bluuebunny/crossref_metadata_2025 huggingface dataset:
Variation in Bariatric Surgery Costs and Complication Rates in the Military Health System
Authors: Luan William Patrick , Leroux Todd C , Olsen Cara , Robb Douglas , Skinner Jonathan S , Richard Patrick
Published: December 2019

Introduction: Within the Military Health System (MHS), facilities have struggled to meet minimum recommended volume thresholds for certain procedures. Understanding variations in complication rates and cost can help policymakers tailor policy to target improvement. Our objective was to quantify the variation in bariatric surgery complication rates and costs across a sample of military hospitals. Materials and Methods: We study a retrospective cohort of 38 military surgeons practicing in 21 military treatment facilities from 2007 to 2014 who performed 1,277 bariatric surgeries. Data from the Centralized Credentials and Quality Assurance System, which provides education and training characteristics of physicians, were linked to patient encounter data from the MHS Data Repository. Physicians were included if they performed at least five bariatric surgeries over the study period. Patients were included if they had a diagnosis of obesity (body mass index > 30) and underwent a bariatric weight loss surgery. We calculated and summarized inpatient costs and complication rates across both surgeons and facilities using multivariable mixed-effects linear or logistic models. We used these models to calculate adjusted complication rates and average costs across both providers and hospitals to characterize variation in bariatric outcomes within the MHS. This study was considered exempt by the Uniformed Services University Institutional Review Board. Results: We find evidence of large variations in both complication rates and costs per admission. Overall, we found a 15.5% complication rate across the sample. When comparing averages across facilities, we find large variation in complications (49.4% coefficient of variation [CV]) and procedure costs (25.9% CV). Controlling for patient comorbidities, BMI, and year attenuates much of the variation (12.6% CV complications, 4.4% CV cost), but cannot completely explain differences across facilities. Our model suggests that complications cost 32% more than complication-free surgeries on average suggesting that quality improvement efforts could potentially yield large savings. Conclusions: We find large variations in complication rates even after controlling for patient health. Furthermore, surgical complications are a significant determinant of cost. Policymakers should target efforts to improve surgical quality across facilities and physicians. Surgical quality improvement initiatives could produce savings to the MHS through reduced complications and improved surgical readiness.
MusE GAs FLOw and Wind (MEGAFLOW) IV. A two sightline tomography of a galactic wind
Authors: Zabl Johannes , Bouché Nicolas F , Schroetter Ilane , Wendt Martin , Contini Thierry , Schaye Joop , Marino Raffaella A , Muzahid Sowgat , Pezzulli Gabriele , Verhamme Anne , Wisotzki Lutz
Published: December 2019

Galactic outflows are thought to eject baryons back out to the circumgalactic medium. Studies based on metal absorption lines (Mg ii in particular) in the spectra of background quasars indicate that the gas is ejected anisotropically, with galactic winds likely leaving the host in a bi-conical flow perpendicular to the galaxy disc. In this paper, we present a detailed analysis of an outflow from a z = 0.7 ‘green-valley’ galaxy [log (M*/M⊙) = 9.8; $\mbox{SFR}=0.5\, \mathrm{M}_{\odot }\, \mathrm{yr}^{-1}$] probed by two background sources from the MusE GAs FLOw and Wind (MEGAFLOW) survey. Thanks to a fortuitous configuration with a background quasar (SDSSJ1358 + 1145) and a bright background galaxy at z = 1.4, both at impact parameters of $\approx\! 15\, \hbox{kpc}$, we can – for the first time – probe both the receding and approaching components of a putative galactic outflow around a distant galaxy. We measure a significant velocity shift between the Mg ii absorption from the two sightlines ($84\pm 17\, \hbox{km~s$^{-1}$}$), which is consistent with the expectation from our simple fiducial wind model, possibly combined with an extended disc contribution.
A study of the physical properties of SB2s with both the visual and spectroscopic orbits
Authors: Piccotti Luca , Docobo José Ángel , Carini Roberta , Tamazian Vakhtang S , Brocato Enzo , Andrade Manuel , Campo Pedro P
Published: December 2019

The study of a selected set of 69 double-lined spectroscopic binaries (SB2) with well-defined visual and spectroscopic orbits was carried out. The orbital parallax, the mass, the colour, and the luminosity of each component were derived from observational data for almost all of these systems. We have also obtained an independent estimation of the component masses by comparing the colour–magnitude diagram (CMD) to the stellar evolution tracks reported by Pietrinferni. Nearly all of the observational points on the CMD are located between two tracks of slightly different mass or which fall very close to the one corresponding to a unique mass value. The masses obtained from the stellar model are in good agreement with their empirical values determined by parallax techniques (orbital, Gaia, and dynamical). This means that our adopted model is rather reliable and can therefore be used to infer further information, such as the age of each component in the studied systems. Our results indicate a fair correspondence between the age of primaries and secondary stars within 3σ. Nevertheless, we caution that these age indications suffer of uncertainties due to both inhomogeneities/low precision of the adopted photometric data and possible systematics. Finally, it is statistically shown that along with the orbital and trigonometric parallaxes, the dynamical parallax can serve as a reliable tool for distance estimates.
Rotation and spots in normal A and Am/Fm stars
Authors: Trust Otto , Jurua Edward , De Cat Peter , Joshi Santosh
Published: December 2019

