderson C. , de Antonio Victor Zandona , Pfeiffer Juergen , Rangachari Narasimhan , Belardinelli Luiz , Verrier Richard L.
Published: June 2018

We compared the pharmacokinetic (PK) profile and electrocardiographic (ECG) changes in response to intratracheal instillation of flecainide acetate into the left atrium and ventricle with intravenous (IV) flecainide acetate administration. In 12 closed-chest anesthetized Yorkshire pigs, we monitored the QRS complex and PR, JTc, and QTc intervals during sinus rhythm and correlated changes with venous plasma drug concentrations before and at 2, 5, 10, 15, and 30 minutes after drug administration. Intratracheal instillation of flecainide (0.75 and 1.5 mg/kg, rapid bolus) caused dose/concentration-dependent increases in the QRS complex duration of 10% and 19%, respectively, at 2 minutes, coinciding with peak venous plasma levels (1688 ± 177 and 2808 ± 217 ng/mL, respectively). IV infusion of flecainide (2 mg/kg) over 2 or 10 minutes similarly prolonged QRS complexes and PR intervals (both, P < 0.001). Intratracheal flecainide instillation increased PR interval briefly at 5 minutes. Neither intratracheal nor IV flecainide affected JTc or QTc intervals. Thus, the PK pattern of intratracheal instillation of flecainide is comparable to IV administration, although the absolute plasma concentrations were higher with IV infusion. Both modes of delivery elicited ECG changes that were consistent with the expected pharmacological activity of flecainide.
Fat Grafting Can Induce Browning of White Adipose Tissue
Authors: Hoppela Erika , Grönroos Tove J. , Saarikko Anne M. , Tervala Tomi V. , Kauhanen Susanna , Nuutila Pirjo , Kivinen Katri , Hartiala Pauliina
Published: June 2018

Background:

Fat grafting is commonly used when treating soft-tissue defects. However, much of the basic biology behind fat transfer is still uncovered. Adipocytes can be divided into energy storing white and energy burning brown adipose cells. It is now well known, that also adult humans have metabolically active brown adipose tissue (BAT) within white adipose tissue (WAT). Previously our group showed that transfer of metabolically inactive WAT into a new environment increased the metabolic activity of the fat grafts to resemble the activity in the recipient site and that different WAT depots have variation in the metabolic activity. This led us to speculate, whether the metabolic increase of the graft is a result of “browning” of the transferred WAT toward beige adipose tissue.

Methods:

We investigated the metabolic and histological characteristics and BAT marker Ucp1 gene expression in different types of WAT grafts placed either in subcutaneous or muscle tissue in mice. Metabolic activity of the grafts was investigated by FDG-PET/CT at 4- and 12-week time-points.

Results:

The glucose uptake of all transferred fat types was increased when compared with respective control WAT regardless of transfer location. Ucp1 gene and protein expression was increased in 4 of 15 intramuscularly placed fat graft samples and showed histological resemblance to BAT with multilocular cells.

Conclusions:

Grafting of metabolically inactive fat intramuscularly may induce browning of fat grafts toward more active beige adipose tissue. This opens up new research areas in exploiting fat grafting in metabolic diseases.
Efficacy of Cultured Epithelial Autograft after Curettage for Giant Melanocytic Nevus of the Head
Authors: Maeda Tamami , Morimoto Naoki , Kakudo Natsuko , Kusumoto Kenji
Published: June 2018

Cultured epithelial autograft (CEA) is an epithelial sheet prepared from a patient’s own skin using cell culture. In Japan, CEA (JACE; Japan Tissue Engineering Co., Ltd., Gamagori, Japan) was approved and covered by public health care insurance for use in the treatment of giant congenital melanocytic nevus (GCMN) in 2016. There are several treatment options for GCMN; however, the complete removal of a GCMN is usually difficult due to the lack of skin. In this report, we describe a case of GCMN in the occipital region that was treated using CEA after curettage. A 2-month-old boy had a GCMN of 13 × 21 cm in his occipital region. We used full-thickness skin taken from the back of the right auricle to prepare CEA under general anesthesia at 4 months of age. Three weeks after preparing CEA, we performed curettage of the right half of the GCMN, and CEA was grafted onto the wound afterward. CEA took completely, and epithelization was observed at 10 days after surgery. We then performed curettage with subsequent grafting of CEA on the left half of the GCMN at 7 months of age. CEA took completely, and epithelization was observed in this procedure as well with no hair loss at 8 months of age. Whether or not curettage can reduce the risk of malignant transformation into malignant melanoma of GCMN is unclear; however, the application of CEA after curettage may be a promising option for obtaining early epithelization.
Composite Grafts for Pediatric Fingertip Amputations: A Retrospective Case Series of 100 Patients
Authors: Borrelli Mimi R. , Dupré Sophie , Mediratta Saniya , Bisquera Alessandra , Greig Aina
Published: June 2018

