bluuebunny/crossref_metadata_2025 huggingface dataset:
Ischemic Stroke Incidence in Patients With Microvascular Ocular Motor Palsy Versus Patients With Lacunar Ischemic Stroke
Authors: Beato-Coelho José , Varela Ricardo , Almendra Luciano , Carvalho Mário , Duque Cristina , Patrício Miguel , Sargento-Freitas João , Freire António , Lemos João
Published: February 2019

Objective:

Presumed microvascular ischemia is the most frequent cause of ocular motor palsy (OMP). Ischemic stroke incidence after an episode of microvascular OMP (mOMP) is not established, contrasting with other common vascular conditions, such as lacunar ischemic stroke (LS). We sought to compare the incidence of subsequent ischemic stroke between mOMP and LS populations.

Methods:

A retrospective observational analysis was conducted on acute patients presenting with either mOMP or LS. A propensity score match was applied to ensure a balance between groups. We compared the incidence of subsequent ischemic stroke during an 80-month follow-up.

Results:

A total of 110 patients were included in the study (57, mOMPs; 53, LS). During follow-up, the annual occurrence rate of ischemic stroke was 2.1% per year in mOMP group and 0.6% per year in the LS group. After performing Cox regression, we found no statistical significance difference between groups in the incidence of subsequent ischemic stroke (P=0.801).

Conclusions:

Patients with presumed mOCP seem to share similar incidence of subsequent ischemic stroke with patients with LS. Presumed mOCP may be an underrecognized independent risk factor for ischemic stroke.
Next-generation Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors for Leptomeningeal Carcinomatosis
Authors: Grimsrud Kate W. , Mrugala Maciej M.
Published: February 2019

Introduction:

Epidermal growth factor receptor (EGFR) mutation status is strongly correlated with leptomeningeal carcinomatosis in non–small cell lung cancer. Historically, patients were treated with radiotherapy, intrathecal chemotherapy or first-generation EGFR tyrosine kinase inhibitors (TKIs); however, most would eventually develop resistance and disease progression. Therefore, recent interest has sparked in investigating next-generation EGFR-TKI monotherapy.

Case reports:

We describe 2 patients with non–small cell lung adenocarcinoma who later presented with leptomeningeal disease, treated with next-generation EGFR-TKI monotherapy, independent of whole-brain radiotherapy, with favorable response and outcome.

Conclusions:

The next-generation EGFR-TKIs may have improved success in treatment of leptomeningeal metastases in non–small cell lung adenocarcinoma when compared with the first-generation and second-generation EGFR-TKIs. Next-generation EGFR-TKI monotherapy should be considered in select patients with leptomeningeal metastases from lung adenocarcinoma. More research is needed to review this potential therapeutic option, especially for use as first-line therapy.
Intraocular Pressure as an Indicator of the Level of Induced Anxiety in Basketball
Authors: Vera Jesús , Jiménez Raimundo , Redondo Beatríz , Madinabeitia Iker , Madinabeitia Iñigo , Alarcón López Francisco , Cárdenas David
Published: February 2019

SIGNIFICANCE

Our data demonstrate that intraocular pressure (IOP) is sensitive to anxiety manipulation in sport scenarios, specifically in a basketball free throw task. The present outcomes may be of special relevance because of its practical advantages for the objective control of athletes' anxiety levels.

PURPOSE

Athletes experience high levels of anxiety during sport competition, and IOP has demonstrated to reflect autonomous nervous system changes during mentally demanding situations. We tested whether different levels of induced anxiety during basketball free throw shooting alter IOP.

METHODS

We followed a repeated-measures design to test the effects of anxiety-induced manipulation during basketball free throw shooting on IOP, shooting performance, and perceived anxiety. Eighteen amateur basketball players performed three experimental sessions consisting of 100 free throws each. However, we gave three different instructions to participants regarding the score assigned to each free throw, allowing us to manipulate the level of induced anxiety (low, medium, and high).

RESULTS

Confirming a successful anxiety manipulation, basketball players reported more perceived anxiety with higher levels of induced anxiety (P < .001, η2 = 0.37). Our data show that higher levels of induced anxiety provoke an acute IOP rise (P < .001, η2 = 0.44), with the low-, medium-, and high-anxiety–induced conditions promoting an average IOP rise of 0.21, 1.63, and 18.46%, respectively. Also, there was a linear IOP rise over time in the high-anxiety–induced condition (r = 0.82). Nevertheless, we found no effect of anxiety-induced manipulation on basketball free throw performance (P = .93).

CONCLUSIONS

Intraocular pressure is sensitive to anxiety-induced manipulation during basketball free throw shooting, showing an increase in parallel with accumulated anxiety. Based on these findings, IOP may be considered a promising tool for the assessment of the level of anxiety in certain sport situations. Future studies are required to explore the generalizability of these results in other scenarios with different physical and mental demands.
Ocular Point-of-Care Ultrasound in the Pediatric Emergency Department
Authors: Seguin Jade , Le Cathie-Kim , Fischer Jason W. , Tessaro Mark Oliver , Berant Ron
Published: February 2019

Objective

Point-of-care ultrasound has become an important adjunct for diagnostic assessment in pediatric emergency medicine. In this case series, we demonstrate how ocular point-of-care ultrasound is used to correctly diagnose ocular pathologies and to expedite care.

