bluuebunny/crossref_metadata_2025 huggingface dataset:
Wrong Site Spine Surgery in the Veterans Administration
Authors: Watts Bradley V. , Rachlin Jacob R. , Gunnar William , Mills Peter D. , Neily Julia , Soncrant Christina , Paull Douglas E.
Published: January 2019

Study Design:

Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA).

Objective:

To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue.

Summary of Background Data:

Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients.

Materials and Methods:

We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated.

Results:

There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues.

Conclusions:

Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.
Amelanotic melanoma
Authors: Gong Hui-Zi , Zheng He-Yi , Li Jun
Published: January 2019

Cutaneous amelanotic melanoma (AM) is a rare amelanotic or a hypomelanotic subtype of melanoma, comprising only 0.4–27.5% of all melanoma cases. The mean age of the patients is over 50 years, and the male/female ratio varies from 0.5 to 4. Patients with red hair, type I skin, freckles, lack of nevi on the back, a sun-sensitive phenotype, or previous AM history are more likely to develop AMs. As AMs lack pigmentation, their appearances vary and can mimic many benign and malignant conditions, thus presenting a diagnostic challenge. AMs are composed of greater proportions of nodular melanoma, acral lentiginous melanoma, and desmoplastic melanoma than pigmented melanomas. They also present with thicker Breslow thickness, higher mitotic rate, more frequent ulceration, higher tumor stage, and lower survival than pigmented melanomas.
Effective Tuberculosis Contact Investigation Using Interferon-Gamma Release Assays
Authors: Bennet Rutger , Nejat Sahar , Eriksson Margareta
Published: January 2019

During 2000 to 2018, 1831 children were screened as part of tuberculosis contact investigation at the Stockholm Northern Clinic. The risk of a child having a positive tuberculin skin test was 33% and positive interferon-gamma release assay 12%. The risk of tuberculosis disease was 6.1% (tuberculin skin test) and 13% (interferon-gamma release assay) in positive-testing children.
Multidrug-resistant Gram-negative Bacterial Bloodstream Infections in Children’s Hospitals in Japan, 2010–2017
Authors: Aizawa Yuta , Shoji Takayo , Ito Kenta , Kasai Masashi , Sakurai Hiroki , Toyofuku Etsushi , Minami Kisei , Hoshino Tadashi , Horikoshi Yuho
Published: January 2019

Background:

The risk factors of multidrug-resistant (MDR) Gram-negative bacilli (GNB) bloodstream infection (BSI) are not yet known in children. Our aim was to evaluate risk factors and outcomes associated with MDR GNB BSI in children.

Methods:

Patients with GNB BSI were enrolled between April 2010 and March 2017 at 8 children’s hospitals in Japan. Clinical and microbiologic data were collected retrospectively. The risk factors and outcomes of MDR and non-MDR GNB BSI were compared.

Results:

In total, 629 GNB BSI episodes met the case definition. The median age and proportion of males were 2 years (interquartile range, 0.3–8.7) and 50.7%, respectively. An underlying disease was found in 94% of patients. The proportion of BSI cases that developed >48 hours after admission was 76.2%. MDR comprised 24.5% of BSI cases. The MDR rate did not change over time (P = 0.540). The effective coverage rate of the initial empiric therapy for the MDR and non-MDR BSI cases was 60.4% and 83.4%, respectively (P < 0.001). The all-cause mortality rate at 28 days for all BSI, MDR-BSI and non-MDR BSI cases was 10.7%, 13.6% and 9.7%, respectively (P = 0.167). MDR BSI was independently associated with cancer chemotherapy within 30 days (odds ratio [OR] 43.90), older age (OR 1.05) and admission to the neonatal ward (OR 0.019).

Conclusions:

One-fourth of GNB BSI cases were MDR. Cancer chemotherapy and older age were risk factors for MDR GNB BSI in children’s hospitals. MDR did not increase the all-cause mortality rate.
Early vedolizumab trough levels at induction in inflammatory bowel disease patients with treatment failure during maintenance
Authors: Liefferinckx Claire , Minsart Charlotte , Cremer Anneline , Amininejad Leila , Tafciu Vjola , Quertinmont Eric , Tops Sophie , Devière Jacques , Gils Ann , van Gossum André , Franchimont Denis
Published: January 2019

Background

Vedolizumab (VDZ) is effective as an induction and maintenance treatment for Crohn’s disease and ulcerative colitis, but, as observed with antitumour necrosis factor-α (anti-TNFα) agents, some patients are nonetheless experiencing loss of response.

Objective

The aim of this study was to investigate the impact of the pharmacokinetics of VDZ during induction on long-term treatment response.

Patients and methods

This study focused on a single cohort of 103 inflammatory bowel disease patients treated with VDZ. VDZ trough levels (TLs) were measured by enzyme-linked immunosorbent assay (n=536 samples), and thereafter correlated to clinical, biological, endoscopic and serological data. For patients exposed previously to infliximab, antibodies to infliximab were measured at baseline. On the basis of the outcome at the end of follow-up, patients were then categorized into long-term response, optimized and treatment failure groups.