Background:

Fingertip amputations are common. This study reports on the outcomes of composite grafts used for fingertip amputations in children, measuring graft take, predictors of graft take, complications, and patient-reported outcomes.

Methods:

A retrospective case series of consecutive patients (≤ 16 years) undergoing composite grafts for fingertip amputations in a tertiary pediatric hospital, January 06 to December 16, was performed. Information was collected on amputations, graft take, and complications. Logistic regression was used to analyze factors predicting graft take (partial/complete or failure) including age; amputation level; mechanism and time delay to surgery. Patients were contacted via post or telephone to ask about functional and cosmetic outcomes and their perception of graft take.

Results:

One hundred patients [57 (57%) males; mean age, 4.41 ± 3.98 years], presenting with 100 fingertip amputations, met the inclusion criteria. Amputation mechanism was crush in 75 (75%), avulsion in 13 (13%), and laceration in 12 (13%). Thirteen (13%) composite grafts survived completely, 46 (46%) partially, and 41 (41%) failed. Graft survival was higher in children under 4 years (P = 0.016). Seventeen (17%) grafts became infected, 9 (9%) required a reoperation, 9 (9%) had wound healing complications, and 4 (4%) patients developed psychological complications. Patient-reported survival was 33% higher than medical-reported survival. Cosmetic issues were the commonest complication reported by patients. Patients rated fingertips looking 3.5/5 normal, and that they were 4/5 satisfied with the appearance. Most patients were using their fingers normally by 2–6 months.

Conclusions:

Composite grafts for fingertip amputations mostly only partially survive, but morbidity is low, patient satisfaction is high, and acceptable cosmetic and functional outcomes are achieved.
Axial Elongation in Myopic Children and its Association With Myopia Progression in the Correction of Myopia Evaluation Trial
Authors: Hou Wei , Norton Thomas T. , Hyman Leslie , Gwiazda Jane ,   the COMET Group
Published: June 2018

Objectives:

Describe axial elongation using 14-year longitudinal data in a large, ethnically diverse group of myopic children, estimate age and axial length (AL) at stabilization, and evaluate associations between the progression and stabilization of AL and myopia.

Methods:

Axial length was measured by A-scan ultrasonography annually. Axial length data were fit with individual polynomial functions and curve-based parameters (AL at stabilization and age at stabilization when annual rate of axial elongation ≤0.06 mm) were estimated. For myopia progression, noncycloplegic spherical equivalent refractions were fit with Gompertz functions.

Results:

Four hundred thirty-one participants, with AL and myopia data fit successfully, were classified into four cohorts: Younger (n=30); Older (n=334); AL Stabilized at Baseline (n=19); and AL Not Stabilized (n=48). At AL stabilization, for participants in the Younger and Older Cohorts, mean (SD) age and AL were 16.3 (2.4) years and 25.2 (0.9) mm, respectively. No associations were found between age at AL stabilization and ethnicity, sex, or number of myopic parents. At stabilization, sex and number of myopic parents (both P<0.003), but not ethnicity, were significantly associated with AL. Axial length and myopia progression curves were highly correlated overall (all r>0.77, P<0.0001). However, unlike AL, the amount of myopia did not differ significantly between males and females.