Frequency analysis of long-term ultraprecise photometry can lead to precise values of rotation frequencies of rotating stars with ‘hump and spike’ features in their periodograms. Using these features, we computed the rotation frequencies and amplitudes. The corresponding equatorial rotational velocity ($V_{\rm{rot}}$) and spot size were estimated. On fitting the autocorrelation functions of the light curves with the appropriate model, we determined the star-spot decay time-scale. The $\rm \mathit{ V}_{rot}$ agrees well with the projected rotational velocity ($\rm \nu ~sin$ i) in the literature. Considering a single circular and black spot, we estimate its radius from the amplitude of the ‘spike’. No evidence for a significant difference in the average ‘spike’ amplitude and spot radius was found for Am/Fm and normal A stars. Indeed, we derived an average value of $\rm \sim\! 21\pm 2$ and $\rm \sim\! 19\pm 2$ ppm for the photometric amplitude and of $\rm 1.01\, \pm \, 0.13$ and $\rm 1.16\, \pm \, 0.12$ $R_\mathrm{ E}$ for the spot radius (where $\rm \mathit{ R}_E$ is the Earth radius), respectively. We do find a significant difference for the average spot decay time-scale, which amounts to 3.6 ± 0.2 and 1.5 ± 0.2 d for Am/Fm and normal A stars, respectively. In general, spots on normal A stars are similar in size to those on Am/Fm stars, and both are weaker than previously estimated. The existence of the ‘spikes’ in the frequency spectra may not be strongly dependent on the appearance of star-spots on the stellar surface. In comparison with G, K, and M stars, spots in normal A and Am/Fm stars are weak, which may indicate the presence of a weak magnetic field.
Gas-dust correlations in nearby galaxies: a case study of NGC 3184 and NGC 7793
Authors: Saikia Gautam , Patra Narendra Nath , Roy Nirupam , Jog Chanda J
Published: December 2019

The study of gas-dust interactions occurring in the interstellar medium of a galaxy is essential for understanding various physical processes taking place within it. A comparison of such events at different locations corresponding to diverse astrophysical environments provides more insight into the star formation as well as dust destruction conditions and time-scales. We present a case study for two galaxies: NGC 3184 and NGC 7793, which are typical examples of a ‘grand design spiral’ and a ‘flocculent spiral’, respectively. We investigate the gas-dust correlations at various spatially resolved locations within each galaxy, including spiral arms, using archival data. Moreover, we have segregated the neutral gas into wide (warm) and narrow (cold) velocity components to check the correlations with individual dust emission bands. We find a positive correlation between the gas and the dust, with the total atomic gas emission mainly dominated by its warm component in both the galaxies. We also find the dust population in NGC 7793 to have a greater fraction of emission coming from cold and diffuse, larger-sized dust particles as compared to NGC 3184. This nearby galaxy pilot study could serve as a template for similar studies of larger galaxy samples with analogous morphologies.
Novel phylogenetic methods are needed for understanding gene function in the era of mega-scale genome sequencing
Authors: Nagy László G , Merényi Zsolt , Hegedüs Botond , Bálint Balázs
Published: December 2019

Ongoing large-scale genome sequencing projects are forecasting a data deluge that will almost certainly overwhelm current analytical capabilities of evolutionary genomics. In contrast to population genomics, there are no standardized methods in evolutionary genomics for extracting evolutionary and functional (e.g. gene-trait association) signal from genomic data. Here, we examine how current practices of multi-species comparative genomics perform in this aspect and point out that many genomic datasets are under-utilized due to the lack of powerful methodologies. As a result, many current analyses emphasize gene families for which some functional data is already available, resulting in a growing gap between functionally well-characterized genes/organisms and the universe of unknowns. This leaves unknown genes on the ‘dark side’ of genomes, a problem that will not be mitigated by sequencing more and more genomes, unless we develop tools to infer functional hypotheses for unknown genes in a systematic manner. We provide an inventory of recently developed methods capable of predicting gene-gene and gene-trait associations based on comparative data, then argue that realizing the full potential of whole genome datasets requires the integration of phylogenetic comparative methods into genomics, a rich but underutilized toolbox for looking into the past.
Reno-duodenal fistula as a complication of longstanding renal tract calculus
Authors: Owen William J , Folkard Samuel S , Rohatgi Ashish , Watson Alan , Peters John L
Published: December 2019

We present a rare case detailing the investigations and subsequent treatment of a lady who presented with a reno-duodenal fistula and perinephric abscess as a complication of staghorn calculus and recurrent upper urinary tract infections. Treatment involved antibiotics, nephrostomy, endoscopic closure of the fistula tract with clips, radiological drain insertion and, ultimately, nephrectomy with primary omental patch closure of the duodenal defect. We discuss the incidence of fistula tract formation as a complication of staghorn calculi, as well as investigations and management strategies employed in the literature to treat such complications, which span from conservative treatment to nephrectomy and closure of the intestinal defect. We illustrate the post-operative complications such patients are prone to and discuss these in context of the case. Whilst such cases are rare clinicians should be vigilant for complications associated with chronic inflammatory processes occurring in the urinary tract and investigate accordingly.
Theoretical Advances in Our Understanding of Network Effectiveness
Authors: Smith Julia Grace
Published: December 2019

