bluuebunny/crossref_metadata_2025 huggingface dataset:
Benefit Finding and Quality of Life in Caregivers of Childhood Cancer Survivors
Authors: Gardner Molly H. , Mrug Sylvie , Schwebel David C. , Phipps Sean , Whelan Kimberly , Madan-Swain Avi
Published: August 2016

Background:

Benefit finding, or finding positive outcomes in the face of adversity, may play a role in predicting quality of life (QoL) among caregivers, but mixed results suggest that other factors may moderate this relationship.

Objective:

This study examined demographic and psychosocial moderators of the association between benefit finding and QoL among caregivers of childhood cancer survivors.

Methods:

Caregivers of childhood cancer survivors (n = 83) completed measures of benefit finding, QoL, coping, optimism, social support, caregiving demand, posttraumatic stress, and demographics.

Results:

The relationship between benefit finding and QoL was moderated by caregiver age, marital status, socioeconomic status, geographic location, acceptance and emotion-focused coping, optimism, caregiving demand, and posttraumatic stress. Benefit finding was more strongly related to QoL among caregivers with fewer demographic/psychosocial resources.

Conclusions:

Results suggest that finding benefits in the cancer experience may have a greater positive impact for caregivers with relatively fewer demographic and psychosocial resources and may have less of an impact for caregivers with relatively greater resources. Findings further point to the complex nature of QoL among caregivers of childhood cancer survivors.

Implications for Practice:

Results may aid clinicians in identifying caregivers at particular risk for low QoL. They may be counseled to find benefits in their experience or provided with resources to strengthen other factors that impact QoL.
Nurses' Perceptions of Quality Care
Authors: Ryan Catherine , Powlesland Jean , Phillips Cynthia , Raszewski Rebecca , Johnson Alexia , Banks-Enorense Kelly , Agoo Victor C. , Nacorda-Beltran Rosalind , Halloway Shannon , Martin Kathleen , Smith Lenore D. , Walczak Debra , Warda Jane , Washington Barbara J. , Welsh Julie
Published: August 2016

Limited research has been conducted on how nurses define or perceive “quality nursing care.” We conducted focus groups to identify nurses' perceptions of quality care at a Midwestern academic medical center. Transcripts of the focus group sessions were analyzed using thematic analysis techniques, and 11 themes emerged: Leadership, Staffing, Resources, Timeliness, Effective Communication/Collaboration, Professionalism, Relationship-Based Care, Environment/Culture, Simplicity, Outcomes, and Patient Experience.
Adolf Meyer
Authors: McHugh Paul R.
Published: August 2016

This lecture, given to celebrate the centennial of the founding of the Henry Phipps Psychiatric Service at Johns Hopkins, addresses the career and contributions to psychiatry and neurology of Adolf Meyer, the first Phipps Professor. It reviews his achievements historically describing the bleak clinical situation of psychiatry when he began as a neuropathologist at Kankakee Hospital in Illinois in 1892, what he did to address them, the sources of help he found and exploited from leading figures in the emerging Progressive Era (1890–1917) in American life, and how he confronted and overcame resistances to his empirical, psychobiological conceptions of mental illness as he advanced. His legacy is reflected in the signal contributions of four leaders of American psychiatry (Drs. Leo Kanner, Alexander Leighton, Jerome Frank, and Paul Lemkau) who had been his residents and in those aspects of contemporary teaching and research at Hopkins that reflect his thought.
Effective Learning of Interprofessional Teamwork
Authors: Rossler Kelly L. , Buelow Janet R. , Thompson Anne W. , Knofczynski Greg
Published: August 2016

Educators are actively identifying optimal teaching-learning strategies that afford future health care professionals opportunities to acquire skills necessary to function as a member of an interprofessional team. This article describes the development of an interprofessional team learning experience consisting of students from 6 health professions programs within 1 college of health professions. Student achievement of interprofessional team competencies were evaluated in a pretest-posttest format. Essential components of a 7-week program, teaching methodologies, and course evaluations are presented.
Bilateral Corneal Epithelial Lesions Associated with Paclitaxel
Authors: Lee Hyo Seok , Ha Jun Young , Choi Won , Yoon Kyung Chul
Published: August 2016

Purpose

An antineoplastic drug, paclitaxel, is widely used in small cell lung cancer, breast cancer, and ovarian cancer. We report a case of bilateral, vision-impairing corneal epithelial lesions that developed in a patient receiving paclitaxel monotherapy for breast cancer.

Case Report

A 45-year-old woman presented with a 1-month history of bilateral visual disturbances. She had been receiving paclitaxel chemotherapy after modified radical mastectomy for invasive ductal carcinoma in her left breast. Best-corrected visual acuity was 20/100 in the right eye and 20/40 in the left eye. Slit-lamp examination revealed irregular triangular corneal lesions in both eyes. The lesions extended to the center of the cornea involving the visual axis and showed late staining with fluorescein dye. The lesions resolved 5 months after discontinuation of paclitaxel chemotherapy, and best-corrected visual acuity was restored to 20/20 in both eyes.