Conclusions:

In most of the participants, AL increased rapidly at younger ages and then slowed and stabilized. The close association between growth and stabilization of AL and myopia is consistent with the suggestion that axial elongation is the primary ocular component in myopia progression and stabilization.
Revision Surgery for Undercorrected Blepharoptosis After Frontalis Sling Operation Using Autogenous Fascia Lata
Authors: Lee Ju-Hyang , Woo Kyung In , Kim Yoon-Duck
Published: June 2018

Purpose:

Undercorrected blepharoptosis can be encountered after frontalis sling operation. Revision surgery for undercorrection has commonly involved introducing a new sling material. We describe and evaluate a simple surgical technique to correct undercorrection by adjusting preexisting fascia.

Methods:

This is a retrospective interventional case series of patients undergoing sling revision between February 2010 and February 2017. Skin incision was made on the previous incision line. Careful dissection was performed superiorly to identify a preexisting fascia, and the dissected fascia was reattached to the tarsal plate using nonabsorbable sutures with adjustments for eyelid height and contour. The success of the procedure was defined as less than 1 mm of difference in the marginal reflex distance 1 of both eyes without any contour deformity.

Results:

Twenty-one eyelids in 18 patients were included with a mean follow-up of 17.5 months (range 6–48) and a mean age of 14.7 years (range 5–57). All patients had undergone frontalis sling with autogenous fascia lata for congenital ptosis. Undercorrection due to recurrent ptosis was found in 12 eyelids, and contour deformity such as temporal ptosis was found in 9 eyelids. The mean time interval between previous frontalis sling operation and sling revision was 6.8 years. Nineteen patients (90.5%) achieved surgical success and a cosmetically acceptable appearance.

Conclusion:

Sling revision is a simple and effective method with low perioperative morbidity for cases of undercorrection or contour deformity following frontalis sling operation using autogenous fascia lata, even long after the primary procedure.
Evaluation of the symptom of itch ambulatory office-based care in the United States
Authors: Fleischer Alan B.
Published: June 2018

Introduction:

This study was designed to assess the characteristics of visits for itch from a cross-sectional study of office-based ambulatory care in the United States.

Methods:

To characterize itch as a symptom, ambulatory visits from the 1993 to 2015 National Ambulatory Medical Care Survey were analyzed when they included “itching” as a symptom or itch as a diagnosis code (ICD-9-CM 692.X).

Results:

This study finds 129 million itch visits occurred, averaging 5.6 million visits per year. There is seasonality to itch visits, with the largest numbers occurring in summer and fewest in winter. Vulvovaginal conditions including candidiasis and vaginitis and vulvovaginitis are commonly associated with itching, yet under-represented in the dermatology literature.

Discussion:

These data provide insights for further investigation into the burden of itch-related diseases.
Over the Scope Clips for Treatment of Acute Nonvariceal Gastrointestinal Bleeding in Children Are Safe and Effective
Authors: Tran Paul , Carroll Joshua , Barth Bradley A. , Channabasappa Nandini , Troendle David M.
Published: June 2018

Objective:

There is little published experience with the use of over‐the‐scope clips (OTSCs) in pediatric patients. The aim of this study is to present our single‐center experience utilizing OTSCs for nonvariceal gastrointestinal (GI) bleeding.

Methods:

This is a retrospective case series of pediatric patients who underwent endoscopic management of GI bleeding during which OTSCs were used.

Results:

Eleven cases of OTSC utilization for hemostasis were identified in 10 unique patients between November 2014 and May 2016. The median age at intervention was 14.7 years (range 3.9–16.8 years) and median weight was 39 kg (range 17.4–85.8 kg). Technical success and hemostasis were achieved in all cases and there were no complications. Median follow‐up was 32.9 months (range 21.2–39.4 months). All nonanastomotic ulcers (4), polypectomy bleeding (2), and sphincterotomy bleeding (1) had no evidence of recurrent GI bleeding at last follow‐up. Two patients with anastomotic ulcerations required additional medical interventions.