Methods/Results

We present a series of cases in which the point-of-care ultrasound ocular examination proved valuable in the timely diagnosis of pathologies involving the lens, vitreous, retina, and retrobulbar segment of the eye.

Conclusion

Point-of-care ultrasound may facilitate diagnosis in children with ocular complaints, even in young and uncooperative patients, and should be considered in children of all ages.
Clinical Characteristics Associated with the Prognosis of One-Stage Grafting for Flexor Digitorum Profundus Reconstruction in Zones I and II
Authors: Zhu Hongyi , Gao Yanchun , Chai Yimin , Han Pei
Published: February 2019

Background:

The authors aimed to identify clinical characteristics related to the prognosis after one-stage grafting for flexor digitorum profundus reconstruction in zones I and II.

Methods:

A total of 401 patients who underwent one-stage flexor digitorum profundus reconstruction after injuries in zones I and II, between January 1, 2006, and June 1, 2016, were included for analysis. The authors recorded the following clinical characteristics: duration from injury to reconstruction, graft type and length, handling (preservation or removal) of flexor digitorum superficialis, tenorrhaphy technique, and duration of postoperative immobilization.

Results:

There was no significant difference in age, sex, duration between injury and reconstruction, graft type, and handling of flexor digitorum superficialis between subjects who underwent successful reconstruction and those who did not. Univariate and multivariate analyses revealed that end-to-end tenorrhaphy, immediate controlled motion, and immobilization for less than 2 weeks all independently were related to improved final outcomes. Grafting within zones I and II contributed to increased incidence of failure. In a subgroup having an injury-reconstruction duration of less than 2 weeks, the authors observed that grafting from zone III to zones I and II tended to result in better outcomes compared with grafting from zone III to the flexor digitorum profundus insertion. This, however, was not statistically significant (p = 0.11).

Conclusions:

The authors recommend end-to-end tenorrhaphy, reducing immobilization to less than 2 weeks, and avoiding grafting within zones I and II. In addition, further studies are still needed to clarify the optimal length of grafting.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Therapeutic Role of Fat Injection in the Treatment of Recalcitrant Migraine Headaches
Authors: Guyuron Bahman , Pourtaheri Navid
Published: February 2019

Background:

This study was designed to assess the safety and efficacy of site-specific fat injection for the treatment of refractory migraine headaches following medical or surgical treatment.

Methods:

A prospective cohort study was performed on consecutive patients who had migraine headaches with persistent symptoms after surgical decompression and were given therapeutic fat injections from September of 2012 to January of 2015 with 12 months’ minimum follow-up. Clinical outcomes assessment included migraine frequency, intensity, duration, migraine headache index, and complications. A 50 percent or greater decrease in frequency, intensity, or duration was considered therapeutic success, whereas 10 percent or greater increase in migraine headache index was considered worsening of symptoms. Pairwise t tests were used to assess statistical significance (p < 0.05).

Results:

Twenty-nine patients met inclusion criteria. All were female, with a mean age of 49.0 years (range, 21.5 to 72.5 years), and mean follow-up was 29.4 months (range, 12.3 to 49.5 months). Twenty patients (69.0 percent) experienced successful improvement; 12 (41.4 percent) experienced complete resolution. Five patients (17.2 percent) experienced subtherapeutic improvement, and four (13.8 percent) experienced worsening of symptoms. Mean improvement per patient at their last follow-up was 5.1 (39.3 percent) fewer attacks per month (p = 0.035); 3.1 (42.0 percent) lower intensity on a scale of 1 to 10 (p = 0.001); 31.8 (74.4 percent) fewer hours of duration (p = 0.219); and 52.8 percent lower migraine headache index (p = 0.012). There were no complications for any patient.

Conclusions:

Migraine headache symptoms were successfully reduced in the majority of cases with fat injection. A comprehensive surgical treatment algorithm including this novel procedure is presented.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Diversity in Plastic Surgery: Trends in Minority Representation among Applicants and Residents
Authors: Parmeshwar Nisha , Stuart Emelia R. , Reid Chris M. , Oviedo Parisa , Gosman Amanda A.
Published: February 2019

Background:

Prior studies have shown a lack of diversity among plastic surgery trainees. The authors evaluate trends in minority representation among applicants to plastic surgery and the correlation with practicing residents, compared to other specialties.

Methods:

The Association of American Medical Colleges Electronic Residency Application Service provided applicant data for integrated, independent plastic surgery, and other select specialties from 2010 to 2016. Journal of the American Medical Association Graduate Medical Education annual reports and Association of American Medical Colleges graduate student questionnaires provided resident and medical student data. Binomial distribution analysis was used to assess differences in Black, Hispanic, and female proportions of applicants and residents. Best-fit trend lines were compared among groups and specialties.

Results:

Women have seen an increase in integrated and independent resident representation (+2.23 percent and +0.7 percent per year, respectively) over the past 7 years, despite a relative decrease in applicants. The proportion of female applicants and residents correlated yearly for all specialties (p > 0.05). Conversely, for all years and all specialties, the Black proportion of applicants was significantly higher than the resident representation of the same year (p < 0.05). Hispanic applicant and resident representation have seen a minimal change.