Conclusions

Microtubule-stabilizing chemotherapeutic drugs such as paclitaxel can cause visually significant corneal lesions, and these lesions appear to be reversible with discontinuation of the drug. This case highlights the need for regular ophthalmologic examinations for the detection of this reversible adverse ocular reaction.
Internal Astigmatism in Myopes and Non-myopes: Compensation or Constant?
Authors: Manny Ruth E. , Deng Li , Gwiazda Jane , Hyman Leslie , Weissberg Erik , Scheiman Mitchell , Fern Karen D.
Published: August 2016

Purpose

To examine internal astigmatism (IA) in myopes and non-myopes using a new method to assess compensation of corneal astigmatism (CA) by IA, to look for predictors of high IA in young adult myopes, and to determine if as CA changes IA changes to reduce refractive astigmatism (RA) in an active compensatory process in myopes.

Methods

Right eye keratometry and cycloplegic autorefraction were measured annually over 14 years in 367 myopes and once in 204 non-myopes age- (mean 21.91 ± 1.47 years), gender-, and ethnicity-matched to myopes at year 12. CA and RA at the corneal plane were expressed as J0, J45. IA = RA − CA. Inverse power transformation provided cylinder power and axis of IA for the compensation factor (IA/CA). Analyses included (1) paired and unpairedt-tests (refractive data), (2) chi-square tests (distributions of compensation factor), (3) logistic regression analysis (predictors of high IA), and (4) linear mixed models (time effect on RA, CA, and IA).

Results

The magnitude of IAJ0 varied by refractive error (myopes −0.25 ± 0.24 vs. non-myopes −0.32 ± 0.21, p < 0.001). Compensation of CA by IA was poorer in myopes than non-myopes (χ2p < 0.001). When matched by CA, compensation remained poorer in myopes than non-myopes (χ2all p ≤ 0.04). Within each refractive group, compensation was better when CA was low than high (χ2p < 0.001). When CA was low in myopes, high IA (≥1.00D) was less likely (p = 0.01). Longitudinal follow-up of myopes found no evidence for an active compensatory role for IA as CA increased over time. There were differences in IAJ0 by ethnicity over time (p < 0.0001).

Conclusions

In myopic and non-myopic eyes with low amounts of CA, IA may reduce CA’s contribution to RA, but IA is not a constant. However, there is no evidence for an active compensatory role for IA reducing CA in myopes.
Contact Lens Methods for Clinical Myopia Control
Authors: Turnbull Philip Raey Kidd , Munro Oliver James , Phillips John Robert
Published: August 2016

Purpose

A number of optical methods for slowing myopia progression have been tested and are now available. However, data on real-world use in clinical use is scarce. Here, we present a review of the clinical outcomes for patients attending a specialist myopia control clinic at The University of Auckland Optometry School, NZ.

Case Series

We report a comparative case series of 110 patients (aged 4–33 years, mean: 12.13 ± 4.58 years, 62% female) who attended the clinic between 2010 and 2014. Fifty-six were prescribed orthokeratology, 32 dual focus soft contact lenses, and 22 received advice only. Initial myopia, vitreous and axial eye length, previous myopia progression, age, number of myopic parents, and gender were not significantly different between orthokeratology and dual focus soft contact lens groups. Mean follow-up time for the orthokeratology and dual focus lens groups was the same (orthokeratology: 1.30 ± 0.88 years; dual focus lens: 1.33 ± 0.80 years (p = 0.989)). There was a significant reduction in the annualized myopia progression in both groups (orthokeratology: −1.17 ± 0.55 to −0.09 ± 017 D/yr, p < 0.001; dual focus soft contact lens: −1.15 ± 0.46 to −0.10 ± 0.23 D/yr, p < 0.001). There was no difference between orthokeratology and dual focus lens treatment efficacy (p = 0.763), nor in axial or vitreous chamber length changes after treatment (p = 0.184). One adverse event was reported over the 4-year period.

Conclusions

Both orthokeratology and dual focus soft contact lenses are effective strategies for targeting myopia progression in the clinic. We saw no significant difference in the efficacy of the two methods in this regard, and so we believe there are very few barriers for any contact lens practitioner to be actively promoting myopia control treatment to at-risk patients.
The p16-Ki-67-HMB45 Immunohistochemistry Scoring System is Highly Concordant With the Fluorescent In Situ Hybridization Test to Differentiate Between Melanocytic Nevi and Melanomas
Authors: Uguen Arnaud , Uguen Marie , Guibourg Briac , Talagas Matthieu , Marcorelles Pascale , De Braekeleer Marc
Published: August 2016

The treatment of melanoma requires early diagnosis and extensive surgical removal of the primary tumor. The differential diagnosis between a melanoma and a nevus is sometimes difficult from a histopathologic point of view and could require ancillary diagnostic tools. Recently, both fluorescent in situ hybridization (FISH) and p16-Ki67-HMB45 combined immunohistochemistry have been proposed as examples of ancillary diagnostic methods to help classify melanocytic tumors as benign or malignant. In this study, we compare FISH and p16-Ki-67-HMB45 immunohistochemistry in a set of melanomas and nevi. A total of 101 formalin-fixed and paraffin-embedded tumor samples (44 melanomas and 57 nevi) were analyzed using FISH for chromosomes 6, 8, 9, and 11 and p16-Ki-67-HMB45 immunohistochemistry. Any chromosomal imbalances and/or a p16-Ki-67-HMB45 immunohistochemistry combined score of 4 or higher were considered to reflect a “favor” malignant tumor. Using FISH, 42 out of 44 melanomas presented at least 1 chromosomal imbalance, whereas 2 melanomas and all nevi did not. Each melanoma, including 6 challenging tumors, had a p16-Ki-67-HMB45 immunohistochemistry combined score of 4 or higher and every nevus had a score inferior to 4. This reflects an excellent strength of agreement between FISH, immunohistochemistry, and definitive histopathologic diagnosis in our tumor set. We conclude that both FISH and p16-Ki67-HMB45 combined immunohistochemistry are valuable ancillary diagnostic tools to help pathologists classify melanocytic tumors as nevi or melanomas.
Sedation and Analgesia in Pediatric Cardiac Critical Care
Authors: Nasr Viviane G. , DiNardo James A.
Published: August 2016