Conclusions:

Our series demonstrates the safety and effectiveness of the OTSCs in the pediatric population for acute GI bleeding throughout the GI tract. In our experience, it is effective for nonanastomotic ulcers, postpolypectomy bleeding, and postsphincterotomy bleeding even when other hemostatic techniques have failed. OTSCs may be less effective in the setting of anastomotic ulcerations, reaffirming the refractory nature of these lesions.
Clinical Characteristics and Outcome of Children With Relapsed Medulloblastoma: A Retrospective Study at a Single Center in China
Authors: Du Shuxu , Yang Shuli , Zhao Xia , Xiao Jiang , Ren Siqi , Li Shuting , Zhang Jin , Wang Yuan , Gong Xiaojun , Li Miao , Sun Yanling , Wu Wanshui , Sun Liming
Published: June 2018

Relapsed medulloblastoma (MB) has a dire prognosis, and chemotherapy remains the main therapeutic option. We retrospectively analyzed the clinical characteristics and survival rates of 60 Chinese children with relapsed MB. The patients received 11 cycles of chemotherapy in sequence, followed by 12 cycles of oral temozolomide and etoposide. Thirty patients were simultaneously administered intrathecal methotrexate (IT-MTX). The Kaplan-Meier method was used to determine survival rates; the patients’ median survival time after relapse was 2.8 years, 5-year progression-free survival (PFS) and overall survival (OS) rates were 26.7%±5.7% and 31.6%±6.9%, respectively. There was no significant difference between these rates according to histology or molecular subgroup. Tumor cells were detected in the cerebrospinal fluid of over 40% of patients; such patients had significantly shorter OS and PFS rates. Patients who received IT-MTX showed significantly longer survival than those who did not (3.73 vs. 2.06 y, respectively, P=0.000); the corresponding 5-year PFS and OS rates were 43.3%±9.0% versus 10.0%±5.5% and 49.5%±11.1% versus 14.6%±6.9%, respectively (P=0.000). In addition, tumor cell-positive cerebrospinal fluid and IT-MTX use significantly influenced PFS and OS in relapsed patients. Taken together, our data show that IT-MTX improves the survival of patients with relapsed MB.
Multiple Micronutrient Plasma Level Changes Are Related to Oxidative Stress Intensity in Critically Ill Children*
Authors: Valla Frédéric V. , Bost Muriel , Roche Sylvain , Pitance Marion , Cuerq Charlotte , Ridout Jenna , Ecochard René , Ginhoux Tiphanie , Bellon Amandine , Ford-Chessel Carole , Portefaix Aurélie , Javouhey Etienne , Blond Emilie
Published: June 2018

Objectives:

Micronutrient supplementation in critically ill adults remains controversial. In the pediatric setting, the impact of oxidative stress on the overall micronutrient status has been poorly explored, due to the limited number of studies and to confounding factors (i.e., malnutrition or extra losses). In order to better understand this phenomenon, we aim to describe micronutrient status, focusing on seven micronutrients, in well-nourished critically ill children presenting with severe oxidative stress.

Design:

Prospective, transversal, observational, single-center study.

Setting:

PICU, and anesthesiology department, Lyon, France.

Patients:

Three groups of patients were clinically defined: severe oxidative stress PICU group (at least two organ dysfunctions), moderate oxidative stress PICU group (single organ dysfunction), and healthy control group (prior to elective surgery); oxidative stress intensity was controlled by measuring plasma levels of glutathione peroxidase and glutathione. Children presenting any former condition leading to micronutrient deficiency were excluded (malnutrition, external losses).

Interventions:

Plasma levels of selenium, zinc, copper, vitamin A, vitamin E, vitamin C, and β-carotene were measured in PICU oxidative stress conditions and compared with those of healthy children.

Measurements and Main Results:

Two hundred one patients were enrolled (51, 48, and 102 in severe, moderate, and healthy control groups, respectively). Median age was 7.1 years (interquartile range, 2.1–13.8 yr). There was a significant trend (p < 0.02) toward plasma level decrease of six micronutrients (selenium, zinc, copper, vitamin E, vitamin C, and β-carotene) while oxidative stress intensity increased. Biological markers of oxidative stress (glutathione peroxidase and glutathione) were in accordance with the clinical definition of the three groups.

Conclusions:

A multiple micronutrient deficiency or redistribution occurs in critically ill children presenting with severe oxidative stress. These findings will help to better identify children who might benefit from micronutrient supplementation and to design adapted supplementation trials in this particular setting.
Predictive Factors for Central Line–Associated Bloodstream Infections in Pediatric Cardiac Surgery Patients With Chylothorax
Authors: Waterhouse Stephanie G. , Vergales Jeffrey E. , Conaway Mark R. , Lee Laura
Published: June 2018

Objectives:

To assess the prevalence of central line–associated bloodstream infections in pediatric patients with and without chylothorax after cardiac surgery and identify risk factors that predict those patients at highest risk for developing a central line–associated bloodstream infection.