Conclusions:

Female representation among trainees has increased greatly, but there has been a decline in Black representation of integrated plastic surgery residents despite increases in medical school graduates and applicants. The data highlight a discrepancy between the population of applicants and residents suggesting that barriers starting from medical school may contribute to the lack of diversity in plastic surgery.
Stacked Profunda Artery Perforator Flap for Breast Reconstruction in Failed or Unavailable Deep Inferior Epigastric Perforator Flap
Authors: Haddock Nicholas T. , Cho Min-Jeong , Gassman Andrew , Teotia Sumeet S.
Published: February 2019

Background:

Recently, the profunda artery perforator flap has become one of the popular flap choices for patients who desire autologous breast reconstruction but are not optimal candidates for deep inferior epigastric perforator (DIEP) flap surgery. These patients are not ideal patients for DIEP flap surgery because of having poor perforators, previous abdominal operations, low body mass index, or previously used/failed DIEP flap. In their institution, the authors have performed stacked profunda artery perforator flaps for these patients to provide full volumetric and aesthetic reconstruction.

Methods:

A retrospective review of 20 patients (40 flaps) who underwent stacked profunda artery perforator flap surgery from 2014 to 2018 was performed. Patient characteristics, demographics, and flap data were collected.

Results:

Forty flaps were used to reconstruct 20 breasts in 20 patients. The mean age of patients was 51.5 years (range, 38 to 74 years), the average body mass index was 27.3 kg/m2 (range, 21.0 to 34.4 kg/m2), and the mean flap weight was 398.5 g (range, 170 to 600 g). The majority of anastomoses were performed in internal mammary vessels (60 percent), followed by thoracodorsal (10 percent), serratus (10 percent), and side branch of profunda artery perforator vessels (20 percent). There were no flap losses, and two patients experienced donor-site wound dehiscence.

Conclusions:

Stacking profunda artery perforator flaps is an innovative yet technically challenging choice of flap for autologous breast reconstruction. It can provide an aesthetically pleasing result in the appropriately selected patient, and we recommend this technique in patients who are not optimal candidates for DIEP flap surgery because of previous flap failure or unavailable donor site.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Achieving Aesthetic Results in the Umbilical Float Mini-Abdominoplasty: Patient Selection and Surgical Technique
Authors: Wan Dinah , Hubbard Bradley A. , Byrd H. Steve
Published: February 2019

Background:

The umbilical float mini-abdominoplasty has been criticized for low final umbilicus position and umbilical distortion. The authors believe that in the properly selected patient and with proper technique, the umbilical float can achieve superior aesthetic results in a subset of patients.

Methods:

A retrospective review was performed of all umbilical floats performed by two surgeons (B.A.H. and H.S.B.) at the authors’ institution. Postoperative photographs were reviewed by 20 blinded evaluators.

Results:

Thirty-one female patients underwent umbilical float mini-abdominoplasty between 2010 and 2017. All patients had starting umbilicus position at or above the level of the iliac crest. The umbilicus was floated for a distance of 1 to 3.5 cm. Average umbilicus position was slightly above the midpoint between the xiphoid and pubis preoperatively, and slightly below the midpoint postoperatively. Final umbilicus was considered “too low” in five patients (18.5 percent), all of which were positioned at the level of the anterior superior iliac spine.

Conclusions:

Optimal candidates for the umbilical float mini-abdominoplasty are postpartum women with normal body mass index, mild to moderate infraumbilical skin excess, and minimal to mild supraumbilical excess. Starting umbilicus position should be at or above the level of iliac crests, or slightly above the mid torso. Final umbilicus position should remain above the anterior superior iliac spine. The umbilical base is reattached with multiple sutures to prevent distortion. At least 10 cm of hairless lower abdominal skin should be maintained between the final scar and navel to prevent a low-appearing umbilicus.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Reappraisal of Perforasomes of the Superficial Femoral, Descending Genicular, and Saphenous Arteries and Clinical Applications to Locoregional Reconstruction
Authors: Mohan Anita T. , Zhu Lin , Morsy Mohamed , Sur Yoo Joon , Michalak Gregory J. , Lachman Nirusha , Mardini Samir , Saint-Cyr Michel
Published: February 2019

Background:

The superficial femoral artery and medial thigh region has been an underused donor site for perforator flaps. This study evaluated perforasomes of the superficial femoral artery and its principal branches to review the clinical applications for locoregional reconstruction.

Methods:

Twenty-six fresh cadaveric lower extremities were dissected. Perforator size and anatomical course from the superficial femoral artery, descending genicular artery, and saphenous artery branch were documented. Perforators were selectively injected with iodinated contrast to assess vascular territories using computed tomography. A retrospective chart review was conducted on consecutive patients (2014 to 2015).

Results:

One hundred thirty perforators were mapped in the medial thigh region. Eleven extended medial thigh perforator flaps and 15 hemicircumferential flaps were harvested. The mean distance from the joint line was 16.7 ± 7.3 cm. Perforators arose from the superficial femoral artery (62 percent), saphenous artery branch (23 percent), and descending genicular artery (15 percent). Superficial femoral artery perforators were located around the mid and proximal thigh region (p < 0.001). The median perforasome surface area was 244 cm2, representing 36 percent in hemithigh flaps with preferential filling in the anteromedial region. Proximal perforasomes were the smallest. Perforasome areas based on vessel origin were comparable; however, saphenous artery perforators had a broader perforasome compared with descending genicular (p = 0.01) and superficial femoral artery perforators (p = 0.04). Six clinical case examples were presented for knee, thigh, and lower leg reconstruction.