Objectives:

This review will focus on the pharmacokinetics (with an emphasis on the context-sensitive half-time), pharmacodynamics, and hemodynamic characteristics of the most commonly used sedative/hypnotic, analgesic, and IV anesthetics used in cardiac intensive care. In addition, the assessment of pain and agitation and withdrawal will be reviewed.

Data Source:

MEDLINE, PubMed.

Conclusions:

Children in the cardiac ICU often require one or more components of general anesthesia: analgesia, amnesia (sedation and hypnosis), and muscle relaxation to facilitate mechanical ventilation, to manage postoperative pain, to perform necessary procedures, and to alleviate fear and anxiety. Furthermore, these same children are often vulnerable to hemodynamic instability due to unique underlying physiologic vulnerabilities. An assessment of hemodynamic goals, postoperative procedures to be performed, physiologic vulnerabilities, and the intended duration of mechanical ventilation should be made. Based on this assessment, the optimal selection of sedatives, analgesics, and if necessary, muscle relaxants can then be made.
Avoidance of Hospital-Acquired Infections in Pediatric Cardiac Surgical Patients
Authors: Taylor Ruston S. , Shekerdemian Lara S.
Published: August 2016

Objectives:

The objectives of this review are to discuss the prevalence and risk factors associated with the development of hospital-acquired infections in pediatric patients undergoing cardiac surgery and the published antimicrobial prophylaxis regimens and rational approaches to the diagnosis, prevention, and treatment of nosocomial infections in these patients.

Data Source:

MEDLINE and PubMed.

Conclusion:

Hospital-acquired infections remain a significant source of potentially preventable morbidity and mortality in pediatric cardiac surgical patients. Through improved understanding of these conditions and implementation of avoidance strategies, centers caring for these patients may improve outcomes in this vulnerable population.
Fluid Management: Pharmacologic and Renal Replacement Therapies
Authors: Wald Eric L. , Finer Gal , McBride Mary E. , Nguyen Nguyenvu , Costello John M. , Epting Conrad L.
Published: August 2016

Objectives:

Focusing on critically ill children with cardiac disease, we will review common causes of fluid perturbations, clinical recognition, and strategies to minimize and treat fluid-related complications.

Data Source:

MEDLINE and PubMed.

Conclusions:

Meticulous fluid management is vital in critically ill children with cardiac disease. Fluid therapy is important to maintain adequate blood volume and perfusion pressure in order to support cardiac output, tissue perfusion, and oxygen delivery. However, fluid overload and acute kidney injury are common and are associated with increased morbidity and mortality. Understanding the etiologies for disturbances in volume status and the pathophysiology surrounding those conditions is crucial for providing optimal care.
Global Perspectives On Pediatric Cardiac Critical Care
Authors: Penny Daniel J.
Published: August 2016

Objectives:

The objectives of this review are to discuss the global epidemiology of cardiovascular disease, emphasizing congenital heart disease; to discuss the concept of epidemiologic transition and its role in studying the evolving epidemiology of disease; and to assess and address the global burden of congenital heart disease including its prevention and treatment.

Data Source:

MEDLINE and PubMed.

Conclusions:

Despite impressive reductions in mortality from congenital and acquired cardiovascular disease in high-income countries, these reductions have not been observed on a global scale. It will be necessary to continue our attempts to extend rational programs of care to middle- and low-income countries based on community empowerment, economics, and population health. The specialist in pediatric cardiac critical care can be a central driver of these programs.
Sepsis in Pediatric Cardiac Intensive Care
Authors: Wheeler Derek S. , Wong Hector R.
Published: August 2016

Objectives:

In this review, we will discuss risk factors for developing sepsis; the role of biomarkers in establishing an early diagnosis, in monitoring therapeutic efficacy, in stratification, and for the identification of sepsis endotypes; and the pathophysiology and management of severe sepsis and septic shock, with an emphasis on the impact of sepsis on cardiovascular function.

Data Source:

MEDLINE and PubMed.

Conclusions:

There is a lot of excitement in the field of sepsis research today. Scientific advances in the diagnosis and clinical staging of sepsis, as well as a personalized approach to the treatment of sepsis, offer tremendous promise for the future. However, at the same time, it is also evident that sepsis mortality has not improved enough, even with progress in our understanding of the molecular pathophysiology of sepsis.
Nutrition and Mesenteric Issues in Pediatric Cardiac Critical Care
Authors: Floh Alejandro A. , Slicker Julie , Schwartz Steven M.
Published: August 2016

Objectives:

The objectives of this review are to discuss the challenges of delivering adequate nutrition to children with congenital heart disease, including pre- and postoperative factors and the role of enteral and parenteral nutrition, as well as the evidence supporting current practices.