Design:

Retrospective single-center cohort study.

Setting:

A PICU located within a tertiary-care academic pediatric hospital.

Patients:

All pediatric patients admitted to the PICU after cardiac surgery between 2008 and 2014.

Interventions:

None.

Measurements and Main Results:

We identified 1,191 pediatric cardiac surgery patients in the study time frame, of which 66 (5.5%) had chylothorax. Patients with chylothorax were more likely to have a central line–associated bloodstream infection (23% vs 3.8%; p < 0.001). Patients with both chylothorax and central line–associated bloodstream infection had longer durations of central venous catheter, higher Risk Adjustment Congenital Heart Surgery score, longer PICU stay, and higher mortality compared with patients with chylothorax who did not have a central line–associated bloodstream infection. Multivariable analysis identified higher Risk Adjustment Congenital Heart Surgery score, longer duration of central venous catheter, and higher chest tube output at 24 hours after initiating treatment for chylothorax to be predictive of increased central line–associated bloodstream infection risk in patients with chylothorax.

Conclusions:

The prevalence of central line–associated bloodstream infection is higher in pediatric patients with chylothorax after heart surgery. In patients with chylothorax, complexity of surgery, central venous catheter duration, and chest tube output are associated with increased risk for developing a central line–associated bloodstream infection. Using this knowledge will allow us to identify patients at increased risk for central line–associated bloodstream infections and to focus extra prevention efforts on them.
Pulmonary Functions in Children Ventilated for Acute Hypoxemic Respiratory Failure*
Authors: Chakdour Stanzen , Vaidya Pankaj C. , Angurana Suresh Kumar , Muralidharan Jayashree , Singh Meenu , Singhi Sunit C.
Published: June 2018

Objective:

To assess pulmonary functions of children who received mechanical ventilation for acute hypoxemic respiratory failure.

Design:

Longitudinal study.

Setting:

PICU and Pediatric Pulmonology Clinic of a tertiary care teaching hospital in North India.

Patients:

All children, 5–12 years old, ventilated for acute hypoxemic respiratory failure in PICU from July 2012 to June 2013 and survived.

Interventions:

The baseline admission variables recorded were as follows: age, sex, duration of illness, primary diagnosis at admission, Pediatric Risk of Mortality III score, lung injury score, mechanical ventilation parameters, oxygenation indices, and duration of PICU stay. The children were followed up twice, at 3 and 9–12 months, after discharge from PICU and evaluated for any residual respiratory symptoms and signs, pulse oximetry, chest radiograph, 6-minute walk test, peak expiratory flow rate, and spirometry. Age, sex, duration of illness, primary diagnosis, Pediatric Risk of Mortality III score, lung injury score, mechanical ventilation parameters, oxygenation indices (Pao
2/Fio
2 ratio and oxygenation index), and duration of PICU stay were recorded from patient records.

Measurements and Main Results:

Twenty-nine children (25 boys and four girls; mean [sd] age, 8.4 [2.4] yr) were followed up at 3.5 (± 1.2) and 10.6 (± 2.7) months after discharge from PICU. Recurrent respiratory symptoms were noted in 37.9% patients (11/29) during first and in none during second follow-up. None had limitation of physical activity or need of supplemental oxygen. Chest examination was normal in all, except one during first follow-up, but 13.8% (4/29) had abnormal chest radiograph during first follow-up. Nearly all children could perform 6-minute walk test although mean distance walked increased significantly from first (352 ± 66.7 m) to second follow-up (401 ± 60.7 m; p = 0.002). Abnormal spirometry was seen in 82.7% (24/29) versus 18.5% (5/27) children during first and second follow-up visits, respectively (p = 0.0001). Most cases had restrictive abnormality (58.6% vs 11.1%; p = 0.002) during first and second follow-up, respectively. There was no correlation between pulmonary functions and lung injury scores, oxygenation indices (Pao
2/Fio
2 ratio and oxygenation index), and mechanical ventilation parameters.

