bluuebunny/crossref_metadata_2025 huggingface dataset:
For Whom the Bell's Toll: Recurrent Facial Nerve Paralysis, A Retrospective Study and Systematic Review of the Literature
Authors: Chweya Cynthia M. , Anzalone C. Lane , Driscoll Colin L. W. , Lane John I. , Carlson Matthew L.
Published: March 2019

Purpose:

To examine the etiology, clinical course, and management of recurrent peripheral facial nerve paralysis.

Methods:

Retrospective review at a single tertiary academic center and systematic review of the literature. Clinical presentation, laboratory and imaging findings, treatment and outcome for all cases of recurrent ipsilateral, recurrent contralateral, and bilateral simultaneous cases of facial paralysis are reviewed.

Results:

Between 2000 and 2017, 53 patients [41.5% men, 29 median age of onset (range 2.5 wk–75 yr)] were evaluated for recurrent facial nerve paralysis at the authors’ institution. Twenty-two (41.5%) cases presented with ipsilateral recurrences only, while the remaining 31 patients (58.5%) had at least 1 episode of contralateral recurrent paralysis. No cases of bilateral simultaneous facial nerve paralysis were observed. The median number of paretic events for all patients was 3 (range 2–20). The median nadir House–Brackmann score was 4, with a median recovery to House–Brackmann grade 1.5 over a mean recovery time of 61.8 days (range 1–420 d). Diagnostic evaluation confirmed Melkersson–Rosenthal syndrome in four (7.5%) cases, neurosarcoidosis in two (3.7%), traumatic neuroma in one (1.9%), Ramsay Hunt syndrome in one (1.9%), granulomatosis with polyangiitis in one (1.9%), and neoplastic causes in three (5.7%) cases [facial nerve schwannoma (n = 2; 3.7%), metastatic squamous cell carcinoma to the deep lobe of the parotid gland (n = 1; 1.9%)]; ultimately, 77.4% (41) of cases were deemed idiopathic. Facial nerve decompression via a middle cranial fossa approach was performed in three (5.7%) cases without subsequent episodes of paralysis.

Conclusion:

Recurrent facial nerve paralysis is uncommon and few studies have evaluated this unique population. Recurrent ipsilateral and contralateral episodes are most commonly attributed to idiopathic facial nerve paralysis (i.e., Bell's palsy); however, a subset harbor neoplastic causes or local manifestations of underlying systemic disease. A comprehensive diagnostic evaluation is warranted in patients presenting with recurrent facial nerve paralysis and therapeutic considerations including facial nerve decompression can be considered in select cases.
Association of Speech Processor Technology and Speech Recognition Outcomes in Adult Cochlear Implant Users
Authors: Dixon Peter R. , Shipp David , Smilsky Kari , Lin Vincent Y. , Le Trung , Chen Joseph M.
Published: March 2019

Objective:

Determine association of advancements in speech processor technology with improvements in speech recognition outcomes.

Study Design:

Retrospective cohort.

Setting:

Tertiary referral center.

Patients:

Adult unilateral cochlear implant (CI) recipients.

Intervention:

Increasing novelty of speech processor defined by year of market availability.

Main Outcome Measures:

Consonant-Nucleus-Consonant (CNC) and Hearing in Noise Test (HINT) in quiet.

Results:

From 1991 to 2016, 1,111 CNC scores and 1,121 HINT scores were collected from 351 patients who had complete data. Mean post-implantation CNC score was 53.8% and increased with more recent era of implantation (p < 0.001, analysis of variance [ANOVA]). Median HINT score was 87.0% and did not significantly vary with implantation era (p = 0.06, ANOVA). Multivariable generalized linear models were fitted to estimate the effect of speech processor novelty on CNC and HINT scores, each accounting for clustering of scores within patients and characteristics known to influence speech recognition outcomes. Each 5-year increment in speech processor novelty was independently associated with an increase in CNC score by 2.85% (95% confidence limits [CL] 0.26, 5.44%) and was not associated with change in HINT scores (p = 0.30).

Conclusion:

Newer speech processors are associated with improved CNC scores independent of the year of device implantation and expanding candidacy criteria. The lack of association with HINT scores can be attributed to a ceiling effect, suggesting that HINT in quiet may not be an informative test of speech recognition in the modern CI recipient. The implications of these findings with respect to appropriate interval of speech processor upgrades are discussed.
Clinical Features of Ears With Otosclerosis and Endolymphatic Hydrops
Authors: Wang Fei , Yoshida Tadao , Sugimoto Satofumi , Shimono Mariko , Teranishi Masaaki , Naganawa Shinji , Sone Michihiko
Published: March 2019

Objective:

Endolymphatic hydrops (EH) has been reported in ears with otosclerosis. The objective of this study was to investigate the clinical features of ears with otosclerosis and EH on magnetic resonance imaging (MRI) and identify predictors for the presence of EH.

Study Design:

Retrospective study.

Setting:

University hospital.

Materials and Methods:

Forty-six ears from 37 patients with otosclerosis were included in the present study.

Interventions:

The subjects were divided into three groups, those with no, mild, or significant EH, based on 3-T MRI with intravenous injection of gadolinium. Hearing levels and the extent of otosclerotic lesions graded based on the computed tomography (CT) findings were compared among the groups. Moreover, to examine the vascular activity of the disease, intraoperative measurements of blood flow were also evaluated.