Data Source:

MEDLINE and PubMed.

Conclusion:

Providing adequate nutritional support is paramount for critically ill infants with congenital heart disease, a population at particular risk for malnutrition. Improved nutritional support has been associated with increased survival and reduction in overall morbidity. Further gains can be achieved by creating a clinical culture that emphasizes optimal perioperative nutritional support. Additional research is required to identify the specific nutrient composition, optimal mode, and timing of delivery to maximize clinical benefit.
Heart Transplantation—The Pediatric Cardiac Critical Care Perspective
Authors: Rossano Joseph W. , Cabrera Antonio G. , Shaddy Robert E.
Published: August 2016

Objectives:

Although there have been tremendous advancements in the care of severe pediatric cardiovascular disease, heart transplantation remains the standard therapy for end-stage heart disease in children. As such, these patients comprise an important and often complex subset of patients in the ICU. The purpose of this article is to review the causes and management of allograft dysfunction and the medications used in the transplant population.

Data Sources:

MEDLINE, PubMed, and Cochrane Database of systemic reviews.

Conclusions:

Pediatric heart transplant recipients represent a complex group of patients that frequently require critical care. Their immunosuppressive medications, while being vital to maintenance of allograft function, are associated with significant short- and long-term complications. Graft dysfunction can occur from a variety of etiologies at different times following transplantation and remains a major limitation to long-term posttransplant survival.
Pulmonary Edema and Hypoxic Respiratory Failure
Authors: Hornik Christoph , Meliones Jon
Published: August 2016

Objectives:

The purpose of this chapter is to outline the causes, physiology, pathophysiology, and management strategies for hydrostatic and permeability pulmonary edema and hypoxic respiratory failure.

Data Source:

MEDLINE and PubMed.

Conclusion:

The pulmonary parenchyma and vasculature are at high risk in conditions where injury occurs to the lung and or heart. A targeted approach that uses strategies that optimize the particular pathophysiology of the parenchyma and vasculature is required.
Cardiopulmonary Interactions
Authors: Bronicki Ronald A. , Penny Daniel J. , Anas Nick G. , Fuhrman Bradley
Published: August 2016

Objectives:

The objectives of this review are to discuss the mechanisms by which respiration impacts cardiovascular function and vice versa, with an emphasis on the impact of these interactions in pediatric cardiac critical care.

Data source:

A search of MEDLINE was conducted using PubMed.

Conclusions:

In the presence of underlying cardiac and respiratory disease, the interplay between these two systems is significant and plays a pivotal role in the pathophysiology of acute and chronic phases of a wide spectrum of diseases. An understanding of these relationships is essential to optimizing the care of critically ill patients.
A Randomized Controlled Comparison of the Internal Jugular Vein and the Subclavian Vein as Access Sites for Central Venous Catheterization in Pediatric Cardiac Surgery
Authors: Camkiran Firat Aynur , Zeyneloglu Pinar , Ozkan Murat , Pirat Arash
Published: August 2016

Objectives:

To compare internal jugular vein and subclavian vein access for central venous catheterization in terms of success rate and complications.

Design:

A 1:1 randomized controlled trial.

Setting:

Baskent University Medical Center.

Patients:

Pediatric patients scheduled for cardiac surgery.

Interventions:

Two hundred and eighty children undergoing central venous catheterization were randomly allocated to the internal jugular vein or subclavian vein group during a period of 18 months.

Measurements and Main Results:

The primary outcome was the first-attempt success rate of central venous catheterization through either approach. The secondary outcomes were the rates of infectious and mechanical complications. The central venous catheterization success rate at the first attempt was not significantly different between the subclavian vein (69%) and internal jugular vein (64%) groups (p = 0.448). However, the overall success rate was significantly higher through the subclavian vein (91%) than the internal jugular vein (82%) (p = 0.037). The overall frequency of mechanical complications was not significantly different between the internal jugular vein (25%) and subclavian vein (31%) (p = 0.456). However, the rate of arterial puncture was significantly higher with internal jugular vein (8% vs 2%; p = 0.03) and that of catheter malposition was significantly higher with subclavian vein (17% vs 1%; p < 0.001). The rates per 1,000 catheter days for both positive catheter-tip cultures (26.1% vs 3.6%; p < 0.001) and central-line bloodstream infection (6.9 vs 0; p < 0.001) were significantly higher with internal jugular vein. There were no significant differences between the groups in the length of ICU and hospital stays or in-hospital mortality rates (p > 0.05 for all).