Results

During VDZ induction, at week 6, inflammatory bowel disease patients with long-term response had higher TLs compared with patients in the treatment failure group (33 vs. 24 µg/ml, P=0.02). A cut-off TL of 28 µg/ml predicted a sustained response in the follow-up with an area under curve of 0.723 (95% confidence interval=0.567–0.878, P=0.02). Patients with mucosal healing in maintenance had higher TLs at week 6 (41.65 µg/ml) compared with patients with mild (26 µg/ml) or severe endoscopic activity (20.8 µg/ml), P=0.009. Positive perinuclear antineutrophil cytoplasmic antibody serology was associated with lower TLs. Patients previously exposed to anti-TNFα had lower TLs than naive patients (22.5 vs. 36 µg/ml, P=0.03) without any impact of detectable antibodies to infliximab. Finally, the presence of an immunomodulator at induction did not impact on VDZ TLs at induction.

Conclusion

We confirmed that a drug exposure–efficacy association was found early on at induction. This study emphasizes that previous exposure to anti-TNFα and positive perinuclear antineutrophil cytoplasmic antibody serology are important factors influencing VDZ TLs at induction.
Risk of death within 7 days of discharge from emergency departments with different organizational models
Authors: Moellekaer Anders , Kirkegaard Hans , Vest-Hansen Betina , Duvald Iben , Eskildsen Jacob , Obel Borge , Madsen Bo
Published: January 2019

Objective

The aim of this study is to investigate the association between emergency department (ED) organizational models and the risk of death within 7 days of ED discharge.

Patients and methods

We included Danish ED discharges between 1 January 2011 and 24 December 2014 that led to death within 7 days of discharge. The inclusion criterion was age older than 18 years. The exclusion criterion was further in-hospital admission. First model (Virtual): other departments employ interns who perform ED tasks. They are responsible for ED patient care and prioritize their task order between their own department and the ED. Second model (Hybrid): the ED/other departments perform tasks; interns/consultants are employed by the ED/other departments. The ED/other departments have patient care responsibility. Third model (Independent): the ED performs all tasks; employs interns/consultants; and have patient care responsibility. Sex, age, Charlson Comorbidity Index score, and primary diagnosis were used to describe patient characteristics. We calculated the risk of death within 7 days of discharge using multiple logistic regression analysis.

Results

In 805 out of 201 299 discharges included in the study, the patient died within 7 days. Compared with the Virtual model, the odds ratio for death within 7 days of discharge was 0.72 (95% confidence interval: 0.59–0.92) for the Independent model and 0.75 (95% confidence interval: 0.61–0.92) for the Hybrid+Virtual model. Increased risk was associated with male sex, older age, and a medium or a high Charlson Comorbidity Index score.

Conclusion

Compared with discharges from a Virtual model, the risk of death within 7 days of discharge was lower if the ED had an Independent or a Hybrid+Virtual model.
From HDL-cholesterol to HDL-function: cholesterol efflux capacity determinants
Authors: Rhainds David , Tardif Jean-Claude
Published: January 2019

Purpose of review

The validity of HDL-cholesterol (HDL-C) elevation as a therapeutic target has been questioned, in comparison to enhancing HDL functionality. Cholesterol efflux capacity (CEC) is an in-vitro assay that measures the ability of an individual's HDL to promote cholesterol efflux from cholesterol donor cells such as macrophages. CEC of HDL is a predictor of cardiovascular risk independent of HDL-C levels. However, molecular determinants of CEC and the effects of diseases and therapeutic interventions on CEC have not been completely defined.

Recent findings

We review here recent findings on elevated HDL-C and disease risk, as well as determinants of CEC, from genetics and proteomics to pathophysiology and therapeutic interventions that contribute to our understanding of CEC as a biomarker of HDL functionality.

Elevated HDL-C levels are not always protective against cardiovascular disease and mortality. CEC is a heritable trait, and genetic polymorphisms in genes involved in HDL and triglycerides metabolism are associated with CEC. Multiple HDL proteins correlate positively with CEC levels and inversely with noncalcified plaque burden. Differences in CEC assays that make comparisons between studies difficult are also emphasized. CEC should be measured in clinical trials of lipid-modifying and anti-inflammatory therapies to determine whether increases are cardioprotective.
Ultra-short bowel syndrome during infancy: improving outcomes and novel therapies
Authors: Walker A. Adjowa , Cole Conrad R.
Published: January 2019

Purpose of review

Ultra-short bowel syndrome is relatively rare and has not yet been extensively reported. In ultra-short bowel syndrome, poor absorption of nutrients and dysmotility, interfere with fluid, energy, electrolyte and micronutrient balance. Patients with this disorder are managed through prolonged parenteral nutrition with the ultimate goal of achieving enteral autonomy. Overall outcomes of these patients are dependent on postsurgical bowel anatomy (residual length, intact colon, ostomy closure timing), incidence of sepsis, and care by a multidisciplinary specialized team.

Recent findings

Over the years, standardization of management has improved outcomes. This includes central line care, lipid alternatives, enteral therapy, medications (antidiarrheal agents, acid suppression medications, bile acid binding salts, and enteral antibiotics) including Teduglutide. Bowel lengthening procedures have also proven beneficial, and finally bowel transplant does remain an option for a patient in whom rehabilitation has failed.