Main Outcome Measures:

Imaging, hearing levels, and blood flow values.

Results:

The overall rate of EH was 58.7% (27 of 46 ears); cochlear EH (52.2%) was more frequent than vestibular EH (26.1%). Average thresholds in ears with significant EH were significantly higher at several frequencies, both on air and bone conduction, than those with no or mild EH. Significant EH was more frequently observed in ears with advanced stages on CT than in those without advanced stages. The values of blood flow in the area anterior to the oval window were higher in some ears with EH than in ears without EH.

Conclusion:

EH was frequently present in ears with otosclerosis, especially those with severe hearing loss or advanced disease on CT.
Optical Coherence Tomography Doppler Vibrometry Measurement of Stapes Vibration in Patients With Stapes Fixation and Normal Controls
Authors: MacDougall Dan , Morrison Loran , Morrison Christine , Morris David P. , Bance Manohar , Adamson Robert B. A.
Published: March 2019

Hypothesis:

Ears with otosclerotic stapes fixation will exhibit lower-than-normal levels of ossicular mobility as measured by Optical Coherence Tomography Doppler Vibrometry (OCT-DV).

Background:

OCT-DV measures the vibration of middle ear structures in response to sound non-invasively through the intact tympanic membrane. This allows, in particular, direct measurement of the vibration at the lenticular process of the incus which is expected to be lower in patients with otosclerotic stapes fixation.

Methods:

OCT-DV was performed on ears presumptively diagnosed with otosclerosis (n = 13) and a group of normal control ears (n = 42). Displacement was measured at the umbo and the lenticular process of the incus in response to 500 and 1000 Hz stimulus tones at 100 dBSPL.

Main Outcome Measure:

The ability to discriminate between groups was assessed using receiver operator characteristic analysis, with the main outcome measures being the area-under-curve (AUC) and the sensitivity and specificity.

Results:

For the best condition tested (500 Hz at the incus), the AUC was 0.998 and discriminated the otosclerotic from normal ears with a sensitivity/specificity of 1.00/0.98. One anomalous patient with surgically confirmed stapes fixation exhibited hypermobility at the umbo, possibly due to a partial ossicular discontinuity. Despite the high umbo mobility, this patient's stapes fixation was correctly discriminated based on the measured incus vibration levels.

Conclusions:

OCT-DV is a promising tool for preoperatively assessing ossicular mobility non-invasively in the clinic. Our results suggest OCT-DV may also be useful in discriminating other ossicular pathologies that result in conductive hearing loss.
Hemolysis and Plasma Free Hemoglobin During Extracorporeal Membrane Oxygenation Support: From Clinical Implications to Laboratory Details
Authors: Dufour Nicolas , Radjou Aguila , Thuong Marie
Published: March 2019

Venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) are lifesaving supports that are more and more frequently used in critically ill patients. Despite of major technological improvements observed during the last 20 years, ECMO-associated hemolysis is still a complication that may arise during such therapy. Hemolysis severity, directly appreciated by plasma free hemoglobin concentration, may be present with various intensity, from a nonalarming and tolerable hemolysis to a highly toxic one. Here, we propose a review dedicated to extracorporeal membrane oxygenation (ECMO)-associated hemolysis, with a particular emphasis on pathophysiology, prevalence, and clinical consequences of such complication. We also focus on laboratory assessment of hemolysis and on the limits that have to be known by clinicians to prevent and manage hemolytic events.
Metabolic Monitoring of Child and Adolescent Patients on Atypical Antipsychotics by Psychiatrists and Primary Care Providers
Authors: Wakefield Sarah , Aligeti Manish , Rachamallu Vivekananda , Baronia Regina , Aynampudi Ram , Parmar Ankit , Peterson Phyllis , Masodkar Kanak
Published: March 2019

Background:

Antipsychotic drug use in children has doubled from 2001 to 2007 with concomitant increase in obesity. Second-generation antipsychotic (SGA) medication use is associated with weight gain, metabolic derangements, and blood sugar and lipid abnormalities in children. The American Psychiatric Association and the American Diabetes Association have recommended metabolic monitoring guidelines for patients using SGA.

Study Question:

The study objective was to investigate and compare metabolic monitoring for SGA medications in psychiatry (PSY), and pediatrics and family medicine [primary care providers (PCP)] outpatient clinics of a university medical center.

Study Design:

This is a retrospective study of 149 charts of patients newly prescribed with SGA, ages 5–18 years, from their initial visit in the outpatient clinics.

Measures and Outcomes:

Compliance with recommended metabolic monitoring was evaluated for initial and subsequent clinic visits. Parameters included body mass index, waist circumference, blood pressure, fasting plasma glucose, and fasting lipid profile.

Results:

Of the 149 charts, 110 patients were in PSY and 39 in PCP. The parameter most regularly monitored was body mass index (baseline: PSY 88.3%, PCP 97.4%; 12 weeks: PSY 86.4%, PCP 85.0%; and 24 weeks: PSY 91.8%, PCP 100%). Fasting plasma glucose (baseline: PSY 18.9%, PCP 25.6% and 12 weeks: PSY 8.6%, PCP 10.0%) and fasting lipid profile (baseline: PSY 12.7%, PCP 25.6% and 12 weeks: PSY 7.0%, PCP 10.0%) had low completions rates. No difference was seen in metabolic monitoring by sex or ethnic group.