Conclusions:

Central venous catheterization through the internal jugular vein and subclavian vein was not significantly different in terms of success at the first attempt. Although the types of mechanical complications were different, the overall rate was similar between internal jugular vein and subclavian vein access. The risk of infectious complications was significantly higher with internal jugular vein access.
Enterovirus D68 in Critically Ill Children: A Comparison With Pandemic H1N1 Influenza*
Authors: Rao Suchitra , Messacar Kevin , Torok Michelle R. , Rick Anne-Marie , Holzberg Jeffrey , Montano Aaron , Bagdure Dayanand , Curtis Donna J. , Oberste M. Steven , Nix W. Allan , de Masellis Gina , Robinson Christine C. , Dominguez Samuel R.
Published: August 2016

Objective:

In 2014, the Unites States experienced an outbreak of enterovirus D68 associated with severe respiratory illness. The clinical characteristics associated with severe illness from enterovirus D68 during this outbreak compared with those associated with the 2009 H1N1 influenza virus outbreak are unknown.

Design and Setting:

In this retrospective cohort study, we characterized the clinical features of children with enterovirus D68 admitted to the PICU between August 1, 2014, and November 1, 2014, and compared them with critically ill children infected with H1N1 influenza during the pandemic admitted between May 1, 2009, and January 31, 2010.

Patients:

PICU patients.

Interventions:

None.

Measurements and Main Results:

Ninety-seven severely ill children with enterovirus D68 infections were compared with 68 children infected with H1N1 influenza during the 2009 pandemic. Children with enterovirus D68 were more likely to have asthma (62% vs 23%; p < 0.001) and present with reactive airway disease exacerbations, with greater receipt of albuterol (94% vs 49%) and steroids (89% vs 40%; p < 0.0001 for both). Although more children with enterovirus D68 were admitted to the ICU compared with those with H1N1 influenza, they had a shorter hospital length of stay (4 vs 7 d; p < 0.0001), with lower intubation rates (7% vs 44%), vasopressor use (3% vs 32%), acute respiratory distress syndrome (3% vs 24%), shock (0% vs 16%), and death (0% vs 12%; p < 0.05 for all). Compared with children with other enteroviruses and rhinoviruses, children with enterovirus D68 were more likely to have a history of asthma (64% vs 45%) or multiple prior wheezing episodes (54% vs 34%; p < 0.01 for both).

Conclusions:

Critically ill children with enterovirus D68 were more likely to present with reactive airway disease exacerbations, whereas children with H1N1 influenza were more likely to present with pneumonia. Compared with the pandemic H1N1 influenza outbreak, the enterovirus D68 outbreak resulted in more children requiring admission to the ICU, but was associated with less severe outcomes.
The Sonographic Appearance of Spinal Fluid at Clinically Selected Interspaces in Sitting Versus Lateral Positions
Authors: Vitberg Yaffa M. , Tseng Peggy , Kessler David O.
Published: August 2016

Objective

Our objective was to describe the sonographic appearance of fluid at clinically selected interspinous spaces and see if additional interspaces could be identified as suitable and safe targets for needle insertion. We also measured the reproducibility of fluid measurements and assessed for positional differences.

Methods

A prospective convenience sample of infants younger than 3 months was enrolled in the pediatric emergency department. Excluded were clinically unstable infants or those with spinal dysraphism. Infants were first held in standard lateral lumbar puncture position. Pediatric emergency medicine (PEM) physicians marked infants' backs at the level they would insert a needle using the landmark palpation technique. A PEM sonologist imaged and measured the spinal fluid in 2 orthogonal planes at this marked level in lateral then sitting positions. Fluid measurements were repeated by a second blinded PEM sonologist.

Results

Forty-six infants were enrolled. Ultrasound verified the presence of fluid at the marked level as determined by the landmark palpation technique in 98% of cases. Ultrasound identified additional suitable spaces 1 space higher (82%) and 2 spaces higher (41%). Intraclass correlation coefficient of all measurements was excellent (>0.85), with differences noted for sitting versus lateral position in mean area of fluid 0.34 mm2 versus 0.31 mm2 (difference, 0.03; 95% confidence interval [CI], 0.005–0.068), dorsal fluid pocket 0.23 mm2 versus 0.15 mm2 (difference, 0.08; 95% CI, 0.031–0.123), and nerve root-to-canal ratio 0.44 versus 0.51 (difference, 0.07; 95% CI, 0.004–0.117).

Conclusions

Ultrasound can verify the presence of fluid at interspaces determined by the landmark palpation technique and identify additional suitable spaces at higher levels. There were statistically greater fluid measurements in sitting versus lateral positions. These novel fluid measurements were shown to be reliable.
A Misdirected Patient Transfer Raises Emergency Medical Treatment and Labor Act Liability Issues
Authors: McDonnell William M. , Lawton Maurice K. , Roback Mark G.
Published: August 2016

Children often require transfer to pediatric hospital emergency departments (EDs) after evaluation in community hospital EDs. Such transfers are regulated by the federal Emergency Medical Treatment and Labor Act. Unusual circumstances, such as logistical errors in the physical transfer of the patient, may increase Emergency Medical Treatment and Labor Act-related liability risks for hospitals and ED physicians.
Recommendations From the International Colorectal Cancer Screening Network on the Evaluation of the Cost of Screening Programs
Authors: Subramanian Sujha , Tangka Florence K. L. , Hoover Sonja , Nadel Marion , Smith Robert , Atkin Wendy , Patnick Julietta
Published: August 2016