Although there are many factors that influence outcomes of ultra-short bowel patients, novel therapies such as Teduglutide have been introduced with the aim of improving intestinal adaptation. Surgical lengthening and transplant are viable options in the setting of failed rehabilitation.
Alanyl‐glutamine Protects Against Damage Induced by Enteroaggregative Escherichia coli Strains in Intestinal Cells
Authors: Prata Mara M.G. , Cavalcante Paloma A. , da Silva Antonio V. Alves , de Medeiros Pedro H.Q.S. , de Assis Júnior Eudmar M. , Reyes Mayra A.V. , Quetz Josiane da S. , Clementino Marco A.F. , Ribeiro Samilly A. , Lima Ila F.N. , Lima‐Junior Roberto C.P. , Havt Alexandre , Guerrant Richard L. , Lima Aldo A.M.
Published: January 2019

Background:

Enteroaggregative Escherichia coli (EAEC) is an important pathogen causing enteric infections worldwide. This pathotype is linked to malnutrition in children from developing countries. Alanyl‐glutamine (Ala‐Gln) is an immune modulator nutrient that acts during intestinal damage and/or inflammation. This study investigated the effect of EAEC infection and Ala‐Gln on cell viability, cell death, and inflammation of intestinal epithelium cells (IEC‐6).

Methods:

Cells were infected with an EAEC prototype 042 strain, an EAEC wild‐type strain isolated from a Brazilian malnourished child, and a commensal E coli HS. Gene transcription and protein levels of caspases‐3, ‐8, and ‐9 and cytokine‐induced neutrophil chemoattractant 1 (CINC‐1/CXCL1) were evaluated using RT‐qPCR, western blot analysis, and ELISA.

Results:

Infections with both EAEC strains decreased cell viability and induced apoptosis and necrosis after 24 hours. Ala‐Gln supplementation increased cell proliferation and reduced cell death in infected cells. Likewise, EAEC strain 042 significantly increased the transcript levels of caspases‐3, ‐8, and ‐9 when compared to the control group, and Ala‐Gln treatment reversed this effect. Furthermore, EAEC induced CXCL1 protein levels, which were also reduced by Ala‐Gln supplementation.

Conclusion:

These findings suggest that EAEC infection promotes apoptosis, necrosis, and intestinal inflammation with involvement of caspases. Supplementation of Ala‐Gln inhibits cell death, increases cell proliferation, attenuates mediators associated with cell death, and inflammatory pathways in infected cells.
Healthcare Professionals' Perceptions of Risk When Care Is Given in Patients' Homes
Authors: Schildmeijer Kristina , Wallerstedt Birgitta , Ekstedt Mirjam
Published: January 2019

Perceptions of risks in decision making for home healthcare were examined. Twenty home healthcare professionals were interviewed. Content analysis yielded one theme (management of known and unpredictable risks) and four categories. Healthcare professionals had to handle both known and unpredictable risks in daily work in patients' homes concerning communication challenges, a fragmented organization at several levels, risky medication management, and balancing respect for patient autonomy and involvement in care against risk taking. Priority must be given to creating safer care in this setting.
Health-Related Quality of Life in Patients With Narcolepsy
Authors: Raggi Alberto , Plazzi Giuseppe , Ferri Raffaele
Published: January 2019

Narcolepsy is a chronic disorder characterized by symptoms of excessive daytime sleepiness, irresistible sleep attacks that may be accompanied by cataplexy brought on by emotions, sleep paralysis, and hypnagogic hallucinations. This is a review of 32 empirical articles on health-related quality of life (HRQoL) published in peer-reviewed journals over the past 37 years. Deleterious implications on education, recreation, driving, sexual life, and personality are associated with the disease with a consequent negative psychosocial impact. Sleepiness has an important influence on HRQoL, more than the other symptoms of this disorder that have disrupting roles, too. Therefore, patients with narcolepsy need assistance not only for medication prescription but also in terms of psychological and social support. It is also of importance to assess patients with narcolepsy carefully in terms of depressive symptoms because they may have a major impact on HRQoL with important clinical implications.
Severe Mental Illness in Community Mental Health Care in Spain
Authors: Martín-Pérez Carlos , Herrero-Martin Juan Jesús , Pérez-López Gonzalo , Pedrosa-García Rafael , Ibañez-Casas Inmaculada , Torres-González Francisco , Moreno-Küstner Berta
Published: January 2019

The aims of this study were to determine the prevalence of severe mental illness (SMI) in patients in contact with mental health services and to determine the factors associated with SMI. A total of 260 patients who met diagnostic criteria for SMI were assessed using the Global Assessment of Functioning (GAF) scale and Health of the Nation Outcome Scales. The overall prevalence of SMI was 6.08 per thousand. According to the three different cutoff points with GAF, the prevalence of SMI ranged from 5.38 per thousand under the weak criterion (GAF < 70) to 1.01 per thousand under the strict criterion (GAF < 50). In the regression model, the dependent variable (presence of SMI) was defined using a GAF < 60, and the variables independently associated with the dependent variable were years of disease duration since diagnose, mental health service use, alcohol or other substance abuse, and depressive anxiety and other psychological symptoms.
Sexual Identity Disorder and Psychosis in Klinefelter Syndrome
Authors: Maillefer Aude , Sabe Michel , Coste Christophe , Bartolomei Javier , Jaafar Jaafar , Sentissi Othman
Published: January 2019