Conclusions:

Metabolic monitoring rate of child and adolescent patients on SGAs was low overall. No statistically significant differences were seen between psychiatry and PCP except a significantly higher rate of fasting plasma glucose level monitoring at baseline among PCP. Limitations to the study include the small sample size obtained for the period investigated and insufficient documentation in some electronic charts. Extending the period studied may increase the statistical significance of the data.
Off-Label Use of Clozapine in Children and Adolescents—A Literature Review
Authors: Rachamallu Vivekananda , Elberson Benjamin W. , Vutam Emily , Aligeti Manish
Published: March 2019

Background:

Clozapine is a second-generation antipsychotic typically used for refractory schizophrenia or otherwise psychotic pathology. There are no FDA or manufacturer guidelines for use of clozapine in pediatric population. We investigated the current state of research concerning the use of clozapine in pediatric patients.

Areas of Uncertainty:

We describe consistent calls for more research into the long-term and short-term effects of clozapine use in a young patient population. Despite the strongly supported efficacy, questions concerning clear indications for use and risk–benefit analysis persist. We acknowledge that a more comprehensive meta-analysis would greatly benefit the field. However, this is the first article of its kind for clozapine in recent history, and therefore, serves as a focus and reference point for future, more in-depth analyses.

Data Sources:

We conducted a search of PubMed, ClinicalKey, PsycINFO, and MEDLINE databases. Keywords used included, in varying combinations: clozapine, off-label, indications, children and adolescent, pediatric, behavioral, suicidality, psychosis, early and very-early onset schizophrenia, side-effect profile, and long-term use. Further criteria and selection are described in Methods below.

Results:

We describe the documented efficacy of clozapine for the management of refractory psychotic and nonpsychotic symptoms in the pediatric population. The authors highlight the risk of unmanaged early-onset schizophrenia, aggressive or suicidal behavior, and severe nonpsychotic pathology. Unfortunately, these studies are generally small. There is little consistency in when clozapine is prescribed, how long it is administered, and how long patients are followed. Despite the lack of FDA and manufacturer guidelines, clozapine continues to be used for the benefit of young patients.

Conclusions:

Indications for prescription of clozapine should be revisited, given the data presented in this manuscript of a low risk–benefit ratio for properly chosen patients. Larger studies should be conducted to provide more statistical power and determine clear guidelines for use, risk of side effects, and long-term adverse events that may arise.
Safe Medication Disposal
Authors: Haughey Cynthia W. , Lawson Delaney , Roberts Katelyn , Santos Melanie , Spinosa Stephanie
Published: March 2019

Safe disposal of expired or unused medications is essential for individual and environmental safety, yet many patients report not having received education on proper medication disposal. Unused medications in homes and improper medication disposal create various risks including intentional or accidental misuse, overdose, addiction in humans, as well as toxic effects in pets. As part of their community health clinical experience, senior nursing students from the University of Pennsylvania School of Nursing visited patients of a large home care and hospice agency in a Philadelphia suburb throughout the semester. A survey conducted with a small number (N = 15) of home care patients suggested the majority of patients had inadequate knowledge about safe medication disposal. The nursing students created and presented a tip sheet on safe medication disposal and a list of local prescription medication disposal sites to home care patients. They also obtained and provided medication disposal bags for patients and caregivers who were unable to get to medication disposal sites.
Home Healthcare Nurses' Attitudes, Confidence, and Engagement in Evidence-Based Practice
Authors: Thiel Linda M. , Ko Arthur , Turner Jill A.
Published: March 2019

Evidence-based practice (EBP) is becoming standard in today's healthcare arena and home care organizations are not exempt from integrating evidence into practice to improve patient outcomes. There is a scarcity of research literature that examines the behaviors and attitudes of home healthcare nurses (HHNs) regarding EBP. In this study, a descriptive survey design was used to investigate HHNs' a) information-seeking behaviors when providing nursing care, b) administrative support for EBP (as perceived by HHNs), c) attitudes toward EBP, and d) EBP engagement and confidence in providing EBP nursing care. Self-reported data were collected by internet and paper survey. The survey consisted of a 65-item questionnaire that included the Nurses' Attitudes Toward Evidence-Based Practice Scale, which has previously established validity and reliability. A convenience sample of 95 HHNs participated in the study. Results suggest HHNs' EBP attitudes are positive. A positive and significant relationship was found between attitudes and hours worked (r = 0.21, p = 0.047) and educational level (r = 0.45, p = 0.0001); 95% confidence level. Confidence levels in providing EBP care were moderate, and HHNs did not perceive EBP as an agency priority. HHNs need to be supported and encouraged in the facilitation of EBP, a task made easier when they are knowledgeable about EBP, have confidence in their EBP skills, and have the support of their organizations.
Ensuring Safety When Pets Are in the Home
Authors: Lombardo Susan , Schmitz Kendra
Published: March 2019

This article discusses safety issues involved when home healthcare clinicians visit the homes of patients with pets, particularly cats and dogs. Threats to the safety of home care clinicians are explored and concerns such as animal bites, animal scratches, and infection control are detailed in this article. Although it is acknowledged that pets can provide positive health benefits to owners, the focus is on the responsibility of the pet owners to secure pets when clinicians visit in order to keep the clinician and patient safe during the home visit. A proposed Pet Policy Agreement is presented whereby the pet owner as patient bears some responsibility for ensuring the safety of home healthcare clinicians.
Telling Adolescents That a Parent Has Died
Authors: Sheehan Denice Kopchak , Hansen Dana , Stephenson Pam , Mayo Murray , Albataineh Raya , Anaba Ezinne
Published: March 2019