Worldwide, colorectal cancer is the fourth leading cause of death from cancer and the incidence is projected to increase. Many countries are exploring the introduction of organized screening programs, but there is limited information on the resources required and guidance for cost-effective implementation. To facilitate the generating of the economics evidence base for program implementation, we collected and analyzed detailed program cost data from 5 European members of the International Colorectal Cancer Screening Network. The cost per person screened estimates, often used to compare across programs as an overall measure, varied significantly across the programs. In addition, there were substantial differences in the programmatic and clinical cost incurred, even when the same type of screening test was used. Based on these findings, several recommendations are provided to enhance the underlying methodology and validity of the comparative economic assessments. The recommendations include the need for detailed activity-based cost information, the use of a comprehensive set of effectiveness measures to adequately capture differences between programs, and the incorporation of data from multiple programs in cost-effectiveness models to increase generalizability. Economic evaluation of real-world colorectal cancer–screening programs is essential to derive valuable insights to improve program operations and ensure optimal use of available resources.
Advances and Refinement in Hyaluronic Acid Facial Fillers
Authors: Costa Christopher R. , Kordestani Reza , Small Kevin H. , Rohrich Rod J.
Published: August 2016

Fillers temporarily augment deflated or ptotic facial compartments to restore a youthful appearance. Hyaluronic acids predominate the fillers market because of their focal volumization, duration of effect, low incidence of adverse reactions, and reversibility. Being able to properly perform these in-office procedures will ensure safety for patients and provide aesthetically optimal results. This communication provides the senior author’s (R.J.R.) stepwise approach to facial aging and deflation with soft-tissue injectable fillers.
Race and Breast Cancer Reconstruction: Is There a Health Care Disparity?
Authors: Sharma Ketan , Grant David , Parikh Rajiv , Myckatyn Terence
Published: August 2016

Background:

Racial disparity continues to be a well-documented problem afflicting contemporary health care. Because the breast is a symbol of femininity, breast reconstruction is critical to mitigating the psychosocial stigma of a breast cancer diagnosis. Whether different races have equitable access to breast reconstruction remains unknown.

Methods:

Two thousand five hundred thirty-three women underwent first-time autologous versus implant-based reconstruction following mastectomy. Information regarding age, smoking, diabetes, obesity, provider, race, pathologic stage, health insurance type, charge to insurance, and socioeconomic status was recorded. Established statistics compared group medians and proportions. A backward-stepwise multivariate logistic regression model identified independent predictors of breast reconstruction type.

Results:

Compared with whites, African Americans were more likely to be underinsured (p < 0.01), face a lesser charge for reconstruction (p < 0.01), smoke (p < 0.01), have diabetes (p < 0.01), suffer from obesity (p < 0.01), live in a zip code with a lower median household income (p < 0.01), and undergo autologous-based reconstruction (p = 0.01). On multivariate analysis, only African American race (OR, 2.23; p < 0.01), charge to insurance (OR, 1.00; p < 0.01), and provider (OR, 0.96; p < 0.01) independently predicted type of breast reconstruction, whereas age (OR, 1.02; p = 0.06) and diabetes (OR, 0.48; p = 0.08) did not.

Conclusions:

African American race remains the most clinically significant predictor of autologous breast reconstruction, even after controlling for age, obesity, pathologic stage, health insurance type, charge to patient, socioeconomic status, smoking, and diabetes. Future research may address whether this disparity stems from patient preferences or more profound sociocultural and economic forces, including discrimination.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
Adipose-Derived Stem Cells Enhance Axonal Regeneration through Cross-Facial Nerve Grafting in a Rat Model of Facial Paralysis
Authors: Abbas Ozan L. , Borman Hüseyin , Uysal Çağri A. , Gönen Zeynep B. , Aydin Leyla , Helvacioğlu Fatma , Ilhan Şebnem , Yazici Ayşe C.
Published: August 2016

Background:

Cross-face nerve grafting combined with functional muscle transplantation has become the standard in reconstructing an emotionally controlled smile in complete irreversible facial palsy. However, the efficacy of this procedure depends on the ability of regenerating axons to breach two nerve coaptations and reinnervate endplates in denervated muscle. The current study tested the hypothesis that adipose-derived stem cells would enhance axonal regeneration through a cross-facial nerve graft and thereby enhance recovery of the facial nerve function.

Methods:

Twelve rats underwent transection of the right facial nerve, and cross-facial nerve grafting using the sciatic nerve as an interpositional graft, with coaptations to the ipsilateral and contralateral buccal branches, was carried out. Rats were divided equally into two groups: a grafted but nontreated control group and a grafted and adipose-derived stem cell–treated group. Three months after surgery, biometric and electrophysiologic assessments of vibrissae movements were performed. Histologically, the spectra of fiber density, myelin sheath thickness, fiber diameter, and g ratio of the nerve were analyzed. Immunohistochemical staining was performed for the evaluation of acetylcholine in the neuromuscular junctions.

Results:

The data from the biometric and electrophysiologic analysis of vibrissae movements, immunohistochemical analysis, and histologic assessment of the nerve showed that adipose-derived stem cells significantly enhanced axonal regeneration through the graft.