Klinefelter syndrome (KS) 47, XXY is the most frequent chromosomal abnormality causing hypogonadism in humans. This chromosomal abnormality of number in its classical form called homogeneous (supernumerary X) is generally the result of a meiosis accident. Several studies have suggested that individuals with KS are at greater risk of developing various psychiatric disorders, including depression and schizophrenia. The diagnosis is made based on subnormal testosterone with high pituitary gonadotropins and confirmed by determining the karyotype on a blood simple. We did a literature review using an electronic search in three databases: Pubmed/MEDLINE, Google Scholar, and PsychInfo. We found that since 1989, seven case reports with KS and mental disorders with similar and different characteristics of our case illustration of a patient with KS and psychosis were published.
In-simulation Debriefing Increases Therapeutic Communication Skills
Authors: Gaylle Debrayh
Published: January 2019

Background

This article describes a formative simulation experience designed to prepare prelicensure nursing students to interact with psychiatric patients.

Purpose

The purpose of this study was to compare the effects of 2 debriefing styles (in-simulation and postsimulation) on nursing students' knowledge, performance, and anxiety related to working with psychiatric patients. The study also explored students' perceptions of the efficacy of in-simulation debriefing.

Methods

The study used a quasi-experimental, mixed-method design.

Results

There were no statistically significant differences between groups in knowledge, assessment, or anxiety. However, both groups demonstrated significant gains in all areas.

Conclusions

In-simulation debriefing is an effective tool for teaching therapeutic communication to nursing students.
Collision Tumor of Urothelial Cell Carcinoma and Clear Cell Renal Cell Carcinoma: A Case Report and Review of the Contemporary Literature
Authors: Griffin Jon , Tahir Fawzia
Published: January 2019

We present a case of synchronous renal cell carcinoma and urothelial carcinoma. Our case was a true collision tumor and both components were high grade. Metastasis to the adrenal gland by the urothelial carcinoma was observed. The morphologic impression was confirmed with GATA3 expression by the urothelial carcinoma component and PAX8 expression by the renal cell carcinoma component. We have reviewed the contemporary literature of this unusual dual diagnosis.
STAT6 Expression in Solitary Fibrous Tumor and Histologic Mimics: a Single Institution Experience
Authors: Saeed Omer , Zhang Shanxiang , Cheng Liang , Lin Jingmei , Alruwaii Fatimah , Chen Shaoxiong
Published: January 2019

STAT6 stain has proved to be a good surrogate marker for the genetic alteration (NAB2-STAT6 gene fusion) in solitary fibrous tumor (SFT). This study aims to validate the use of STAT6 rabbit monoclonal antibody in differentiating SFT from its histologic mimics. Forty-five cases of SFT and 110 cases from 9 other spindle cell tumors were collected for STAT6 immunostaining. Positive nuclear STAT6 staining was present in all 45 SFT cases (100% sensitivity). No nuclear staining was identified in other spindle cell neoplasms (0/13, dedifferentiated liposarcoma; 0/17, synovial sarcoma; 0/16, malignant peripheral nerve sheath tumors; 0/25, undifferentiated pleomorphic sarcoma; 0/10, dermatofibrosarcoma protuberans; 0/9, low-grade fibromyxoid sarcoma; 0/6, angiofibroma; 0/5, deep fibromatosis; 0/9, gastrointestinal tumor). The STAT6 staining in SFT was usually diffuse (5+ in 19 cases; 4+ in 17 cases) and strong (40 cases). Monoclonal STAT6 stain is highly sensitive and specific for SFTs and particularly useful in the diagnosis of difficult SFT cases.
A Novice Guide to Applications of Simulation in the Pediatric Emergency Department
Authors: Waseem Muhammad , Horsley Elizabeth
Published: January 2019

Healthcare systems and health professions education have gone through radical changes in the past decades. These changes have made it imperative to explore innovative and alternative ways of teaching and training. Simulation-based education has emerged as an effective teaching strategy for both learners and practicing health professionals. Simulation is an educational technique that recreates real-life experiences. Learning occurs through participation in these simulation experiences followed by a period of guided debriefing and reflection. Pediatric emergency medicine, by its very nature, can benefit greatly from a well-designed and thoughtfully implemented simulation program. This review outlines situations where simulation may be used for maximum effectiveness in a pediatric emergency department and provides an overview of the basics of debriefing. A thorough description of each identified use of simulation is beyond the scope of this article.
A Case of Pott's Puffy Tumor Associated With Barosinusitis From Scuba Diving
Authors: Patel Ami , Vuppula Sharon , Hayward Harrison , Lakhani Anisa , Lighter Jennifer
Published: January 2019