Conclusions:

The superficial femoral artery or its branches can provide nontraditional reconstructive perforator flap options in regional reconstruction. They can be simple to harvest using a free-style approach, do not require preoperative imaging, offer a one-stage reconstructive method with low morbidity, and obviate the need for microsurgery or muscle flaps.
Current Risk Estimate of Breast Implant–Associated Anaplastic Large Cell Lymphoma in Textured Breast Implants
Authors: Collett David J. , Rakhorst Hinne , Lennox Peter , Magnusson Mark , Cooter Rodney , Deva Anand K.
Published: February 2019

Background:

With breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL.

Methods:

All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed.

Results:

Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial reports of 1 per million to current estimates of 1/2,832, and is largely dependant on the “population” (implant type and characteristics) examined and increased awareness of the disease.

Conclusions:

Although many barriers stand in the way of calculating accurate estimates of the incidence and risk of developing BIA-ALCL, steady progress, international registries, and collegiality between research teams are for the first time allowing early estimates. Most striking is the exponential rise in incidence over the last decade, which can largely be explained by the increasingly specific implant subtypes examined—driven by our understanding of the pathologic mechanism of the disease. High-textured high-surface area implants (grade 4 surface) carry the highest risk of BIA-ALCL (1/2,832).
Breast Reconstruction Following Breast Implant–Associated Anaplastic Large Cell Lymphoma
Authors: Lamaris Gregory A. , Butler Charles E. , Deva Anand K. , Miranda Roberto N. , Hunt Kelly K. , Connell Tony , Lipa Joan E. , Clemens Mark W.
Published: February 2019

Background:

Standard of care treatment of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) involves surgical resection with implant removal and complete capsulectomy. We report a case series of BIA-ALCL reconstruction with proposals for timing and technique selection.

Methods:

We retrospectively reviewed and prospectively enrolled all BIA-ALCL patients at 2 tertiary care centers and 1 private plastic surgery practice from 1998 to 2017. Demographics, treatment, reconstruction, pathology staging, patient satisfaction, and oncologic outcomes were reviewed.

Results:

We treated 66 consecutive BIA-ALCL patients and 18 (27%) received reconstruction. Seven patients (39%) received immediate reconstruction, and 11 (61%) received delayed reconstruction. Disease stage at presentation was IA (T1N0M0 disease confined to effusion or a layer on luminal side of capsule with no lymph node involvement and no distant spread) in 56%, IB in 17%, IC (T3N0M0 cell aggregates or sheets infiltrating the capsule, no lymph node involvement and no distant spread) in 6%, IIA (T4N0M0 lymphoma infiltrating beyond the capsule, no lymph node involvement and no distant spread) in 11%, and III in 11%. Types of reconstruction included smooth implants (72%), immediate mastopexy (11%), autologous flaps (11%), and fat grafting (6%). Outcomes included no surgical complications, but 1 patient progressed to widespread bone metastasis (6%); ultimately, all patients achieved complete remission. Ninety-four percent were satisfied/highly satisfied with reconstructions, whereas 6% were highly unsatisfied with immediate smooth implants.

Conclusions:

Breast reconstruction following BIA-ALCL management can be performed with acceptable complications if complete surgical ablation is possible. Immediate reconstruction is reserved for disease confined to capsule on preoperative positive emission tomography/computed tomography scan. Genetic predisposition and bilateral cases suggest that BIA-ALCL patients should not receive textured implants. Autologous options are preferable for implant adverse BIA-ALCL patients. Patients with extensive disease at presentation should be considered for 6- to 12-month delayed reconstruction with interval positive emission tomography/computed tomography evaluation.
Kinematic Analysis of the Distal Radioulnar Joint in Asymptomatic Wrists Using 4-Dimensional Computed Tomography–Motion Pattern and Interreader Reliability
Authors: Shakoor Delaram , Hafezi-Nejad Nima , Haj-Mirzaian Arya , Shores Jaimie T. , Lifchez Scott D. , Morelli John N. , Thakur Uma , Demehri Shadpour
Published: February 2019

Purpose

The aim of this study was to determine the normal measurement values and interobserver performance of the distal radioulnar joint during wrist pronation-supination using 4-dimensional computed tomography (CT).

Methods

Four-dimensional CT examinations were performed on the asymptomatic contralateral wrists of 10 patients with unilateral chronic wrist pain. Measurements were conducted using the modified radioulnar (mRU) line and epicenter (Epi) methods. Volar subluxation of the ulnar head was demonstrated with negative values. Wilcoxon rank sum test was used to determine the measurement changes. Interobserver agreements were assessed using interclass correlation coefficients.