Network effectiveness is heavily theorized in the public management and administration literatures. In this article, I synthesize the literature on network effectiveness and the role of organizational theory within this literature. The review illustrates a considerable amount of organization theorizing, which suggests that the subfield of organizational theory, while not always explicit, is very much alive and well. Next, I identify what the literature does well, areas for improvement, and recent work addressing those gaps. One such gap is the mismatch between the theory in its formulation and the methods used to test said theory. While theory is configurational, testing rarely makes use of configurational methods. Further, the majority of the literature treats networks as static despite widespread recognition that networks are in fact quite dynamic. Recent theoretical and methodological advancements have been made to address these shortcomings, but these efforts continue to be the aberration rather than the norm. Finally, I provide an example of one future direction for theorizing which builds upon recent advancements. More specifically, I provide two ideal type configurational paths to network effectiveness which account for one dynamic aspect of a network, namely the sequential introduction of actors into the network.
Hysteroscopic endometrial resection vs. hysterectomy for abnormal uterine bleeding: impact on quality of life and sexuality. Evidence from a systematic review of randomized controlled trials
Authors: Vitale Salvatore G. , Ferrero Simone , Ciebiera Michal , Barra Fabio , Török Péter , Tesarik Jan , Vilos George A. , Cianci Antonio
Published: December 2019

Purpose of review

The aim of this systematic review is to summarize the current evidence regarding the effectiveness of hysterectomy and hysteroscopic endometrial resection in improving quality of life (QoL), sexual function and psychological wellbeing of women abnormal uterine bleeding.

Recent findings

We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO 2019 CRD42019133632), using the terms ‘endometrial ablation’, ‘endometrial destruction’, ‘endometrial resection’, ‘hysterectomy’, ‘menorrhagia’, ‘dysfunctional uterine bleeding’, ‘quality of life’, ‘sexuality’ published up to April 2019. Our literature search produced 159 records. After exclusions, nine studies were included showing the following results: both types of treatment significantly improve QoL and psychological wellbeing; hysterectomy is associated with higher rates of satisfaction; hysterectomy is not associated with a significant deterioration in sexual function.

Hysterectomy is currently more advantageous in terms of improving abnormal uterine bleeding and satisfaction rates than hysteroscopic endometrial destruction techniques. Furthermore, there is some evidence of a greater improvement in general health for women undergoing hysterectomy. However, high-quality prospective randomized controlled trials should be implemented to investigate the effectiveness of hysterectomy and endometrial ablation in the improvement of QoL outcomes in larger patient cohorts.
Structural equation model analysis for the evaluation of factors associated with overweight and obesity in menopausal women in RaNCD cohort study
Authors: Darbandi Mitra , Najafi Farid , Pasdar Yahya , Rezaeian Shahab
Published: December 2019

Objective:

Weight gain and increased body fat mass are among the common complications of menopause. In addition to hormonal changes, behavioral and environmental factors aggravate transition through this phase. This study uses a structural equation model (SEM) to evaluate factors associated with overweight and obesity in menopausal women.

Methods:

This is a cross-sectional study of 4,471 women (pre/perimenopausal 3,150, menopausal 1,321) from baseline data of the Ravansar Non-Communicable Disease (RaNCD) cohort study in the west region of Iran in 2018. Obesity and overweight were the outcome variables. SEM was used to examine the relationships, using IBM SPSS, AMOS version 23.

Results:

The mean body fat percentage and visceral fat area in menopausal women was significantly greater than among pre/perimenopause women. The direct association of higher socioeconomic status (SES) with a healthy dietary pattern was stronger among pre/perimenopausal women than among menopausal women (ß = 0.574 vs ß = 0.552). In both groups, less physical activity was associated with depression and musculoskeletal disorders, and this association was stronger in menopausal women (ß = −0.174 vs ß = −0.215; P > 0.05). Overweight and obesity were directly decreased (ß = −0.011, P > 0.05) and indirectly increased (ß = 0.013, P > 0.05) in pre/perimenopausal women by sleep duration, but they were directly and indirectly decreased in menopausal women.

Conclusions:

The direct and indirect effects of well-known risk factors associated with overweight and obesity were found to be different in pre/perimenopausal and menopausal groups. Some risk factors showed stronger effects among menopausal women compared with the pre/perimenopausal women. Physical activity and healthy dietary pattern had a mediator impact in the two study groups.
Use of Micro-focused Ultrasound for Skin Tightening of Mid and Lower Face
Authors: Shome Debraj , Vadera Sapna , Ram M. Shiva , Khare Stuti , Kapoor Rinky
Published: December 2019

Background:

The changes in the mid face and lower face are among the most prominent features of the aging process. Intense focused ultrasound, known as the Ulthera System (Ulthera Inc., Mesa, AZ, USA), was designed to correct this process. It employs micro-focused ultrasound to cause discrete focal heating of the dermis and stimulates neocollagenesis and elastin remodeling.

Methods:

This study enrolled 50 adult patients of Indian ethnicity who opted for correction of mid face and lower face sagging by Ulthera. The subjects were treated using Ulthera 3.0 mm probes which targets deep dermis and 4.5 mm, which targets the superficial muscular aponeurotic system. All patients were evaluated for allergic reactions and side effects like scarring and nerve/muscle dysfunction. Investigators Global Aesthetic Improvement Scales Scores and Patients Global Aesthetic Improvement Scales Scores were used for analysis at 30 days, 60 days, 3 months, 6 months, and 1 year. Photographs were taken for detailed facial evaluation. Patients were asked to fill a self-assessment questionnaire.