Barosinusitis, or sinus barotrauma, is a well-described condition associated with changes in barometric pressure during flight and diving that can result in sinonasal mucosal injury. In this case report, we present an adolescent who experienced barosinusitis during scuba diving and subsequently developed Pott's puffy tumor (PPT), characterized by frontal sinusitis, frontal bone osteomyelitis, and overlying subperiosteal abscess. This unique case of PPT following scuba diving provides the opportunity to review the pathophysiology of both barotrauma-induced sinus disease and PPT, a rare and unreported serious complication of barosinusitis. Furthermore, we discuss how scuba diving and associated barosinusitis can be considered a risk factor in the development of PPT.
Unintentional Opioid Ingestions Presenting to a Pediatric Emergency Department
Authors: Ghosh Pallavi , Pruitt Christopher , Shah Nipam , Kulkarni Abhay , Slattery Ann , Nichols Michele
Published: January 2019

Objectives

The purpose of this study was to describe unintentional opioid exposures in young children, including demographics, medical interventions, and clinical outcomes.

Methods

This was a retrospective, cross-sectional study of children 0 to 6 years of age with possible opioid exposure over a 3-year period (July 2010 to June 2013). Data collected included sex, age, specific drug, whether they were referred to the emergency department (ED) by the Regional Poison Control Center, presence of symptoms, therapeutic interventions, ED disposition, and clinical outcomes for admitted patients.

Results

Median age of patients included in the study was 2 years, and 64% of these children were male. The most common drug of exposure was buprenorphine/naloxone. Of the 429 charts screened, 140 patients were reported to be symptomatic and referred to the ED, of which 113 patients actually presented to the ED. An additional 122 patients presented to the ED without Regional Poison Control Center referral. Of the total 235 patients presenting to ED, 76 (32%) received a therapeutic intervention. Of 231 total opioid exposures, 31 exposures were administered naloxone. Three children underwent endotracheal intubation. Sixty-five patients were hospitalized, with a median length of stay of 1 day. Although there were no fatalities, 1 child suffered severe morbidity (anoxic brain injury).

Conclusions

While opioid exposures in young children are a common and potentially life-threatening problem, most children remain asymptomatic. The majority of patients are able to be discharged from the ED after observation, and of those who are admitted, most have favorable outcomes and brief hospital stays. A small number of these patients require considerable medical interventions.
Patterned Bruises From Abusive Squeezing
Authors: Petska Hillary W. , Frasier Lori D. , Livingston Nina , Moles Rebecca , Sheets Lynn K.
Published: January 2019

Bruising is the most common presentation of child physical abuse. Many patterns of abusive bruising result in positive or negative imprints of the implement used (eg, fingertips in “grab mark” contusions or hand in slap injury). However, bruising may also form along the lines of greatest anatomical stress (eg, gluteal cleft or pinna bruising). Bruising due to abusive squeezing also forms along lines of greatest anatomical stress, resulting in a negative imprint of the flexural folds of the hand. Four cases of children with this unique pattern of bruising due to abusive squeezing are presented. Recognition of these bruises as inflicted represents an opportunity for early identification and intervention in cases of child physical abuse.
Delayed Subaponeurotic Fluid Collections
Authors: Stephan Alexander M. , Feldman Kenneth W. , Otjen Jeffrey P. , Metz James B.
Published: January 2019

Delayed subaponeurotic fluid collections (DSFCs) are a recently described cause of idiopathic scalp swelling in young infants. Associated with traumatic birth and the use of vacuum-assisted devices or fetal scalp electrodes, DSFCs can be differentiated from similar causes of neonatal scalp swelling based on characteristic history and physical examination findings. In this article, we highlight 2 cases of young infants presenting to a pediatric emergency department with large, fluctuant scalp swellings, which were appropriately diagnosed as DSFCs; clinical data on an additional eight cases are presented in table format. In cases of isolated DSFCs in otherwise well-appearing infants, further laboratory work, imaging, subspecialty consultation, and child abuse investigation is not necessary. Recommendations for the diagnosis and management of DSFCs presented reflect the clinical experience of the authors in conjunction with a review of the available medical literature on this topic.
Craniocervical Dissociation in Pediatric Patients
Authors: Hazboun Rajaie , Muñoz Amanda , Krafft Paul R. , Harder Sheri , Vannix Rosemary , Zouros Alexander , Kim Paggie , Baerg Joanne
Published: January 2019

Aims

The aims of this study were to document the injury pattern in pediatric traumatic craniocervical dissociation (CCD) and identify features of survivors.

Methods

Pediatric traumatic CCDs, diagnosed between January 2004 and July 2016, were reviewed. Survivors and nonsurvivors were compared. Categorical and continuous variables were analyzed with Fisher exact and t tests, respectively.