Results

In pronation, mRU line measurements (median, 0.09; interquartile range, 0–0.15) were significantly larger than in supination (median, −0.1; interquartile range, −0.18 to 0; P = 0.008).The Epi measurements were not significantly different in pronation (median, 0.03; interquartile range, 0.01–0.07) and supination (median, 0.06; interquartile range, 0.01–0.1; P = 0.799). There was an excellent inter-observer agreement between the two readers using mRU and Epi methods in pronation (0.982, 0.898), midpoint (0.994, 0.827) and supination (0.989, 0.972) positions, respectively.

Conclusions

Using 4-dimensional CT examination, distal radioulnar joint kinematics in asymptomatic wrists demonstrate excellent interobserver agreements with increased volar ulnar subluxation with supination as detected using mRU, but not the Epi method.
Spectral Computed Tomography Imaging in the Differential Diagnosis of Lung Cancer and Inflammatory Myofibroblastic Tumor
Authors: Yu Yixing , Wang Ximing , Shi Cen , Hu Su , Zhu Hui , Hu Chunhong
Published: February 2019

Objective

The aim of this study was to explore the value of spectral computed tomography (CT) imaging in differentiating lung cancer from inflammatory myofibroblastic tumor (IMT).

Methods

One hundred twelve patients with 96 lung cancers and 16 IMTs underwent spectral CT during arterial phase (AP) and venous phase (VP). The normalized iodine concentration in AP (NICAP) and VP (NICVP), slope of spectral Hounsfield unit curve in AP (λAP) and VP (λVP), and normalized iodine concentration difference between AP and VP (ICD) were calculated. The 2-sample t test compared quantitative parameters. Two readers qualitatively assessed lesion types according to imaging features. Receiver operating characteristic curves were generated to calculate sensitivity and specificity. Sensitivity and specificity of the qualitative and quantitative studies were compared.

Results

The patients with IMT had significantly higher NICAP, NICVP, λAP, λVP, and ICD than did the patients with lung cancer (P < 0.05). The threshold NICVP of 0.425 would yield the highest sensitivity and specificity of 92.7% and 81.3%, respectively, for differentiating lung cancer from IMT. The logistic regression model produced from combining quantitative parameters NICAP, NICVP, λAP, and λVP provided a sensitivity and specificity of 100% and 81.3%, respectively, for differentiating lung cancer from IMT.

Conclusions

Spectral CT imaging with the quantitative analysis may help to increase the accuracy of differentiating lung cancer from IMT.
Noncontrast Chest Computed Tomographic Imaging of Obesity and the Metabolic Syndrome
Authors: Schlett Christopher L. , Nattenmüller Johanna , Tsuchiya Nanae , Vogel-Claussen Jens , Kauczor Hans-Ulrich , Levin David , Hatabu Hiroto , Estépar Jose R. , Wu Ming-Ting , van Beek Edwin J.R. , Schiebler Mark L.
Published: February 2019

There are physiological consequences of overeating that can lead to increased morbidity and mortality. The purpose of this review article is to acquaint the reader with the current state of the art in the non–cardiac-gated, noncontrast chest computed tomographic (NCCT) imaging biomarkers of the metabolic syndrome and their prognostic significance found in the lower neck and chest. NCCT imaging biomarkers associated with metabolic syndrome in the chest include premature coronary artery calcification, acceleration of large vessel arterial and valvular calcifications associated with atherosclerosis, and pulmonary arterial enlargement from pulmonary hypertension associated with sleep apnea. These easily identified imaging biomarkers have prognostic implications for major adverse cardiac events (MACE). These NCCT chest-imaging biomarkers are likely targets for artificial intelligence algorithms to harvest for longitudinal assessment of their individual and multifactorial contributions to chronic disease, MACE, and mortality. Early recognition and treatment of these common disorders may help improve patient outcomes and quality of life while decreasing medical costs.
A Simple Low-Cost Method to Integrate Telehealth Interprofessional Team Members During In Situ Simulation
Authors: Bond William F. , Barker Lisa T. , Cooley Kimberly L. , Svendsen Jessica D. , Tillis William P. , Vincent Andrew L. , Vozenilek John A. , Powell Emilie S.
Published: February 2019

Introduction

With the growth of telehealth, simulation personnel will be called upon to support training that integrates these new technologies and processes. We sought to integrate remote telehealth electronic intensive care unit (eICU) personnel into in situ simulations with rural emergency department (ED) care teams. We describe how we overcame technical challenges of creating shared awareness of the patient's condition and the care team's progress among those executing the simulation, the care team, and the eICU.

Methods

The objective of the simulations was to introduce telehealth technology and new processes of engaging the eICU via telehealth during sepsis care in 2 rural EDs. Scenario development included experts in sepsis, telehealth, and emergency medicine. We describe the operational systems challenges, alternatives considered, and solutions used. Participants completed surveys on self-confidence presimulation/postsimulation in using telehealth and in managing patients with sepsis (1–10 Likert scale, with 10 “completely confident”). Pre-post responses were compared by two-tailed paired t test.