Results:

At the end of 6 months, improvements in mid face and lower face were reported in 93% patients by blinded reviewers and 85% patients found the results to be satisfactory. The same results were maintained at the end of 1 year.

Conclusion:

Our study showed that substantial results can be achieved in overall aesthetic improvement of sagging of mid face and lower face with this modality using intense focused ultrasound which utilizes delivering of treatment at a single focal depth.
Reduction Mammaplasty in Adolescents: A Comparison of Wise and Vertical Incision Patterns
Authors: Kulkarni Kritika , Egro Francesco M. , Kenny Elizabeth M. , Stavros Alexander G. , Grunwaldt Lorelei J.
Published: December 2019

Background:

Reduction mammaplasty was shown to ameliorate physical and psychological problems in adolescents suffering from macromastia. However, benefits of the Wise compared to the vertical incision pattern have not yet been established in this population. The aim of this study is to compare the outcomes of these 2 techniques in adolescents undergoing reduction mammaplasty.

Methods:

A retrospective study of adolescents undergoing breast reduction by a single surgeon between 2011 and 2017 was conducted. Wise and vertical reduction techniques were compared based on demographics, surgical outcomes, patient satisfaction, and aesthetic outcomes. Patient satisfaction was determined using the validated BREAST-Q survey, and aesthetic outcomes using the validated ABNSW system.

Results:

A total of 60 adolescents underwent reduction mammaplasty (Wise/inferior pedicle = 80.0%, Wise/superior medial pedicle = 1.7%, vertical/superior medial pedicle = 18.3%). Patients who reported preoperative pain (Wise = 95.9%, vertical = 72.7%, P = 0.039) were more likely to undergo Wise reduction. Patients with Wise reductions also were more likely to undergo bilateral reduction (Wise = 93.9%; vertical = 63.6%, P = 0.017). The major and minor complication rates were 1.7% (Wise = 2.0%, vertical = 0%, P = NS) and 23.3% (Wise = 20.4%, vertical = 36.4%, P = NS), respectively. Adolescents undergoing Wise incision demonstrated statistically significant improvement in NAC contour (Wise = 61%, vertical = 47%, P = 0.028) and overall aesthetic outcome (Wise = 25%, vertical = 17%, P = 0.008) with scarring not being a negative factor (Wise = −16%; vertical = −35%, P = 0.004). Patient satisfaction was comparable in both groups.

Conclusions:

Reduction mammaplasty is a safe, effective treatment for adolescent macromastia. The similarity in complication and satisfaction rates between Wise and vertical patterns suggests that both techniques can be safely performed in the adolescent population and allow for overall improvements in aesthetic outcomes.
Veritas in Immediate Implant-based Breast Reconstruction Is Associated with Higher Complications Compared with TiLOOP
Authors: Quah Gaik Si , French James R. , Cocco Annelise , Hsu Jeremy , Meybodi Farid , Elder Elisabeth
Published: December 2019

Background:

Biologic and synthetic meshes are used in immediate implant-based breast reconstruction for coverage of the lower pole of the implant. This study aimed to compare outcomes of Veritas with TiLOOP bra (TiLOOP group [TG]).

Methods:

Retrospective study of skin- and nipple-sparing mastectomies in patients who underwent an implant-based reconstruction using either Veritas or TiLOOP bra between January 2014 and December 2016 was performed.

Results:

Thirty-six reconstructions (22 unilateral, 7 bilateral) using the Veritas mesh and 179 breast reconstructions (61 unilateral, 59 bilateral) using TiLOOP bra were identified. The Veritas group (VG) showed a higher rate of postoperative complications compared with the TG (VG = 54% versus TG = 14%, P < 0.01%), including higher rates of seroma, nonintegration of mesh (VG = 51.4% versus TG = 1.6%, P < 0.01), implant rotation (VG = 16.2% versus TG = 1.6%, P < 0.01), infection (VG = 18.9% versus TG = 2.1%, P < 0.01), and wound breakdown (VG = 10.8% versus TG = 0.5%, P < 0.01). The VG also had a higher rate of major interventions (VG = 35.1% versus TG = 7.8%, P < 0.01) and minor interventions (VG = 18.9% versus TG = 2.2%, P < 0.01) compared with TG, including a higher rate of implant loss and unplanned return to theater.

Conclusions:

Veritas mesh was associated with a significantly higher rate of postoperative complications compared with TiLOOP bra. Our data strongly question the safety profile of Veritas in implant-based breast reconstruction. Further studies in this area are warranted.
Infectious Hepatitis in Pregnancy
Authors: HAMBURG-SHIELDS EMILY , PRASAD MONA
Published: December 2019

Infectious hepatitis in pregnancy is clinically significant in both the acute and chronic phases. Here, we review the perinatal implications of chronic hepatitis B and C and acute hepatitis A and E. Familiarity with screening, transmission, diagnosis, and management of infectious hepatitis is of ongoing importance during obstetric care, as these diseases are endemic in much of the world. Pregnancy and interpregnancy care provide opportunities to prevent infection and transmission of hepatitis.
Trends and Outcomes of Intravascular Imaging-guided Percutaneous Coronary Intervention in the United States
Authors: Lemor Alejandro , Patel Nish , Jain Tarun , Baber Usman , Hernandez Gabriel , Villablanca Pedro , Basir Mir B. , Alaswad Khaldoon , Mehran Roxana , Dangas George , Sharma Samin K. , Kini Annapoorna
Published: December 2019

Introduction:

Intravascular imaging-guided percutaneous coronary intervention (PCI) has shown to improve outcomes in randomized controlled trials. However, there are little real-world data about intravascular imaging utilization during PCI and its outcomes in the United States.