Results

Twenty-seven children were identified; 10 died (37%). The median age was 60 months (ranges, 6–109 months [survivors], 2–98 months [nonsurvivors]). For survivors, the median follow-up was 13.4 months (range, 1–109 months). The median time to mortality was 1.5 days (range, 1–7 days). The injury modality was motor vehicle collision in 18 (67%), pedestrian struck in 8 (30%), and 1 shaken infant (3%). For nonsurvivors, CCD was equally diagnosed by plain radiograph and head/cervical spine computed tomography scan. For survivors, CCD was diagnosed by computed tomography in 7 (41%), magnetic resonance imaging in 10 (59%), and none by radiograph. Seven diagnosed by magnetic resonance imaging (41%) had nondiagnostic initial imaging but persistent neck pain. Magnetic resonance imaging was obtained and was diagnostic of CCD in all 7 (P < 0.01). Survivors required significantly less cardiopulmonary resuscitation (P < 0.01), had lower Injury Severity Scores (P < 0.01), higher Glasgow Coma Scale scores (P < 0.01), and shorter transport times (P < 0.01). Significantly more involved in motor vehicle collisions survived (P = 0.04). Nine (53%) had no disability at follow-up evaluation.

Conclusions

In pediatric CCD, high-velocity mechanism, cardiac arrest, high Injury Severity Score, and low Glasgow Coma Scale score are associated with mortality. If CCD is correctly managed in the absence of cardiac arrest or traumatic brain or spinal cord injury, children may survive intact.
A Frosty Challenge
Authors: Bréhin Camille , Cortey Caroline , Claudet Isabelle
Published: January 2019

Background

We report a case of geometrical skin lesions in a teenage patient.

Case

A previously healthy 14-year-old boy presented in our pediatric emergency department with unusual skin lesions on his left forearm. The patient said the lesions started 2 weeks earlier following a spider bite. His physical examination revealed an otherwise healthy child with no medical history with raised square lesions of the left forearm. The lesions were in different stages of healing and resembled second-degree burns. Examination showed no other lesions. Vital signs were normal. The patient was discharged after the lesions were dressed with antibiotic ointment. A follow-up consultation was scheduled a week later, but the patient did not attend the follow-up consultation. A senior emergency physician called the family and learned that the lesions were progressively healing and no other lesions appeared. The teen admitted he played the “salt and ice challenge.”

Discussion

The salt and ice challenge involves putting salt on the skin and then applying and/or pressing ice cubes on top of the salt. The challenge is to resist the pain consecutive to frostbite for as long as possible. The result is often second-degree burns and possible partial third-degree burns.

Conclusions

Because of the current popularity of this practice, emergency or family physicians, pediatricians, dermatologists, and burn or orthopedic surgery units might encounter these injuries. When young patients present with geometrical burn injuries and unexplained or bizarre circumstances, self-inflicted burn “challenges” should be considered.
Trends in Emergent Head Computed Tomography Utilization for Minor Head Trauma After Implementation of a Clinical Pathway
Authors: Corwin Daniel J. , Durbin Dennis R. , Hayes Katie L. , Zonfrillo Mark R.
Published: January 2019

Objective

The aims of this study were to evaluate trends over time in computed tomography (CT) scan utilization after implementation of a clinical pathway in a tertiary care children's hospital emergency department (ED), to determine how ED throughput differs by CT utilization, and to determine provider reasoning for obtaining head CT in low-risk patients.

Methods

This was a retrospective cohort study of patients 21 years or younger discharged from our ED with head trauma (Glasgow Coma Scale score ≥13 and a head trauma International Classification of Diseases code) over a 5-year period, starting 1 year after pathway implementation (January 2012 to December 2016). A manual chart review of 10% of patients who received a CT was performed to determine reasoning for CT utilization and guideline compliance.

Results

In total, 6.3% (95% confidence interval [CI], 5.9%–6.6%) of 21,129 discharged patients received a head CT, decreasing annually by an average of 0.9%. Pediatricians were more likely to obtain a CT than pediatric emergency medicine physicians after adjusting for acuity (odds ratio, 1.37; 95% CI, 1.02–1.82). Those who received a CT stayed 90 minutes longer (95% CI, 79–101 minutes) than those who did not after propensity score matching. Thirty percent of patients who received a CT in our manual chart review met low-risk Pediatric Emergency Care Applied Research Network criteria.

Conclusions

Head CT rates in patients with minor head trauma consistently decreased each year after guideline implementation. Children who received head CT did not have prolonged lengths of stay compared with those who did not. A minority of patients who received a CT and were discharged met low-risk criteria by standardized guidelines.
Clinical Features and Biomarkers Suggestive of Bloodstream Infection in Pediatric Patients With Intestinal Failure and Central Venous Lines for Parenteral Nutrition
Authors: Fischer Jason B. , Sturza Julie , Kim Zio , Lopez M. James , Rogers Alexander J.
Published: January 2019

Objectives

This study aimed to describe demographic, clinical, and laboratory values in febrile pediatric intestinal failure patients with indwelling central venous catheters presenting to the emergency department to determine if there are low-risk features predictive of negative blood cultures that could help identify a subset that do not need hospitalization and/or broad-spectrum antibiotics.

Methods

We conducted a retrospective cohort study of febrile patients younger than 18 years with diagnosis of intestinal failure requiring a central venous catheter for home parenteral nutrition to identify factors associated with normal blood cultures to identify a low-risk subset.

Results

Of 119 encounters, 46% had a bloodstream infection. Children with a bloodstream infection were older than those without. A normal lactate and heart rate were associated with negative blood cultures.