Results

We successfully engaged the staff of two EDs: 42 nurses, 9 physicians or advanced practice providers, and 9 technicians (N = 60). We used a shared in situ simulation clinical actions observational checklist, created within an off-the-shelf survey software program, completed during the simulations by an on-site observer, and shared with the eICU team via teleconferencing software, to message and cue eICU nurse engagement. The eICU nurse also participated in debriefing via the telehealth video system with successful simulation engagement. These solutions avoided interfering with real ED or eICU operations. The postsimulation mean ± SD ratings of confidence using telehealth increased from 5.3 ± 2.9 to 8.9 ± 1.1 (Δ3.5, P < 0.05) and in managing patients with sepsis increased from 7.1 ± 2.5 to 8.9 ± 1.1 (Δ1.8, P < 0.05).

Conclusions

We created shared awareness between remote eICU personnel and in situ simulations in rural EDs via a low-cost method using survey software combined with teleconferencing methods.
Factors Associated With Functional Recovery Among Older Survivors of Major Surgery
Authors: Becher Robert D. , Murphy Terrence E. , Gahbauer Evelyne A. , Leo-Summers Linda , Stabenau Hans F. , Gill Thomas M.
Published: February 2019

Objective:

The objectives of the current study were 2-fold: first, to evaluate the incidence and time to recovery of premorbid function within 6 months of major surgery and second, to identify factors associated with functional recovery among older persons who survive a major surgery with increased disability.

Background:

Most older persons would not choose a surgical treatment resulting in persistently increased postsurgical disability, even if survival was assured. Potential predictors of functional recovery after major surgery have, however, not been well-studied among geriatric patients.

Methods:

It is a prospective longitudinal study of 754 community-living persons 70 years or older. The analytic sample included 266 person-admissions in which participants survived major surgery with increased disability and were monitored on a monthly basis for 6 months.

Results:

Of the 266 person-admissions assessed, 174 (65.4%) recovered to their presurgical level of function, with median time to recovery of 2 months (interquartile range, 1–3), whereas 16 (6.0%) died. Two factors were significantly associated with an increased likelihood of functional recovery: being nonfrail (hazard ratio 1.60; 95% confidence interval 1.03–2.51; P = 0.038) and having elective surgery (hazard ratio 1.72; 95% confidence interval 1.14–2.59; P = 0.009). Three factors were associated with a reduced likelihood of functional recovery: hearing impairment, greater increase in postsurgical disability in the month after hospital discharge, and years of education.

Conclusions:

Among older persons, nonfrailty and elective surgery were positively associated with functional recovery, whereas hearing impairment, greater increases in postsurgical disability, and years of education were associated with higher risk of protracted disability.
A Simple Method of Intracorporeal “W-shaped” Liver Retraction Technique for Minimally Invasive Gastric Cancer Surgery
Authors: Wang Chih-Jung , Chao Ying-Jui , Sy Edgar D. , Shan Yan-Shen
Published: February 2019

Background:

Minimally invasive gastric cancer surgery requires an extended liver retraction in order to provide optimal operative view, working space for lymph node dissection, and esophageojejunal reconstruction. Ideally, it should avoid reposition of the retractor, additional skin incision or puncture, and liver parenchyma injury. Herein, we introduced an intracorporeal W-shaped liver retraction technique (W-LRT) for minimally invasive gastric cancer surgery without an additional incision or abodminal puncture.

Methods:

Between October 2013 and October 2016, the W-LRT was applied in 80 patients undergoing minimally invasive gastric cancer surgery. The W-LRT was performed using one 75 cm 3-0 monocryl suture with its end fixed to one hemoclip. The perioperative outcome was recorded.

Results:

The W-LRT was applied in 80 gastric cancer patients using either laparoscopic approach (N=69) or robotic approach (N=11). The mean age was 62.7±14 years and the mean body mass index (BMI) was 24.1±3.6 kg/m2. The time required for W-LRT was 5.6±5.2 minutes in laparoscopic approach and 6.2±4.7 minutes in robotic approach. This technique was successfully applied in all procedures and no other technique or additional instrument was required. Major complications developed in 7 patients (8.8%), classified as greater than Clavien-Dindo classification II; however, there was neither any intraoperative nor postoperative major complication related to W-LRT. The length of hospital stay was 9.1±4.4 days.

Conclusions:

In laparoscopic or robotic gastric cancer surgery, the W-LRT can provide excellent operative view during lymph node dissection and reconstruction of esophagojejunostomy and eliminate an additional skin incision or abdominal puncture.
The acute inflammatory response after trauma is heightened by frailty: A prospective evaluation of inflammatory and endocrine system alterations in frailty
Authors: Palmer James , Pandit Viraj , Zeeshan Muhammad , Kulvatunyou Narong , Hamidi Mohammad , Hanna Kamil , Fain Mindy , Nikolich-Zugich Janko , Zakaria El-Rasheid , Joseph Bellal
Published: February 2019

BACKGROUND

Frailty is a geriatric syndrome characterized by decreased physiological reserves, increased inflammation, and decreased anabolic-endocrine response. The biomarkers associated with frailty are poorly understood in trauma. The aim of this study was to analyze the association between frailty and immune: IL-1β, IL-6, IL-2Rα, tumor necrosis factor (TNF)-α, and endocrine biomarkers: insulin-like growth factor-1 and growth hormone in trauma patients.