Methods:

We conducted an observational analysis on the use of intravascular imaging (Intravascular Ultrasound or Optical Coherence Tomography)-guided PCI in 2,425,036 patients undergoing PCI between January 2010 and December 2014 from the Nationwide Inpatient Sample database. Utilizing propensity score matching, 83,988 matched pairs were identified. The primary outcome was in-hospital mortality. The secondary outcomes included cardiogenic shock and acute kidney injury.

Results:

Among the 2,425,036 patients, 161,808 (6.7%) underwent imaging-guided PCI. Use of imaging-guidance increased from 6% in 2010 to 6.6% in 2014 (Ptrend < 0.001). The in-hospital mortality was significantly different between imaging-guided PCI and angiography-guided PCI [1.0% vs. 1.5%; adjusted OR: 0.67; 95% confidence interval (CI): 0.54–0.83, P < 0.001]. The rates of cardiogenic shock (2.5% vs. 3.1%; adjusted OR: 0.78; 95% CI: 0.66–0.93; P = 0.005) were significantly lower in imaging-guided PCI group and acute kidney injury rates (7.0% vs. 7.1%; adjusted OR: 0.99; 95% CI: 0.89–1.12; P = 0.919) were not significantly different.

Conclusions:

Imaging-guided PCI is associated with lower in-hospital mortality. Yet, a small proportion of patients undergoing PCI have imaging-guidance.
Approach to stage IV non-small-cell lung cancer: how to select among first-line therapy options?
Authors: Pacheco Jose M.
Published: December 2019

Purpose of review

There are several first-line systemic therapy options for patients with newly diagnosed stage IV non-small-cell lung cancer. Targeted therapy with tyrosine kinase inhibitors provide a good first option for some. Unfortunately, most patients do not have an alteration for which there is an available tyrosine kinase inhibitor. For these patients there are immunotherapy and chemoimmunotherapy options; however, there is debate about how to choose amongst these treatments for a given individual. This review attempts to simplify this decision-making process.

Recent findings

The data on first-line immunotherapy and chemoimmunotherapy regimens is highlighted. Programed death ligand-1 cut-points and how these may influence therapy decision making are discussed. Molecular markers that may help predict benefit or lack thereof in patients treated with immunotherapy regimens are touched upon.

Provided is a guide for the practicing clinician to help them select amongst immunotherapy and chemoimmunotherapy options for a given patient.
Neighborhood Disadvantage and Hospital Quality Ratings in the Medicare Hospital Compare Program
Authors: Fahrenbach John , Chin Marshall H. , Huang Elbert S. , Springman Mary K. , Weber Stephen G. , Tung Elizabeth L.
Published: December 2019

Background:

The Centers for Medicare and Medicaid Services provide nationwide hospital ratings that may influence reimbursement. These ratings do not account for the social risk of communities and may inadvertently penalize hospitals that service disadvantaged neighborhoods.

Objective:

This study examines the relationship between neighborhood social risk factors (SRFs) and hospital ratings in Medicare’s Hospital Compare Program.

Research Design:

2017 Medicare Hospital Compare ratings were linked with block group data from the 2015 American Community Survey to assess hospital ratings as a function of neighborhood SRFs.

Subjects:

A total of 3608 Medicare-certified hospitals in 50 US states.

Measures:

Hospital summary scores and 7 quality group scores (100 percentile scale), including effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care, and timeliness of care.

Results:

Lower hospital summary scores were associated with caring for neighborhoods with higher social risk, including a reduction in hospital score for every 10% of residents who reported dual-eligibility for Medicare/Medicaid [−3.3%; 95% confidence interval (CI), −4.7 to −2.0], no high-school diploma (−0.8%; 95% CI, −1.5 to −0.1), unemployment (−1.2%; 95% CI, −1.9 to −0.4), black race (−1.2%; 95% CI, −1.7 to −0.8), and high travel times to work (−2.5%; 95% CI, −3.3 to −1.6). Associations between neighborhood SRFs and hospital ratings were largest in the timeliness of care, patient experience, and hospital readmission groups; and smallest in the safety, efficiency, and effectiveness of care groups.

Conclusions:

Hospitals serving communities with higher social risk may have lower ratings because of neighborhood factors. Failing to account for neighborhood social risk in hospital rating systems may reinforce hidden disincentives to care for medically underserved areas in the United States.
Modified Valsalva Maneuver for Pediatric Supraventricular Tachycardia
Authors: Rayburn David , Wagers Brian
Published: December 2019

Vagal maneuvers can be successful in terminating supraventricular tachycardia in pediatric patients. We present a case of a modified Valsalva maneuver identified in the REVERT trial successfully terminating supraventricular tachycardia in a 9-year-old boy.
A Call to Restore Your Calling: Self-Care of the Emergency Physician in the Face of Life-Changing Stress
Authors: Mull Colette C. , Bowman Wesley R.
Published: December 2019

This fifth article in our series focuses on burnout in practicing pediatric emergency medicine physicians. As opposed to a general review of burnout, we address understudied and undervalued risk factors, drivers, and individual- and organizational-level solutions applicable to the emergency medicine workplace.