Conclusion:

These observations suggest that adipose-derived stem cells could be a clinically translatable route toward new methods to enhance recovery after cross-facial nerve grafting.
Malignant Melanoma: Beyond the Basics
Authors: Pavri Sabrina N. , Clune James , Ariyan Stephan , Narayan Deepak
Published: August 2016

Learning Objectives:

After reading this article, the participant should be able to: 1. Discuss the initial management of cutaneous malignant melanoma with regard to diagnostic biopsy and currently accepted resection margins. 2. Be familiar with the management options for melanoma in specific situations such as subungual melanoma, auricular melanoma, and melanoma in the pregnant patient. 3. Discuss the differentiating characteristics of desmoplastic melanoma and its treatment options. 4. List the indications for sentinel lymph node biopsy and be aware of the ongoing trials and current literature. 5. Discuss the medical therapies available to patients with metastatic melanoma.

Management of the melanoma patient is a complex and evolving subject. Plastic surgeons should be aware of the recent changes in the field. Excisional biopsy remains the gold standard for diagnosis, although there is no evidence that use of other biopsy types alters survival or recurrence. Wide local excisions should be carried out with margins as recommended by National Comprehensive Cancer Network guidelines according to lesion Breslow depth, with sentinel lymph node biopsy being offered to all medically suitable candidates with intermediate thickness melanomas (1.0 to 4.0 mm), and with sentinel lymph node biopsy being considered for high-risk lesions (ulceration and/or high mitotic figures) with melanomas of 0.75 to 1.0 mm. Melanomas diagnosed during pregnancy can be treated with preoperative lymphoscintigraphy and wide local excision under local anesthesia, with sentinel lymph node biopsy under general anesthesia delayed until after delivery. Management of desmoplastic melanoma is currently controversial with regard to the indications for sentinel lymph node biopsy and the efficacy of postoperative radiation therapy. Subungual and auricular melanoma have evolved from being treated by amputation of the involved appendage to less radical procedures—ear reconstruction is now attempted in the absence of gross invasion into the perichondrium, and subungual melanomas may be treated with wide local excision down to and including the periosteum, with immediate full-thickness skin grafting over bone. Although surgical treatment remains the current gold standard, recent advances in immunotherapy and targeted molecular therapy for metastatic melanoma show great promise for the development of medical therapies for melanoma.
Impact of Safety Net Hospitals in the Care of the Hand-Injured Patient: A National Perspective
Authors: Yuan Frank , Chung Kevin C.
Published: August 2016

A clear disparity in the pattern and provision of surgical care exists, particularly for patients with vulnerable socioeconomic backgrounds. For hand-injured patients in particular, this discrepancy has been frequently shown in their receiving appropriate care. With the advent of the Affordable Care Act and with Medicaid expansion on the horizon, more patients will be requiring access to care. Safety net programs have been shown to provide equivalent levels of care for patients compared with non–safety net providers, and the survival of these hospitals for the disadvantaged is essential to providing quality care for this growing patient population. In this article, the authors review the factors that affect the barriers to care, the importance of safety net hospitals, the epidemiology of the hand-injured patient, and how the Affordable Care Act will impact these safety net programs.
Systematic Review and Meta-Analysis of Unconventional Perfusion Flaps in Clinical Practice
Authors: Casal Diogo , Cunha Teresa , Pais Diogo , Videira Paula , Coloma Joana , Zagalo Carlos , Angélica-Almeida Maria , O’Neill João Goyri
Published: August 2016

Background:

Although unconventional perfusion flaps have been in clinical use since 1975, many surgeons are still deterred from using them, because of some reports of high necrosis rates.

Methods:

The authors performed a systematic review and meta-analysis of all articles written in English, French, German, Spanish, and Portuguese on the clinical use of unconventional perfusion flaps and indexed to PubMed from 1975 until July 15, 2015.

Results:

A total of 134 studies and 1445 patients were analyzed. The estimated survival rate of unconventional perfusion flaps was 89.5 percent (95 percent CI, 87.3 to 91.3 percent; p < 0.001). Ninety-two percent of unconventional perfusion flaps (95 percent CI, 89.9 to 93.7 percent; p < 0.001) presented complete or nearly complete survival. Most defects mandating unconventional perfusion flap reconstruction were caused by trauma (63.6 percent), especially of the hand and fingers (75.1 percent). The main complication of all types of flaps was a variable degree of necrosis (7.5 percent of all unconventional perfusion flaps presented marginal necrosis; 9.2 percent and 5.5 percent had significant and complete necrosis, respectively). There was a positive correlation between the rate of postoperative infection and the need for a new flap (Pearson coefficient, 0.405; p = 0.001). Flaps used to reconstruct the upper limb showed better survival than those transferred to the head and neck or to the lower limb (p < 0.001).

Conclusion:

Unconventional perfusion flaps show high survival rates and should probably be used more liberally, particularly in the realm of upper limb reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Developing a Nanoparticle-Delivered High-Efficacy Treatment for Infantile Hemangiomas Using a Mouse Hemangioendothelioma Model
Authors: Orbay Hakan , Li Yuanpei , Xiao Wenwu , Cherry Simon R. , Lam Kit , Sahar David E.
Published: August 2016

Background:

Current treatments for infantile hemangiomas have unpredictable outcomes. The authors’ aim was to develop a nanoporphyrin-delivered, high-efficacy treatment for infantile hemangiomas using a mouse hemangioendothelioma model.