The aim of this study was to explicate ways in which parents tell their adolescents about a parent's death. This study used a descriptive, qualitative design. From a large hospice in northeastern Ohio, nine adolescent children and six surviving spouses of recently deceased hospice patients were recruited. Participants completed a demographic questionnaire and a semistructured individual interview. Thematic content analysis techniques were used to analyze the data. Surviving parents tell adolescents about the parent's death in ways that are intended to inform and ease the adolescents' distress. They engage in the process of disclosure in one of three ways: measured telling, matter-of-fact telling, and inconsistent telling. Findings from the current study are consistent with the ways parents told their children about an ill parent's life-threatening illness and imminent death. The findings support a framework that describes the processes of disclosure of a parent's illness, imminent death, and death to their adolescent children. Predeath findings about telling foreshadowed the postdeath findings. These results can be used to inform the development of interventions in which nurses and other health care professionals assist families with disclosure before and after death by tailoring strategies according to the family's communication style.
Cancer Pain and Quality of Life
Authors: Rodriguez Carmen , Ji Ming , Wang Hsiao-Lan , Padhya Tapan , McMillan Susan C.
Published: March 2019

Cancer pain is an unrelenting symptom with the potential to alter the quality of life of patients. To adequately manage pain, nurses caring for cancer patients need to fully understand each patient's pain experience. The purpose of this study was to identify the intensity, distress, frequency, or constancy of pain in patients treated for cancer or cancer symptoms and to better understand patient barriers to pain management. This cross-sectional study included patients (N = 105) treated for cancer or cancer symptoms at 2 outpatient medical centers. Assessments included the Pain Barriers Scale, the Cancer Symptom Scale, and the Multidimensional QOL Scale–Cancer. Descriptive statistics and Spearman correlations were used to analyze the data. Sixty-nine percent of patients reported present pain of moderate to severe intensity that caused distress, was frequent/constant, or interfered with their lives. Patients with the greatest pain distress reported the greatest intensity of pain (r = 0.77) and the greatest interference (r = 0.78) with daily lives. Cancer pain was associated with significant distress and interference with life activities and occurred frequently or constantly for many study patients.
Development and Evaluation of an Outpatient Palliative Care Clinic
Authors: Benton Kathleen , Zerbo Kotwoallama Reine , Decker Megan , Buck Brian
Published: March 2019

Palliative care (PC) is an interdisciplinary team approach to address patients’ physical, psychosocial, and spiritual needs to improve quality of life among those who have faced a life-threatening illness. When PC services are provided in an outpatient setting, patients can stay in their homes and have all their physical, psychosocial, and spiritual needs met by a comprehensive health care team to ensure a good quality of life. Because outpatient PC clinics offer a viable option for delivering PC in communities but are not prevalent in the US health care system and were rarely described in the literature, this article has described the development and evaluation of an outpatient PC clinic that was dedicated to integrating spiritual care. Specifically, this article describes (1) the factors prompting development of the clinic and its growth, (2) how a chaplain was integrated into the PC provision process, and (3) the processes and outcomes of evaluation of this clinic.
Impact of Psychological Empowerment on Workplace Bullying and Intent to Leave
Authors: Hampton Debra , Rayens Mary Kay
Published: March 2019

OBJECTIVE

The objective of this study was to understand the association of psychological empowerment (PE) with workplace bullying and intent to leave among nurse leaders.

BACKGROUND

Nurse leaders who experience bullying cope in varied ways. Some leaders have higher levels of empowerment and resilience, whereas others are more negatively impacted by bullying.

METHODS

This study used a descriptive, cross-sectional survey design. Instruments used in the study included 2 PE tools: a bullying instrument and an intent-to-leave tool. The analysis tested for bivariate correlations and used analysis of variance to discern differences among nurse leaders.

RESULTS

PE was negatively correlated with both bullying and intent to leave. Chief nursing officers and directors had significantly higher PE than did nurse managers, but there was no significant difference in intent to leave among the leader groups.

CONCLUSIONS

PE may help protect against the impact of bullying. Continued development of leaders to strengthen their PE is needed.
The Effect of Leadership Interventions on Staff Nurse Job Enjoyment and Leadership Perception
Authors: Correa Paula B. , Bacon Cynthia Thornton
Published: March 2019

Nurse managers (NMs) influence retention and job satisfaction, although many facilities lack NM training programs. A program examined staff nurse perceptions after their NMs participated in leadership training. NMs with limited training may find it more challenging to positively affect their nurses' job satisfaction and retention. This program evaluation suggests that nurse executive investment in and support of the NM role yield positive benefits for the NM leader and their staff.
New-to-Setting Nurse Transitions
Authors: Chicca Jennifer , Bindon Susan
Published: March 2019

New graduate nurses transitioning to practice have gained significant attention and dedicated resources. Less obvious are the transitions experienced nurses make to new settings or specialties during their careers. Experienced nurses still need support as they make these adjustments. This article explores the concept of nurse transition and specifically analyzes the concept of new-to-setting nurse transition. Nursing professional development practitioners and others can support experienced nurses through the challenges of new-to-setting transitions.
Ninety Years and Counting
Authors: Maloney Patsy , Woolforde Launette
Published: March 2019