Conflicting studies impact our understanding of the prevalence of burnout in our field and the role of depression. This article's story is anonymously submitted and leads us to our discussion of the heightened risk of burnout in underrepresented physicians, those who identify themselves as women, as belonging to a racial, ethnic, gender and/or sexual minority group, and/or as having a physical and/or sensory disability.

Thus far, our articles have described coping tools for individuals and health care organizations to prevent and/or mitigate the untoward effects of life-changing stressors on a pediatric emergency physician's life. They include staying healthy and active, cultivating outside interests, and nurturing relationships with peers, friends, and family. We have shared the techniques and benefits of constructive engagement when one is faced with challenging events or individuals. We have underscored the value of peer support, support groups, emotional debriefing, and engaging with outside organizations able to address specific stressors. We have introduced the practice of political engagement as a way of addressing systems-level pressures. Throughout this series, we have emphasized the need to ask for help from family, friends, peers, primary care providers, and mental health professionals. This article describes the benefits of Employee Assistance Programs, Physician Wellness Programs, positive psychology, and grounding behaviors as self-care strategies.
Quantification of Aortic Stiffness by Ultrasound Time-Harmonic Elastography
Authors: Schaafs Lars-Arne , Tzschätzsch Heiko , Steffen Ingo G. , Braun Jürgen , Hamm Bernd , Sack Ingolf , Elgeti Thomas
Published: December 2019

Objectives

The aim of this study was to investigate blood pressure dependency of ultrasound time-harmonic elastography (THE) for quantification of aortic stiffness.

Materials and Methods

Thoracoabdominal aortas were surgically removed from 9 healthy domestic pigs and prepared for elastographic experiments. All vessels were connected to a saline-filled water column with adjustable height and pressurized over a range of 0 to 110 mm Hg in 10 mm Hg increments to simulate different levels of mean arterial pressure. In addition, 3 of the 9 aortas were soaked in 4% buffered formaldehyde for 60 minutes to simulate pathologic aortic stiffening. Ultrasound THE was performed in each vessel at each pressure level. For each pressure level, shear-wave speed (SWS) as a measure of aortic wall stiffness and luminal diameter were recorded. The pressure range between 30 and 110 mm Hg was used for statistical evaluation as it reflects a physiological mean arterial pressure range. Linear regression analysis and multivariate analysis with a general linear model were performed to evaluate the influence of increasing intravascular pressure and vessel diameter on measured SWS.

Results

Median SWS in formalin-soaked aortas was significantly higher with 3.22 m/s (interquartile range [IQR], 0.01 m/s) versus 2.14 m/s (IQR, 0.09) at 30 mm Hg and 3.38 m/s (IQR, 0.01 m/s) versus 2.28 m/s (IQR, 0.07 m/s) at 110 mm Hg (each P = 0.01). Using linear regression analysis, an increase of aortic wall SWS of 0.017 m/s per 10 mm Hg intraluminal pressure was found in untreated aortas, whereas SWS increased by 0.020 m/s per 10 mm Hg in formalin-soaked aortas (both P = 0.001). The percentage of SWS caused by intraluminal pressure was 1.89% in formalin-soaked aortas and 2.50% in untreated aortas at 30 mm Hg and 6.61% for formalin-soaked aortas and 8.60% for untreated aortas at 110 mm Hg. Multivariate analysis showed no significant interaction of luminal diameter and measured SWS (P = 0.893).

Conclusions

In our model, aortic stiffness measurements by ultrasound time-harmonic elastography are influenced to a small extent by mean arterial pressure in a range of 1.89% to 8.60%. These findings emphasize the potential of ultrasound THE for measuring the intrinsic stiffness of the aortic wall in clinical routine.
The Physical-Virtual Patient Simulator
Authors: Daher Salam , Hochreiter Jason , Schubert Ryan , Gonzalez Laura , Cendan Juan , Anderson Mindi , Diaz Desiree A. , Welch Gregory F.
Published: December 2019

Introduction

We introduce a new type of patient simulator referred to as the Physical-Virtual Patient Simulator (PVPS). The PVPS combines the tangible characteristics of a human-shaped physical form with the flexibility and richness of a virtual patient. The PVPS can exhibit a range of multisensory cues, including visual cues (eg, capillary refill, facial expressions, appearance changes), auditory cues (eg, verbal responses, heart sounds), and tactile cues (eg, localized temperature, pulse).

Methods

We describe the implementation of the technology, technical testing with healthcare experts, and an institutional review board–approved pilot experiment involving 22 nurse practitioner students interacting with a simulated child in 2 scenarios: sepsis and child abuse. The nurse practitioners were asked qualitative questions about ease of use and the cues they noticed.

Results

Participants found it easy to interact with the PVPS and had mixed but encouraging responses regarding realism. In the sepsis scenario, participants reported the following cues leading to their diagnoses: temperature, voice, mottled skin, attitude and facial expressions, breathing and cough, vitals and oxygen saturation, and appearance of the mouth and tongue. For the child abuse scenario, they reported the skin appearance on the arms and abdomen, perceived attitude, facial expressions, and inconsistent stories.