METHODS

We conducted a 1-year (2017–2018) prospective analysis of geriatric (≥65 years) trauma patients admitted to our Level I trauma center. Frailty was measured using the trauma-specific frailty index (TSFI) and blood samples were collected within 24 hours of admission. Patients were stratified into two groups: frail (TSFI > 0.25) and nonfrail (TSFI ≤ 0.25). We then measured the levels of immune and endocrine biomarkers by a colorimetric output that was read by a spectrophotometer (Quantikine ELISA). The outcome measures were the levels of the immune and endocrine markers in the two groups. Multivariable linear regression was performed.

RESULTS

A total of 100 geriatric trauma patients were consented and enrolled. The mean age was 77.1 ± 9.8 years and 34% were female. Thirty-nine (39%) patients were frail. Frail patients were more likely to present after falls (p = 0.01). There was no difference in age (p = 0.78), sex (p = 0.77), systolic blood pressure (p = 0.16), and heart rate (p = 0.24) between the two groups. Frail patients had higher levels of TNF-α (p = 0.01), IL-1β (p = 0.01), and IL-6(p = 0.01) but lower levels of growth hormone (p = 0.03) and insulin-like growth factor-1 (p < 0.04) compared with nonfrail patients. There was no difference in the level of IL-2Rα (p = 0.25). On regression analysis, frailty was positively correlated with the levels of proinflammatory biomarkers, that is, TNF- α, IL-1 β, and IL-6 and negatively correlated with endocrine biomarkers.

CONCLUSION

This study supports the association between frailty and immune and endocrine markers. Frailty acts synergistically with trauma in increasing the acute inflammatory response. Moreover, frail patients have lower levels of anabolic hormones. Understanding the inflammatory and endocrine response in frail trauma patients may result in better therapeutic strategies.
Effect of Timing and Complement Receptor Antagonism on Intragraft Recruitment and Protolerogenic Effects of Mesenchymal Stromal Cells in Murine Kidney Transplantation
Authors: Casiraghi Federica , Todeschini Marta , Azzollini Nadia , Cravedi Paolo , Cassis Paola , Solini Samantha , Fiori Sonia , Rota Cinzia , Karachi Aida , Carrara Camillo , Noris Marina , Perico Norberto , Remuzzi Giuseppe
Published: February 2019

Background.

Mesenchymal stromal cells (MSCs) have protolerogenic effects in renal transplantation, but they induce long-term regulatory T cells (Treg)-dependent graft acceptance only when infused before transplantation. When given posttransplant, MSCs home to the graft where they promote engraftment syndrome and do not induce Treg. Unfortunately, pretransplant MSC administration is unfeasible in deceased-donor kidney transplantation.

Methods.

To make MSCs a therapeutic option also for deceased organ recipients, we tested whether MSC infusion at the time of transplant (day 0) or posttransplant (day 2) together with inhibition of complement receptors prevents engraftment syndrome and allows their homing to secondary lymphoid organs for promoting tolerance. We analyzed intragraft and splenic MSC localization, graft survival, and alloimmune response in mice recipients of kidney allografts and syngeneic MSCs given on day 0 or on posttransplant day 2. C3a receptor (C3aR) or C5a receptor (C5aR) antagonists were administered to mice in combination with the cells or were used together to treat MSCs before infusion.

Results.

Syngeneic MSCs given at day 0 homed to the spleen increased Treg numbers and induced long-term graft acceptance. Posttransplant MSC infusion, combined with a short course of C3aR or C5aR antagonist or administration of MSCs pretreated with C3aR and C5aR antagonists, prevented intragraft recruitment of MSCs and graft inflammation, inhibited antidonor T-cell reactivity, but failed to induce Treg, resulting in mild prolongation of graft survival.

Conclusions.

These data support testing the safety/efficacy profile of administering MSCs on the day of transplant in deceased-donor transplant recipients and indicate that complement is crucial for MSC recruitment into the kidney allograft.
Risk Indices in Deceased-donor Organ Allocation for Transplantation: Review From an Australian Perspective
Authors: Ling Jonathan E. H. , Fink Michael , Westall Glen , Macdonald Peter , Clayton Philip A. , Holdsworth Rhonda , Opdam Helen , Polkinghorne Kevan R. , Kanellis John
Published: February 2019

Over the last decade, organ donation and transplantation rates have increased in Australia and worldwide. Donor and recipient characteristics for most organ types have generally broadened, resulting in the need to consider more complex data in transplant decision-making. As a result of some of these pressures, the Australian software used for donor and recipient data management is currently being updated. Because of the in-built capacity for improved data management, organ allocation processes will have the opportunity to be significantly reviewed, in particular the possible use of risk indices (RIs) to guide organ allocation and transplantation decisions. We aimed to review RIs used in organ allocation policies worldwide and to compare their use to current Australian protocols. Significant donor, recipient, and transplant variables in the indices were summarized. We conclude that Australia has the opportunity to incorporate greater use of RIs in its allocation policies and in transplant decision-making processes. However, while RIs can assist with organ allocation and help guide prognosis, they often have significant limitations which need to be properly appreciated when deciding how to best use them to guide clinical decisions.
Successful Single-kidney Transplantation in Adult Recipients Using Pediatric Donors Aged 8 to 36 Months: Comparable Outcomes With Those Using Pediatric Donors Aged >3 Years
Authors: Zhu Lan , Fu Cheng , Chen Song , Liu Bin , Du Dunfeng , Chang Sheng , Gong Nianqiao , Jiang Jipin , Chen Zhishui , Chen Gang
Published: February 2019

Background.