Conclusion

Pediatric intestinal failure patients with a central venous catheter for home parenteral nutrition presenting to the emergency department with fever and found to have a normal lactate and heart rates had lower rates of bloodstream infection. Although we were unable to create a highly sensitive clinical decision-making rule to identify a low-risk cohort because of the low number of patients meeting both criteria, the promising candidate variables identified merit for future multicenter studies.
Degree of Agreement between Electrodiagnostic Testing and Magnetic Resonance Imaging in the Evaluation of Brachial Plexopathy
Authors: Kang Seok , Yoon Joon Shik , Hong Suk-Joo , Yang Seung Nam
Published: January 2019

Objective

Electrodiagnostic study (EDX) and magnetic resonance imaging (MRI) are commonly used in the diagnosis of brachial plexopathy, but the agreement between these 2 studies is unknown. The aim of this study was to evaluate the agreement of EDX and MRI in patients with brachial plexopathy.

Design

The records of 69 patients with symptoms of brachial plexopathy who underwent EDX and MRI were reviewed. Based on the degree of agreement of EDX and MRI results, patients were classified as a “complete match,” “partial match,” or “mismatch.”

Results

Both studies yielded similar results for the majority of patients (63.2%). Among the enrolled patients, 26.4% were classified as a “complete match,” 36.8% as “partial match,” and 36.8% as “mismatch.” However, only 1 test, either EDX or MRI, revealed abnormal findings in 21.1% of patients.

Conclusions

The agreement between EDX and MRI was high in patients with brachial plexopathy. However, only one of these tests, not both, revealed abnormal findings in several cases. Although both EDX and MRI were in accord with the diagnosis of brachial plexopathy in majority of cases, these 2 studies remain complementary diagnostic modalities for evaluating brachial plexopathies.
Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP)
Authors: Baptista Abrahão Fontes , Fernandes Ana Mércia B.L. , Sá Katia Nunes , Okano Alexandre Hideki , Brunoni André Russowsky , Lara-Solares Argelia , Jreige Iskandar Aziza , Guerrero Carlos , Amescua-García César , Kraychete Durval Campos , Caparelli-Daquer Egas , Atencio Elias , Piedimonte Fabián , Colimon Frantz , Hazime Fuad Ahmed , Garcia João Batista S. , Hernández-Castro John Jairo , Cantisani José Alberto Flores , Karina do Monte-Silva Kátia , Lemos Correia Luis Claudio , Gallegos Manuel Sempértegui , Marcolin Marco Antonio , Ricco María Antonieta , Cook María Berenguel , Bonilla Patricia , Schestatsky Pedro , Galhardoni Ricardo , Silva Valquíria , Delgado Barrera William , Caumo Wolnei , Bouhassira Didier , Chipchase Lucy S. , Lefaucheur Jean-Pascal , Teixeira Manoel Jacobsen , de Andrade Daniel Ciampi
Published: January 2019

Introduction:

Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP.

Objective:

To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice.

Methods:

Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study.

Results:

The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain.

Conclusion:

Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.
Development and Validation of a Safety Scale Perceived by the Witness of Prehospital Emergency Care
Authors: Péculo-Carrasco Juan-Antonio , Rodríguez-Bouza Mónica , Casal-Sánchez María-del-Mar , de-la-Fuente-Rodríguez José-Manuel , Puerta-Córdoba Antonio , Rodríguez-Ruiz Hugo-José , Sánchez-Almagro César-Pedro , Failde Inmaculada
Published: January 2019

Objective

The aim of the study was to design and validate a new tool to measure the security perceived by witnesses of patient care and hospital transfers, after requesting urgent assistance via the “061” phone number.

Methods

This is a descriptive observational, cross-sectional, design, and validation study of a scale conducted by telephone interview. Witnesses of urgent assistance and transfers by prehospital emergency medical services in the province of Cadiz, in the south of Spain, were the subjects of study. A questionnaire was designed after focus groups with patients, witnesses, and professionals. It consisted of 10 items, with Likert-type answers, and a range of 0 to 50 points. In addition to basic criteria (frequency of endorsement and ability to discriminate between groups), their validity (content and construct) and reliability (stability and homogeneity) were evaluated. Stability was evaluated by test-retest and homogeneity by means of two properties: internal consistency of items (corrected item-scale correlation coefficient) and internal consistency of the scale (Cronbach α coefficient).

Results

A total of 849 questionnaires were obtained, with scores between 0 and 50 points, with an average of 47.31 (median of 50). The exploratory factor analysis detected a component that explained 61.1% of the total variance. The intraclass correlation coefficient was 0.933 with 95% confidence interval between 0.900 and 0.954. The corrected item-scale correlation coefficient was greater than 0.596, and the Cronbach α coefficient was 0.927 (95% confidence interval, 0.919–0.934).