Conclusions:

Significant number of children ventilated for acute hypoxemic respiratory failure had subclinical pulmonary function abnormality, without limiting physical activity, which improved over time. Further research on this topic with a larger sample size and patient categorization according to recent pediatric acute respiratory distress syndrome definition is needed.
Factors Associated With Mechanical Ventilation Use in Children With Sickle Cell Disease and Acute Chest Syndrome
Authors: Takahashi Takuto , Okubo Yusuke , Pereda Maria A. , Handa Atsuhiko , Miller Scott
Published: June 2018

Objectives:

Acute chest syndrome is the leading cause of death in children with sickle cell disease and is generally due to respiratory failure. Epidemiologic factors for a need for mechanical ventilation in children with acute chest syndrome require further clarification.

Design:

Retrospective observational study.

Setting:

Nationally representative pediatric inpatient records in the United States by using the Kids’ Inpatient Database for the years 2003, 2006, 2009, and 2012.

Patients:

Patients age less than 20 years old with a discharge diagnosis of acute chest syndrome.

Measurements and Marin Results:

Data were weighted to estimate annual hospitalizations according to hospital characteristics in the United States. Multivariable logistic regression was conducted to ascertain factors associated with use of mechanical ventilation, after adjusting for patient and hospital characteristics. Total hospitalizations for acute chest syndrome were 5,018 in 2003, 6,058 in 2006, 6,072 in 2009, and 6,360 in 2012. Mechanical ventilation use was associated with comorbidities of obesity (odds ratio, 3.35; 95% CI, 1.94–5.78), obstructive sleep apnea (odds ratio, 3.72; 95% CI, 2.23–6.20), and heart disease (odds ratio, 2.19; 95% CI, 1.47–3.27). In addition, nonblack compared with black children (odds ratio, 1.53; 95% CI, 1.02–2.31) and the fall season (p= 0.018) were associated with mechanical ventilation use.

Conclusions:

Comorbidity of obesity, obstructive sleep apnea, or heart disease could be potentially associated with mechanical ventilation use during an episode of acute chest syndrome. Prospective observational studies would be required to confirm these findings and infer potential interventions for preventing illness severity.
Changes in Therapist Actions During a Novel Pediatric Physical Therapy Program: Successes and Challenges
Authors: Akhbari Ziegler Schirin , Dirks Tineke , Reinders-Messelink Heleen A. , Meichtry André , Hadders-Algra Mijna
Published: June 2018

Purpose:

To monitor changes in time spent on pediatric physical therapy actions during a COPing With and CAring for Infants With Special Needs (COPCA) course.

Methods:

Data were collected before (T0), during, and after (T3) the course, which was attended by 15 Swiss physical therapists. Four treatment sessions of each therapist were video recorded and analyzed with the Groningen Observation Protocol 2.0, allowing for quantification of relative duration of therapeutic actions.

Results:

Between T0 and T3, time spent on caregiver coaching and hands-off approaches significantly increased.

Conclusions:

The shift from caregiver trainer to family coach and the increasing hands-off techniques represent successful changes in various domains of behavior. The moderate changes in hands-off approaches suggest that changing habits requires specific attention. The COPCA course will be adapted accordingly.
Use of an In-Home Body Weight Support System by a Child With Spina Bifida
Authors: Kokkoni Elena , Logan Samuel W. , Stoner Tracy , Peffley Terri , Galloway James C.
Published: June 2018

Purpose:

To examine the feasibility of a new open-area body weight support system (BWSS) to act as both an “assistive” and a “rehabilitative” device within the home.

Intervention:

A 5-year-old boy with spina bifida used the BWSS during self-selected activities for 10 weeks. Feasibility, behavioral, and clinical assessments provided a quantification of his activity in and out of the BWSS.

Outcomes:

On average, the child used the device on 2.7 days/week and for 67 minutes/day during intervention. When in the BWSS (assistive role), the child's locomotor activity and engagement in adapted sports activities increased. When not in the BWSS (rehabilitative role), the child's functional mobility and ambulatory ability increased.