This article describes the long history of the specialty of nursing professional development (NPD), the founding of NPD’s specialty organization, National Nursing Staff Development Organization, and the organization’s transformation and growth to meet the ever-changing needs of NPD practitioners. Finally, the future of the NPD specialty is envisioned. This article provides the NPD practitioner with critical information to advocate for the specialty.
Efficacy of a Breastfeeding Pain Self-Management Intervention: A Pilot Randomized Controlled Trial
Authors: Lucas Ruth , Zhang Yiming , Walsh Stephen J. , Evans Heather , Young Erin , Starkweather Angela
Published: March 2019

Background

Over 90% of women experience pain during breastfeeding initiation and lack strategies to self-manage breast and nipple pain. Guided by the Individual and Family Self-Management Theory, a breastfeeding self-management (BSM) intervention targeted women's knowledge, beliefs, and social facilitation to manage their breast and nipple pain and achieve their breastfeeding goals.

Objectives

The purpose of this longitudinal pilot randomized control trial (RCT) was to test the preliminary efficacy of the BSM intervention on general and specific pain related to breastfeeding.

Methods

Sixty women intending to breastfeed were approached within 48 hours of delivery to participate in this pilot RCT (30 randomized to the BSM intervention and 30 randomized to the control group). All participants provided baseline data before discharge and pain and breastfeeding measures at 1, 2, and 6 weeks. Participants in the BSM intervention group received educational modules addressing breast and nipple pain and biweekly, text-based nurse coaching and completed a daily breastfeeding journal.

Results

Women in the BSM intervention group reported significantly less breast and nipple pain at 1 and 2 weeks using a visual analog scale (p < .014 and p < .006) and at 2 weeks using the Brief Pain Inventory intensity scale (p < .029), but no difference in breastfeeding duration.

Discussion

The BSM intervention pilot demonstrates a positive effect on breastfeeding specific and overall generalized pain. Future investigation is needed to identify at-risk women of ongoing breastfeeding pain and develop precision interventions to sustain this beneficial health behavior for mothers and infants.
Guideline Adherence in Diagnostic Testing and Treatment of Community-Acquired Pneumonia in Children
Authors: McLaren Son H. , Mistry Rakesh D. , Neuman Mark I. , Florin Todd A. , Dayan Peter S.
Published: March 2019

Objectives

The objective of this study was to determine emergency department (ED) physician adherence with the 2011 Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) guidelines for outpatient management of children with mild-to-moderate community-acquired pneumonia (CAP).

Methods

A cross-sectional survey of physicians on the American Academy of Pediatrics Section on Emergency Medicine Survey listserv was conducted. We evaluated ED physicians' reported adherence with the PIDS/IDSA guidelines through presentation of 4 clinical vignettes representing mild-to-moderate CAP of presumed viral (preschool-aged child), bacterial (preschool and school-aged child), and atypical bacterial (school-aged child) etiology.

Results

Of 120 respondents with analyzable data (31.4% response rate), use of chest radiograph (CXR) was nonadherent to the guidelines in greater than 50% of respondents for each of the 4 vignettes. Pediatric emergency medicine fellowship training was independently associated with increased CXR use in all vignettes, except for school-aged children with bacterial CAP. Guideline-recommended amoxicillin was selected to treat bacterial CAP by 91.7% of the respondents for preschool-aged children and by 75.8% for school-aged children. Macrolide monotherapy for atypical CAP was appropriately selected by 88.2% and was associated with obtaining a CXR (adjusted odds ratio, 3.9 [95% confidence interval, 1.4–11.1]). Guideline-adherent antibiotic use for all vignettes was independently associated with congruence between respondent's presumed diagnosis and the vignette's intended etiologic diagnosis.

Conclusions

Reported ED CXR use in the management of outpatient CAP was often nonadherent to the PIDS/IDSA guidelines. Most respondents were adherent to the guidelines in their use of antibiotics. Strategies to increase diagnostic test accuracy are needed to improve adherence and reduce variation in care.
Epinephrine at 25°C Core Body Temperature and During Rewarming
Authors: Mann Christian , Baer Walter , Riedel Thomas
Published: March 2019

Epinephrine plays a controversial role in accidental hypothermia (<30°C). We report its use in the advanced life support of a 13-month-old white girl with pulseless electrical activity and 25°C core body temperature after 32 minutes of submersion in a fast-running Swiss mountain stream at 8°C. Two doses of epinephrine (10 μg/kg) were given in the field, followed by 12 doses (10 μg/kg) and an infusion of 0.1 μg/kg per minute during rewarming. Spontaneous circulation returned at 29.5°C after 2.5 hours of cardiopulmonary resuscitation. Neurologic long-term outcome was excellent. We conclude that in the presence of nonshockable rhythm the benefits of epinephrine may outweigh the risks of side effects when used in pediatric advanced life support for accidental hypothermia.
Massive Iatrogenic Pediatric Ketamine Overdose With Serial Levels and Minimal Morbidity
Authors: Bowman Connor F. , Pruitt Brandon , Marx Jared , Thornton Stephen L.
Published: March 2019

Ketamine is a dissociative anesthetic commonly used for procedural sedation owing to its perceived favorable safety profile. Despite its frequent use, overdoses of ketamine are rarely reported, and no cases with serum levels of ketamine or its metabolite have previously been reported. We report a case of an iatrogenic pediatric ketamine 20 mg/kg intramuscular overdose with serial ketamine and norketamine levels that resulted in minimal toxicity.
Pancreatic Steatosis Is Associated With Impaired Exocrine Pancreatic Function
Authors: Kromrey Marie-Luise , Friedrich Nele , Hoffmann Ralf-Thorsten , Bülow Robin , Völzke Henry , Weiss Frank U. , Lerch Markus M. , Motosugi Utaroh , Kühn Jens-Peter
Published: March 2019

Objectives

The aim of this study was to investigate if pancreatic steatosis measured by proton density fat fraction (PDFF) is associated with exocrine pancreatic function defined by fecal elastase concentrations.