Conclusions

We are encouraged by the initial results and user feedback regarding the perceived realism of visual (eg, mottling), audio (eg, breathing sounds), and tactile (eg, temperature) cues displayed by the PVPS, and ease of interaction with the simulator.
Pediatric firearm mortality in the United States, 2010 to 2016: A National Trauma Data Bank analysis
Authors: Hatchimonji Justin S. , Swendiman Robert A. , Goldshore Matthew A. , Blinman Thane A. , Nance Michael L. , Allukian Myron , Nace Gary W.
Published: December 2019

BACKGROUND

Pediatric firearm injury is a leading cause of death for U.S. children. We sought to further characterize children who die from these injuries using a validated national database.

METHODS

The National Trauma Data Bank 2010 to 2016 was queried for patients aged 0 to 19 years old. International Classification of Diseases external cause of injury codes were used to classify patients by intent. Differences between groups were analyzed using χ2 or Mann-Whitney U tests. Patterns over time were analyzed using nonparametric tests for trend. Multivariable logistic regression was used to investigate associations between the above factors and mortality.

RESULTS

There were a total of 45,288 children with firearm injuries, 12.0% (n = 5,412) of whom died. Those who died were younger and more often white than survivors. Mortality was associated with increased injury severity, shock on presentation, and polytrauma (p < 0.001 for all). There was an increasing trend in the proportion of self-inflicted injuries over the study period (p < 0.001), and mortality from these self-inflicted injuries increased concordantly (35.3% in 2010 to 47.8% in 2016, p = 0.001). Location of severe injuries had significant different mortality rates, ranging from 51.3% of head injuries to 3.9% in the extremities. In the multivariable model, treatment at a pediatric trauma center was protective against mortality, with odds ratios of 2.10 (confidence interval, 1.64–2.68) and 1.80 (confidence interval, 1.39–2.32) for death at adult and dual-designated trauma centers, respectively. This finding was confirmed in age-stratified cohorts.

CONCLUSION

Proportions of self-inflicted pediatric firearm injury in the National Trauma Data Bank increased from 2010 to 2016, as did mortality from self-inflicted injury. Because mortality is highest in this subpopulation, prevention and treatment efforts should be prioritized in this group of firearm-injured children.

LEVEL OF EVIDENCE

Epidemiological study, level V.
Comparison of Medium-term Outcomes of Living Kidney Donors With Longitudinal Healthy Control in the United Kingdom
Authors: Krishnan Nithya , Mumford Lisa , Lipkin Graham , Gill Paramjit , Fletcher Simon , Dasgupta Indranil , Ryan Ronan , Raymond Neil T.
Published: December 2019

Background.

Understanding the outcomes and risks for live kidney donors (LD) is increasingly important; this study investigated all-cause mortality and morbidity outcomes of LD compared with a healthy cohort.

Methods.

Live donor dataset was obtained from the UK Transplant Registry and a comparator nondonor cohort selected from The Health Improvement Network (THIN) database, a UK primary healthcare database. All LD from January 1, 2001, to December 31, 2013, were included, with follow-up until December 31, 2016.

Results.

There were 9750 LD and 19 071 THIN participants. Median follow-up (interquartile range) for LD was 8.4 (6.0–11.3) years and for THIN was 5.4 (2.6–8.5) years. In up to 15 years, follow-up end-stage renal disease was observed in 1 LD versus 7 THIN (P = 0.280). Nine LD had estimated glomerular filtration rate of <30 mL/min/1.73 m2 versus 43 in THIN (P = 0.012), but no statistically significant difference in adjusted logistic regression analyses. Risk of diabetes mellitus, depression, and cardiovascular disease was significantly higher for THIN cohort in adjusted analyses. The risk of hypertension was higher for LD at 5 years but was not significantly different in fully adjusted analyses at 10 years. There were 68 deaths in LD and 485 in THIN over the follow-up period, with significant difference in mortality favoring LD (P < 0.001).

Conclusions.

The medium-term morbidity and mortality outcomes of live donors in comparison with a healthy cohort suggest that live donation is not associated with excess mortality, end-stage renal disease, or morbidity, in at least 10 years follow-up.
Prolonged Cold Ischemia Time in Mouse Heart Transplantation Using Supercooling Preservation
Authors: Que Weitao , Hu Xin , Fujino Masayuki , Terayama Hayato , Sakabe Kou , Fukunishi Nahoko , Zhu Ping , Yi Shuang-Qin , Yamada Yoshio , Zhong Lin , Li Xiao-Kang
Published: December 2019

Background.

Supercooling preservation techniques store a donor organ below 0°C without freezing. This has great advantages in inhibiting metabolism and preserving the organ in comparison to conventional preservation at 4°C. We developed a novel supercooling technique using a liquid cooling apparatus and novel preservation and perfusion solutions. The purpose of this study was to evaluate the preservation effect of our supercooling preservation technique in a mouse heart transplantation model.

Methods.

Syngeneic heterotopic heart transplantation was performed in 3 groups of mice: (1) the nonpreservation group, in which the cardiac grafts were transplanted immediately after retrieval; (2) the conventional University of Wisconsin (UW) group, in which the cardiac grafts were stored in UW solution at 4°C for different periods of time; and (3) the supercooling group, in which the cardiac grafts were stored in a novel supercooling preservation solution at –8°C for different periods of time. The maximal preservation time was investigated. Twenty-four-hour sample data were collected and analyzed to compare supercooling preservation to conventional UW preservation.