What This Case Adds:

The use of the open-area in-home BWSS was feasible for regular home use and associated with an increase in functional mobility for a child with spina bifida.
Cost Analysis of 3 Concurrent Public Health Response Events: Financial Impact of Measles Outbreak, Super Bowl Surveillance, and Ebola Surveillance in Maricopa County
Authors: McCullough J. Mac , Fowle Nicole , Sylvester Tammy , Kretschmer Melissa , Ayala Aurimar , Popescu Saskia , Weiss Jolie , England Bob
Published: June 2018

Objective:

To generate estimates of the direct costs of mounting simultaneous emergency preparedness and response activities to respond to 3 major public health events.

Design:

A cost analysis was performed from the perspective of the public health department using real-time activity diaries and retrospective time and activity self-reporting, wage and fringe benefit data, and financial records to track costs.

Setting:

Maricopa County Department of Public Health (MCDPH) in Arizona. The nation's third largest local public health jurisdiction, MCDPH is the only local health agency serving Maricopa's more than 4 000 000 residents. Responses analyzed included activities related to a measles outbreak with 2 confirmed cases, enhanced surveillance activities surrounding Super Bowl XLIX, and ongoing Ebola monitoring, all between January 22, 2015, and March 4, 2015.

Participants:

Time data were sought from all MCDPH staff who participated in activities related to any of the 3 relevant responses. In addition, time data were sought from partners at the state health department and a community hospital involved in response activities. Time estimates were received from 128 individuals (response rate 88%).

Main Outcome Measure:

Time and cost to MCDPH for each response and overall.

Results:

Total MCDPH costs for measles-, Super Bowl-, and Ebola-related activities from January 22, 2015, through March 4, 2015, were $224 484 (>5800 hours). The majority was for personnel ($203 743) and the costliest response was measles ($122 626 in personnel costs). In addition, partners reported working more than 700 hours for these 3 responses during this period.

Conclusions:

Funding for public health departments remains limited, yet public health responses can be cost- and time-intensive. To effectively plan for future public health responses, it may be necessary to share experiences and financial lessons learned from similar public health responses. External partnerships represent a key contribution for responses such as those examined. It can be expensive for local public health departments to mount effective responses, especially when multiple responses occur simultaneously.
The Value of Real-Time Thoracic Radiology Consulting in an Integrated Lung Center Clinic
Authors: Mortani Barbosa Eduardo J. , Novak Sean
Published: June 2018

Purpose:

We have established an integrated thoracic radiology reading room within a multidisciplinary lung center clinic (LC). While our subjective experience has been positive, we sought to quantify how this model affects radiology workflow and whether the referring practitioners perceive value in having real-time access to a radiologist consultant.

Materials and Methods:

Two diagnostic radiology workstations staffed by rotating thoracic radiologists and trainees were integrated within the LC. We assessed the impact on workflow by recording over 6 months the number, duration, and type of face-to-face radiology consultations to LC practitioners. We also conducted an anonymous survey to assess how LC practitioners felt with regard to the utility and value of our service.

Results:

Face-to-face consultations account for an average of 10% of total time spent by radiologists in the LC, although on busy clinical days this can reach 25% to 30%. Our survey response rate was very high (86.4%, n=51), with overwhelming positive response by referring practitioners, who unanimously rate the usefulness of this service as high (9.8%) or extremely high (90.2%). Not a single respondent had a negative or even neutral view of this service. Moreover, 90.2% thought that radiology consultations directly add clinical value in >60% of episodes, whereas 86.2% responded that these alter management in >40% of episodes.

Conclusions:

Face-to-face radiology consultations in an integrated LC are numerous and comprise a sizable share of radiologist workload. More importantly, the radiologist is highly praised as a consultant, and this service is considered valuable and impactful for patient care.
Interpretation and Reporting of Coronary Arteries in Transposition of the Great Arteries
Authors: Swanson Sara K. , Sayyouh Mohamed M. , Bardo Dianna M.E. , Ghadimi Mahani Maryam , Lu Jimmy C. , Dorfman Adam L. , Agarwal Prachi P.
Published: June 2018

Knowledge of coronary artery nomenclature in transposition of the great arteries is essential, given the increasing population of adults with congenital heart disease and greater utilization of imaging in these patients. This article reviews appropriate terminology for describing coronary artery anatomy, commonly encountered coronary artery patterns, and postoperative coronary complications in the setting of transposition of the great arteries.