Using pediatric donors for single-kidney transplantation (SKT) can increase the number of possible recipients. However, it is unclear when SKT involving small pediatric donors and adult recipients can safely be performed without compromising graft outcome.

Methods.

From 2013 to 2017, a total of 102 SKTs in adult recipients were performed in our center using pediatric donors aged <12 years. We compared the outcomes from donors aged 8 to 36 months (the small-kidney group [SKG], n = 46) and from donors aged 3 to 12 years (the big-kidney group [BKG], n = 56). The median follow-up time was 30 months in the SKG and 28 months in the BKG.

Results.

All patients achieved satisfactory renal function after transplantation, despite the fact that some patients (SKG, 19.6%; BKG, 28.6%) developed delayed graft function. One-year graft survival and death-censored graft survival in the SKG were 89.1% and 100%, respectively, comparable to the results in the BKG (92.9% and 98.2%). One year later, the graft and patient survival rates in both groups remained unchanged. Pulmonary infection was the main cause of death in patients with a functioning graft (SKG, 4 patients; BKG, 2 patients). Proteinuria occurred early in some patients (SKG, 30.4%; BKG, 19.6%) and decreased gradually within the first year posttransplantation.

Conclusions.

SKT from pediatric donors aged 8 to 36 months to selected adult recipients produced excellent intermediate-term outcomes, comparable with those when older pediatric donors were used. This study provides evidence to support a lower age limit for SKT from pediatric donors.
Enhancing the Value of Histopathological Assessment of Allograft Biopsy Monitoring
Authors: Wood-Trageser Michelle A. , Lesniak Andrew J. , Demetris Anthony J.
Published: February 2019

Traditional histopathological allograft biopsy evaluation provides, within hours, diagnoses, prognostic information, and mechanistic insights into disease processes. However, proponents of an array of alternative monitoring platforms, broadly classified as “invasive” or “noninvasive” depending on whether allograft tissue is needed, question the value proposition of tissue histopathology. The authors explore the pros and cons of current analytical methods relative to the value of traditional and illustrate advancements of next-generation histopathological evaluation of tissue biopsies. We describe the continuing value of traditional histopathological tissue assessment and “next-generation pathology (NGP),” broadly defined as staining/labeling techniques coupled with digital imaging and automated image analysis. Noninvasive imaging and fluid (blood and urine) analyses promote low-risk, global organ assessment, and “molecular” data output, respectively; invasive alternatives promote objective, “mechanistic” insights by creating gene lists with variably increased/decreased expression compared with steady state/baseline. Proponents of alternative approaches contrast their preferred methods with traditional histopathology and: (1) fail to cite the main value of traditional and NGP—retention of spatial and inferred temporal context available for innumerable objective analyses and (2) belie an unfamiliarity with the impact of advances in imaging and software-guided analytics on emerging histopathology practices. Illustrative NGP examples demonstrate the value of multidimensional data that preserve tissue-based spatial and temporal contexts. We outline a path forward for clinical NGP implementation where “software-assisted sign-out” will enable pathologists to conduct objective analyses that can be incorporated into their final reports and improve patient care.
Analytical Validation of a Single-nucleotide Polymorphism-based Donor-derived Cell-free DNA Assay for Detecting Rejection in Kidney Transplant Patients
Authors: Altuğ Yücel , Liang Nathan , Ram Rosalyn , Ravi Harini , Ahmed Ebad , Brevnov Maxim , Swenerton Ryan K. , Zimmermann Bernhard , Malhotra Meenakshi , Demko Zachary P. , Billings Paul R. , Ryan Allison
Published: February 2019

Background.

Early detection of rejection in kidney transplant recipients holds the promise to improve clinical outcomes. Development and implementation of more accurate, noninvasive methods to detect allograft rejection remain an ongoing challenge. The limitations of existing allograft surveillance methods present an opportunity for donor-derived cell-free DNA (dd-cfDNA), which can accurately and rapidly differentiate patients with allograft rejection from patients with stable organ function.

Methods.

This study evaluated the analytical performance of a massively multiplexed polymerase chain reaction assay that targets 13 962 single-nucleotide polymorphisms, characterized and validated using 66 unique samples with 1064 replicates, including cell line-derived reference samples, plasma-derived mixtures, and transplant patient samples. The dd-cfDNA fraction was quantified in both related and unrelated donor-recipient pairs.

Results.

The dd-cfDNA assay showed a limit of blank of 0.11%, a limit of detection and limit of quantitation of 0.15% for unrelated donors, and limit of blank of 0.23%, a limit of detection and limit of quantitation of 0.29% for related donors. All other metrics (linearity, accuracy, and precision) were observed to be equivalent between unrelated and related donors. The measurement precision of coefficient of variation was 1.8% (repeatability, 0.6% dd-cfDNA) and was <5% for all the different reproducibility measures.

Conclusions.

This study validates the performance of a single-nucleotide polymorphism-based massively multiplexed polymerase chain reaction assay to detect the dd-cfDNA fraction with improved precision over currently available tests, regardless of donor-recipient relationships.