Materials and Methods

A total of 1458 volunteers (777 women; age range, 21–88 years) underwent magnetic resonance imaging of the pancreas, and organ fat content was quantified by using confounder corrected PDFF. Exocrine pancreatic function was categorized by fecal elastase levels using defined cutoffs: greater than 200 μg/g normal function (n = 1319) and 200 μg/g or less impaired function (n = 139). Statistical analysis to correlate pancreatic fat content with fecal elastase included linear regression, and analyses were adjusted for known confounders for pancreatic steatosis, such as age, sex, and body mass index.

Results

Overall mean (±standard deviation) of pancreatic fat content was 7.50% ± 3.78%. Pancreatic fat content was significantly higher in subjects with impaired pancreatic exocrine function (9.36% ± 4.95%) compared with subjects with normal function (7.30% ± 3.59%; P < 0.01). Linear regression analyses showed an inverse correlation between pancreatic fat and fecal elastase levels over the whole study population (beta, −7.19 [standard error, 1.39]; P < 0.01) as well as in the subgroup of subjects with normal function (−4.26 [1.32]; P < 0.01). Among subjects with impaired pancreatic exocrine function, a trend toward an inverse relation was detected (−1.28 [0.84]; P < 0.13).

Conclusions

An inverse correlation between PDFF of the pancreas and fecal elastase suggests an association between pancreatic steatosis and impaired pancreatic exocrine function.
Digital Variance Angiography as a Paradigm Shift in Carbon Dioxide Angiography
Authors: Óriás Viktor Imre , Gyánó Marcell , Góg István , Szöllősi Dávid , Veres Dániel Sándor , Nagy Zsuzsa , Csobay-Novák Csaba , Zoltán Oláh , Kiss János P. , Osváth Szabolcs , Szigeti Krisztián , Zoltán Ruzsa , Sótonyi Péter
Published: March 2019

Objectives

Our aim was to investigate the feasibility of digital variance angiography (DVA) in lower extremity CO2 angiography and to compare the quantitative and qualitative performance of the new image processing technique with that of the current reference standard digital subtraction angiography (DSA).

Materials and Methods

This prospective study enrolled 24 patients (mean age ± SD, 65.5 ± 9.2 years; 14 males, 65.1 ± 7.5 years; 10 females, 66.1 ± 11.6 years) undergoing lower-limb CO2 angiography between December 2017 and April 2018 at 2 clinical centers: The Heart and Vascular Center (HVC) of Semmelweis University, Budapest (7 patients), and the Bács-Kiskun County Hospital (BKCH) in Kecskemét (17 patients). The interventional protocol was similar at both sites, but the image acquisition instruments and protocols were different, which allowed us to investigate DVA in different settings. For comparison, the signal-to-noise ratio (SNR) of DSA and DVA images were calculated. The visual quality of DSA and DVA images were compared by independent clinical specialists using an online questionnaire. Interrater agreement was characterized by percent agreement and Fleiss kappa. The specialists also evaluated in a random and blinded manner the individual DSA and DVA images on a 5-grade scale ranging from poor (1) to outstanding (5) image quality, and the mean ± standard error of mean (SEM) was calculated.

Results

A total of 4912 regions of interest were carefully selected in 110 image pairs to determine the SNRs. The ratio of SNRDVA/SNRDSA was calculated. At HVC, it ranged between 2.58 and 4.16 in the anatomical regions (abdominal, iliac, femoral, popliteal, crural, talar), and the overall median value was 3.53, whereas at BKCH the range was 2.71 to 4.92 and the overall median value was 4.52. During the visual evaluation, 120 DSA and DVA image pairs were compared. At HVC in 78%, although at BKCH in 90% of comparisons, it was judged that DVA provided higher quality images. The interrater agreement was 88% (P < 0.001) and 90% (P < 0.01), respectively. DVA images received consistently higher individual rating than DSA images, regardless of the research site and anatomical region. At HVC, the overall DSA and DVA scores (mean ± SEM) were 2.75 ± 0.12 and 3.23 ± 0.16, respectively (P < 0.05), whereas at BKCH these values were 2.49 ± 0.10 and 3.03 ± 0.09, respectively (P < 0.001).