Conclusions

The ESPT10 Witness Perceived Safety Scale is valid and reliable for quantifying the safety perception of witnesses of emergency assistance and transfers.
Prosthetic joint infections: clinical management, diagnosis, and treatment
Authors: Bassetti Matteo , Castaldo Nadia , Cadeo Barbara , Carnelutti Alessia
Published: January 2019

Purpose of review

Prosthetic joint infections (PJIs) represent one of the most disastrous complications in prosthetic surgery, requiring long hospitalization, prolonged antimicrobial treatment and repeated surgical interventions. No gold standard test to formulate diagnosis exist. A combination of high index of suspicion, physical examination, microbiological and biohumoral investigations is required. Therapeutical approach should be based on a multidisciplinary team. In our center, a two-stage approach is preferred. As regards the choice of the empirical antibiotic backbone, individual risk factors for multiple-drug resistant (MDR) pathogens should be considered. Several studies enhance the possibility to shorten the length of antibiotic couses.

Recent findings

Some interesting improvements have been made in the setting of PJIs management. As regards diagnosis, novel biomarkers and nuclear imaging are acquiring more importance. Molecular biology techniques also offer the possibility to formulate rapid microbiological identification. The pattern of PJIs is evolving towards higher rates of MDR causes. During the last decade, a number of new antibiotic molecules with activity against MDRs have been approved. Some of them are also available either in oral formulation or as long-acting compounds, offering the opportunity for early patient's discharge, with expected healthcare costs saving.

Management of PJIs still represents a major threat for clinicians. Improvements in surgical techniques and antibiotic pipeline promise to revolutionize the approach in next years. Despite data from our experience confirm the efficacy of shorter antibiotic courses and the value of new molecules, randomized clinical trials are lacking. More data are needed in order to modify the routine clinical practice.
The evolving burden of viruses in pneumonia
Authors: Brenner Nicole R. , Shorr Andrew F.
Published: January 2019

Purpose of review

To describe the evolving microbiology of various forms of pneumonia and the importance of viruses as etiologic causes of pneumonia.

Recent findings

Multiple studies utilizing novel diagnostic modalities demonstrate that the prevalence of viruses as causes for pneumonia varies from approximately 10–30% depending on the specific pneumonia type evaluated. Viral pneumonias appear similar in presentation and severity of illness to bacterial causes of pulmonary infection. Clinical criteria do not reliably allow the differentiation of viral from bacterial causes in pneumonia.

Viruses represent a pool of important culprit organisms in pneumonia and identification of a viral pathogen may facilitate attempts at antibiotic stewardship.
Longitudinal Visualization of Viable Cancer Cell Intratumoral Distribution in Mouse Models Using Oatp1a1-Enhanced Magnetic Resonance Imaging
Authors: Nyström Nivin N. , Hamilton Amanda M. , Xia Wenyao , Liu Shirley , Scholl Timothy J. , Ronald John A.
Published: January 2019

Objectives

Multimodality reporter gene imaging provides valuable, noninvasive information on the fate of engineered cell populations. To complement magnetic resonance imaging (MRI) measures of tumor volume and 2-dimensional reporter-based optical measures of cell viability, reporter-based MRI may offer 3-dimensional information on the distribution of viable cancer cells in deep tissues.

Materials and Methods

Here, we engineered human and murine triple-negative breast cancer cells with lentivirus encoding tdTomato and firefly luciferase for fluorescence imaging and bioluminescence imaging (BLI). A subset of these cells was additionally engineered with lentivirus encoding organic anion transporting polypeptide 1a1 (Oatp1a1) for MRI. Oatp1a1 operates by transporting gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) into cells, and it concomitantly improves BLI substrate uptake. After orthotopic implantation of engineered cells expressing or not expressing Oatp1a1, longitudinal fluorescence imaging, BLI, and 3-Tesla MRI were performed.

Results

Oatp1a1-expressing tumors displayed significantly increased BLI signals relative to control tumors at all time points (P < 0.05). On MRI, post–Gd-EOB-DTPA T
1-weighted images of Oatp1a1-expressing tumors exhibited significantly increased contrast-to-noise ratios compared with control tumors and precontrast images (P < 0.05). At endpoint, tumors expressing Oatp1a1 displayed intratumoral MR signal heterogeneity not present at earlier time points. Pixel-based analysis of matched in vivo MR and ex vivo fluorescence microscopy images revealed a strong, positive correlation between MR intensity and tdTomato intensity for Oatp1a1-expressing tumors (P < 0.05), but not control tumors.

Conclusions

These results characterize Oatp1a1 as a sensitive, quantitative, positive contrast MRI reporter gene for 3-dimensional assessment of viable cancer cell intratumoral distribution and concomitant BLI enhancement. This multimodality reporter gene system can provide new insights into the influence of viable cancer cell intratumoral distribution on tumor progression and metastasis, as well as improved assessments of anticancer therapies.
FDG PET/CT Findings of a Synovial Sarcoma in a Renal Transplant
Authors: Yang Xu , Wang Wei , Kan Ying , Liu Jie , Yang Jigang
Published: January 2019

A 48-year old man who underwent renal transplantation 2 years ago due to chronic renal failure underwent FDG PET/CT to determine the etiology of multiple lesions in the renal transplant incidentally found on routine examination. The images demonstrated several foci of the abnormally increased activity in the transplanted kidney with SUVmax of 7.5. Surgical pathology demonstrated multiple synovial sarcoma in the transplanted kidney.