Results.

Our technique yielded a stable –8°C supercooling state. Cardiac graft revival was successfully achieved after supercooling preservation for 144 hours, and long-term survival was observed after supercooling preservation for 96 hours. Posttransplant outcomes, including myocardial ischemia–reperfusion injury, oxidative stress-related damage, and myocardial cell apoptosis, were improved in comparison to conventional 4°C UW preservation.

Conclusions.

Supercooling heart preservation at –8°C greatly prolonged the preservation time and improved the posttransplant outcomes in comparison to conventional 4°C UW preservation. Supercooling preservation is a promising technique for organ preservation.
Excess Stroke Deaths in Kidney Transplant Recipients: A Retrospective Population-based Cohort Study Using Data Linkage
Authors: De La Mata Nicole L. , Kelly Patrick J. , Wyld Melanie , Masson Philip , Al-Shahi Salman Rustam , Webster Angela C.
Published: December 2019

Background.

Kidney transplant recipients are thought to experience a high risk of stroke; however, little data exist. We aimed to compare the stroke deaths in kidney transplant recipients with the general population and identify risk factors for stroke death in kidney transplant recipients.

Methods.

Cause of death was established using data linkage between the Australian and New Zealand Dialysis and Transplant Registry and national death registers: Australia, 1980–2013, and New Zealand, 1988–2012. We estimated standardized mortality ratios (SMR) and used competing risks models to identify risk factors. Subanalysis explored those with polycystic kidney disease.

Results.

Among 17 628 kidney transplant recipients, there were 158 stroke deaths and 5126 nonstroke deaths in 175 084 person-years. Those aged 30–49 years experienced more stroke deaths than expected, especially women (SMR in females: 19.7 [95% confidence interval, 12.9-30.3] and males: 9.1 [95% confidence interval, 5.6-14.6]). Higher risk of stroke death was associated with older age at transplant, ever graft failure, earlier era of transplant, preexisting cerebrovascular disease, and no previous malignancy. Polycystic kidney disease did not result in different SMR.

Conclusions.

Kidney transplant recipients had excess stroke deaths, particularly at younger ages and women. Preexisting cerebrovascular disease was a potentially modifiable risk factor for stroke death, suggesting further studies of secondary stroke prevention for kidney transplant recipients.
Rev-erbα heterozygosity produces a dose-dependent phenotypic advantage in mice
Authors: Welch Ryan D. , Billon Cyrielle , Burris Thomas P. , Flaveny Colin A.
Published: December 2019

Numerous mutational studies have demonstrated that circadian clock proteins regulate behavior and metabolism.Nr1d1(Rev-erbα)is a key regulator of circadian gene expression and a pleiotropic regulator of skeletal muscle homeostasis and lipid metabolism. Loss ofRev-erbαexpression induces muscular atrophy, high adiposity, and metabolic syndrome in mice. Here we show that, unlike knockout mice,Nr1d1heterozygous mice are not susceptible to muscular atrophy and in fact paradoxically possess larger myofiber diameters and improved neuromuscular function, compared to wildtype mice. Heterozygous mice lacked dyslipidemia, a characteristic ofNr1d1knockout mice and displayed increased whole-body fatty-acid oxidation during periods of inactivity (light cycle). Heterozygous mice also exhibited higher rates of glucose uptake when fasted, and had elevated basal rates of gluconeogenesis compared to wildtype and knockout littermates.Rev-erbαablation suppressed glycolysis and fatty acid-oxidation in white-adipose tissue (WAT), whereas partialRev-erbαloss, curiously stimulated these processes. Our investigations revealed thatRev-erbαdose-dependently regulates glucose metabolism and fatty acid oxidation in WAT and muscle.
A standardized gnotobiotic mouse model harboring a minimal 15-member mouse gut microbiota recapitulates SOPF/SPF phenotypes
Authors: Darnaud Marion , Vadder Filipe De , Bogeat Pascaline , Boucinha Lilia , Bulteau Anne-Laure , Bunescu Andrei , Couturier Céline , Delgado Ana , Dugua Hélène , Elie Céline , Mathieu Alban , Novotná Tereza , Ouattara Djomangan Adama , Planel Séverine , Saliou Adrien , Šrůtková Dagmar , Yansouni Jennifer , Stecher Bärbel , Schwarzer Martin , Leulier François , Tamellini Andrea
Published: December 2019

Mus musculusis the classic mammalian model for biomedical research. Despite global efforts to standardize breeding and experimental procedures, the undefined composition and interindividual diversity of the microbiota of laboratory mice remains a limitation. In an attempt to standardize the gut microbiome in preclinical mouse studies, we developed a simplified mouse microbiota composed of 15 strains from 7 of the 20 most prevalent bacterial families representative of the fecal microbiota of C57BL/6J Specific (and Opportunistic) Pathogen-Free (SPF/SOPF) animals and derived a new standardized gnotobiotic mouse model called GM15. GM15 recapitulates extensively the functionalities found in the C57BL/6J SOPF microbiota metagenome, and GM15 animals are phenotypically similar to SOPF or SPF animals in two different facilities. They are also less sensitive to the deleterious effects of post-weaning malnutrition. The GM15 model provides increased reproducibility and robustness of preclinical studies by limiting the confounding effect of fluctuation in microbiota composition, and offers new opportunities for research focused on how the microbiota shapes host physiology in health and disease.