Conclusions

These data show that lower-limb CO2 angiography DVA, regardless of the image acquisition instruments and protocols, produces higher SNR and significantly better image quality than DSA; therefore this new image processing technique might help the widespread use of CO2 as a safer contrast agent in clinical practice.
α-Ketoglutarate Modulates Macrophage Polarization Through Regulation of PPARγ Transcription and mTORC1/p70S6K Pathway to Ameliorate ALI/ARDS
Authors: Liu Meiyun , Chen Yuanli , Wang Suyu , Zhou Huanping , Feng Di , Wei Juan , Shi Xuan , Wu Lingmin , Zhang Pengcheng , Yang Hao , Lv Xin
Published: March 2019

As tissue-resident cells in the lung, alveolar macrophages display remarkable heterogeneity and play a crucial role in the development and control of septic acute lung injury/acute respiratory distress syndrome (ALI/ARDS). Recent evidence suggests that α-ketoglutarate (α-KG) plays an important role in alternative activation of macrophage (M2) through metabolic and epigenetic reprogramming, and thus possesses anti-inflammatory properties. However, the underlying mechanisms of α-KG's effect on alveolar macrophage polarization and the potential effects of α-KG in ALI/ARDS remain unclear. Here, we examined the effects and mechanisms of α-KG on alveolar macrophage polarization, and investigated the possible effects of α-KG on lipopolysaccharide (LPS)-induced ALI/ARDS in a mouse model. We found that α-KG inhibited M1 macrophage polarization and promoted IL-4-induced M2 macrophage polarization in MH-S cells (a murine alveolar macrophage cell line). Further experiments showed that α-KG down-regulated the expression of M1-polarized marker genes and inhibited the activities of mammalian target of rapamycin complex 1 (mTORC1)/p70 ribosomal protein S6 kinase (p70S6K) signaling pathway in M1-polarized MH-S cells. Moreover, our results showed that α-KG promoted IL-4-induced M2 polarization of MH-S cells by augmenting nuclear translocation of peroxisome proliferator-activated receptor γ (PPARγ) and increasing expression of relevant fatty acid metabolic genes. Finally, using an LPS-induced ALI/ARDS mouse model, we found that α-KG ameliorated the LPS-induced inflammation and lung pathological damage, as well as α-KG pretreated mice had better clinical scores compared with the LPS group. These findings reveal new mechanisms of α-KG in regulating macrophage polarization which may provide novel strategies for the prevention and treatment of inflammatory diseases, including sepsis and septic ALI/ARDS.
Inhibition of Aerobic Glycolysis Promotes Neutrophil to Influx to the Infectious Site Via CXCR2 in Sepsis
Authors: Tan Chuyi , Gu Jia , Chen Huan , Li Tao , Deng Huafei , Liu Ke , Liu Meidong , Tan Sipin , Xiao Zihui , Zhang Huali , Xiao Xianzhong
Published: March 2019

Recent evidences suggest that metabolic reprogramming plays an important role in the regulation of innate inflammatory response; however, the specific mechanism is unclear. In this study, we found that glycolytic inhibitor 2-deoxyglucose (2-DG) significantly improved the survival rate in cecal ligation and puncture (CLP)-induced septic mice. 2-DG-treated mice developed increased neutrophil migration to the infectious site and more efficient bacterial clearance than untreated mice. 2-DG reversed the down-regulation of chemokine receptor 2 (CXCR2) and the impaired chemotaxis induced by CLP in mice or lipopolysaccharides (LPS) in human neutrophils. Furthermore, 2-DG reversed the down-regulation of CXCR2 in neutrophils by decreasing the expression of G protein-coupled receptor kinase-2 (GRK2), a serin-threonine protein kinase that mediated the internalization of chemokine receptors, which was induced via the inhibition of extracellular regulated protein kinases (ERK) phosphorylation and the promotion of P38 phosphorylation. Finally, SB225002, a CXCR2 antagonist, partially blocked the protective effects of 2-DG in sepsis. Together, we found a novel mechanism for the migration of neutrophils regulated by metabolism and suggested that aerobic glycolysis might be a potential target of intervention in sepsis.
Vitamin D Deficiency and Neurologic Outcome After Sudden Cardiac Arrest
Authors: Cha Jung-Joon , Wi Jin
Published: March 2019

Background:

Vitamin D deficiency is related to various cardiovascular diseases, including sudden cardiac arrest (SCA). This study investigated the association of vitamin D level with neurologic outcome and mortality after resuscitation from SCA.

Patients and Methods:

We enrolled patients who were successfully resuscitated from out-of-hospital cardiac arrest of presumed cardiac cause in Severance Cardiovascular Hospital as a prospective cohort registry. Baseline blood samples including pH, lactate, and vitamin D were obtained without fluid replacement just after hospital admission. Outcome was assessed by cerebral performance category (CPC) score at 1 month after SCA. Favorable outcome was defined as survival with CPC score of 1 or 2, whereas unfavorable one as death or survival with CPC scores of 3 through 5. Severe vitamin D deficiency was defined as 25(OH)D <10 ng/mL.

Results:

A total of 163 patients were included. Overall 96 (59%) patients had a favorable neurologic outcome, whereas 67 patients (41%) showed unfavorable outcome, including 37 (23%) mortality. Patients with unfavorable outcome were likely to be female and have initial non-shockable rhythm, longer arrest time, severe shock, diabetes, and baseline renal dysfunction. In multivariate analysis, severe vitamin D deficiency was one of the poor prognostic factors of both unfavorable neurologic outcome and mortality after SCA.

Conclusions:

Vitamin D deficiency is very prevalent and strongly associated with both unfavorable neurologic outcome and mortality in patients resuscitated from SCA.
The Impact of Plasma-Derived Microvesicles From a Femoral Fracture Animal Model on Osteoblast Function
Authors: Qiao Zhi , Wang Weikang , Luo Peng , Hofman Martijn , Horst Klemens , Müller-Newen Gerhard , Greven Johannes , Hildebrand Frank
Published: March 2019

The role of microvesicles (MVs) in transcellular signal transduction has been demonstrated in different studies. However, the potential modulatory role of MVs in fracture healing remains unclear. Therefore, we investigated the impact of plasma-derived MVs after a femoral fracture on cranial osteoblasts. A femoral fracture with intramedullary stabilization was induced in Sprague Dawley rats. The animals were killed 3 days (group A), 1 week (group B), or 2 weeks (group C) after trauma induction. Animals without trauma served as controls. Osteoblasts from the cranial bone of a neonatal Sprague Dawley rats were cultured and stimulated with either plasma-derived MVs or MV-free plasma of groups A to C. The effects of MVs on osteoblasts were analyzed by growth assay, metabolic assay, and quantitative real-time polymerase chain reaction for osteocalcin, RUNX2, and collagen 1A to test differentiation of osteoblasts. MVs were time-dependently incorporated in osteoblasts and localized mainly around the nucleus. MVs increased the viability of osteoblasts, particularly in the late phase after femoral fracture (group A,P = 0.0276; group B,P = 0.0295; group C,P = 0.0407). Late-phase differentiation of osteoblasts was not stimulated by MVs but was by MV-free plasma (osteocalcin, groups C vs. control,P = 0.0454). The levels of transforming growth factor β1 (P = 0.0320) and insulin-like growth factor 1 (P = 0.0211) were significantly higher in plasma than in MVs. MVs seem to modulate the viability of osteoblasts but not to affect osteoblast differentiation. Further studies are warranted to determine the characteristics and interactions of MVs. Potentially, MVs might act as a diagnostic or therapeutic tool in cases of impairment of fracture healing.
The Changing Face of Liver Transplantation in the United States: The Effect of HCV Antiviral Eras on Transplantation Trends and Outcomes
Authors: Parrish Nicholas F. , Feurer Irene D. , Matsuoka Lea K. , Rega Scott A. , Perri Roman , Alexopoulos Sophoclis P.
Published: March 2019

Background

Hepatitis C virus (HCV) cirrhosis is the leading indication for liver transplantation in the United States, although nonalcoholic steatohepatitis (NASH) is on the rise. Increasingly effective HCV antivirals are available, but their association with diagnosis-specific liver transplantation rates and early graft survival is not known.

Methods

The Scientific Registry of Transplant Recipients database records were retrospectively stratified by HCV antiviral era: interferon (2003-2010), protease inhibitors (2011-2013), and direct-acting antivirals (2014 to present). Kaplan-Meier, χ2, and multivariable Cox proportional hazards regression models evaluated the effects of antiviral era and etiology of liver disease on transplantation rates and graft survival over 3 years.

Results

Liver transplants for HCV decreased (35.3% to 23.6%), whereas those for NASH and alcoholic liver disease increased (5.8% to 16.5% and 15.6% to 24.0%) with each advancing era (all P < 0.05). Early graft survival improved with each advancing era for HCV but not for hepatitis B virus, NASH, or alcoholic liver disease (multivariable model era by diagnosis interaction P < 0.001). Era-specific multivariable models demonstrated that the risk of early graft loss for NASH was 22% lower than for HCV in the interferon era (hazard ratio, 0.78; 95% confidence interval, 0.64-0.96; P = 0.02) but risks associated with these diagnoses did not differ significantly in the protease inhibitor (P = 0.06) or direct-acting antiviral eras (P = 0.08).

Conclusions

Increasing effectiveness of HCV antivirals corresponds with decreased rates of liver transplantation for HCV and improved early graft survival. As the rates of liver transplant for NASH continue to increase, focus will be needed on the prevention and effective therapies for this disease.
Early Persistent Progressive Acute Kidney Injury and Graft Failure Post Liver Transplantation
Authors: Hussaini Trana , Yoshida Eric M. , Partovi Nilu , Erb Siegfried R. , Scudamore Charles , Chung Stephen , Marquez Vladimir
Published: March 2019

Background

Acute kidney injury (AKI) in the setting of liver transplantation is a common and multifaceted complication. Studies in the general population have demonstrated worse prognosis with AKI episodes that persist for a longer duration. Our primary objective was to evaluate the impact of early AKI episodes that are persistent or progressive in nature, on patient outcomes and graft survival.

Methods

This was a retrospective cohort study including all patients who received a liver transplant between 2011 and 2015 at our center. Moderate to severe AKI episodes (AKIN II or III) were recorded immediately before transplantation and after surgery until hospital discharge. We evaluated the incidence density rate (IDR) of graft failure and the time to graft failure in patients with persistent or progressive AKI (ppAKI) as compared to controls.

Results

Two hundred seventy-nine patients received 301 deceased donor liver allografts. Progressive or persistent AKI was documented in more than half of transplant cases (152/301). The rate of graft loss was 3 times higher in the ppAKI group (25%) versus the controls (8.7%). The IDR of graft failure was 13.79 per 100 case-years in the ppAKI group as compared with 3.79 per 100 case-years in the controls (IDR ratio, 3.64; 95 % confidence interval, 1.88–7.50). After adjusting for hepatic artery thrombosis, ischemic cholangiopathy, infectious complications and Model for End-stage Liver Disease, ppAKI was associated with a decreased graft survival time.

Conclusions

Persistent or progressive AKI after liver transplantation is associated with an increased incidence rate of graft failure and is an independent predictor of decreased graft survival time.