Methods:

The authors injected mouse hemangioendothelioma cells intradermally to axillary regions of 5-week-old, female, nude mice (n = 19) to induce hemangioendothelioma growth. They documented nanoporphyrin accumulation in hemangioendotheliomas using positron emission tomography. For the treatment study, the authors randomized hemangioendothelioma-bearing nude mice (n = 9) into three groups (n = 3 each). Group I received only saline injections. Group II received only laser treatment after saline injection, and group III received laser treatment after nanoporphyrin injection through the tail vein. The authors followed up the treatment response with digital caliper measurements.

Results:

Hemangioendotheliomas started to grow approximately 1 week after inoculation and resembled infantile hemangiomas histologically. Nanoporphyrin uptake in hemangioendotheliomas was 19.7 ± 2.2, 16.7 ± 2.02, 8.4 ± 0.3, and 4.9 ± 0.6 percent injected dose per gram of tissue at 3, 6, 24, and 48 hours after injection, respectively. Nanoporphyrin uptake was significantly higher than in blood at 24 and 48 hours after injection (p < 0.05). Results of ex vivo biodistribution study were consistent with positron emission tomographic imaging. Hemangioendotheliomas in group III started to regress 1 day after the treatment and disappeared totally by day 21. The difference between tumor volumes in group III and other groups was significant on days 17 and 21 (p < 0.05).

Conclusions:

Nanoporphyrin accumulated in hemangioendotheliomas at high concentrations, enabling a high-efficacy photodynamic therapy. Given the similarities between hemangioendotheliomas and infantile hemangiomas, this treatment potentially can be a high-efficacy treatment for infantile hemangiomas.
Complications Related to Pectus Carinatum Correction: Lessons Learned from 15 Years’ Experience. Management and Literature Review
Authors: Del Frari Barbara , Sigl Stephan , Schwabegger Anton H.
Published: August 2016

Background:

Various methods of corrective thoracoplasty for pectus carinatum deformity have been described, but to date no studies describe a review of complications and how to manage them. Complications are dependent not only on the technique used and the patient’s age, but also on the experience of the treating surgeon. The authors present their 15 years’ experience with surgical correction of pectus carinatum and the complications that have occurred. A literature review regarding complications with pectus carinatum surgery is performed.

Methods:

A retrospective review of 95 patients (mean age, 19 years) was performed. One hundred four surgical procedures for repair of pectus carinatum were performed from July of 2000 to July of 2015 using a modified Ravitch technique, bioabsorbable material, postoperative bracing, and in some cases a diced rib cartilage graft technique. Intraoperative and postoperative complications were evaluated.

Results:

The mean patient follow-up was 13.6 months (range, 4 months to 9.75 years). Intraoperative complications were pleura lesion and laceration of the internal mammary vein. Postoperative complications were recurrent mild protrusion, persistent protrusion of one or two costal cartilages, minor wound healing delay, skin ulcer, hypertrophic scar, transient intercostal dysesthesia, marginal pneumothorax, seroma, meningitis, and epidural hematoma.

Conclusions:

In our reported series of pectus carinatum repair, increasing experience and progressively less extensive techniques have resulted in fewer complications, low morbidity, and early return to activity. Complications were observed in the early period of application, predominantly because of a lack of experience, and usually subsided with increasing numbers of patients and frequency of surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Suggestions to Reduce Clinical Fibromyalgia Pain and Experimentally Induced Pain Produce Parallel Effects on Perceived Pain but Divergent Functional MRI–Based Brain Activity
Authors: Derbyshire Stuart W.G. , Whalley Matthew G. , Seah Stanley T.H. , Oakley David A.
Published: August 2016

Objective

Hypnotic suggestion is an empirically validated form of pain control; however, the underlying mechanism remains unclear.

Methods

Thirteen fibromyalgia patients received suggestions to alter their clinical pain, and 15 healthy controls received suggestions to alter experimental heat pain. Suggestions were delivered before and after hypnotic induction with blood oxygen level–dependent (BOLD) activity measured concurrently.

Results

Across groups, suggestion produced substantial changes in pain report (main effect of suggestion, F
2, 312 = 585.8; p < .0001), with marginally larger changes after induction (main effect of induction, F
1, 312 = 3.6; p = .060). In patients, BOLD response increased with pain report in regions previously associated with pain, including thalamus and anterior cingulate cortex. In controls, BOLD response decreased with pain report. All changes were greater after induction. Region-of-interest analysis revealed largely linear patient responses with increasing pain report. Control responses, however, were higher after suggestion to increase or decrease pain from baseline.

Conclusions

Based on behavioral report alone, the mechanism of suggestion could be interpreted as largely similar regardless of the induction or type of pain experience. The functional magnetic resonance imaging data, however, demonstrated larger changes in brain activity after induction and a radically different pattern of brain activity for clinical pain compared with experimental pain. These findings imply that induction has an important effect on underlying neural activity mediating the effects of suggestion, and the mechanism of suggestion in patients altering clinical pain differs from that in controls altering experimental pain. Patient responses imply that suggestions altered pain experience via corresponding changes in pain-related brain regions, whereas control responses imply suggestion engaged cognitive control.
Trends in the Marginal Cost of Male Circumcision in Rural Rakai Uganda
Authors: Alfonso Yira N. , Bishai David , Nantongo Agnes , Kakembo Rebecca , Kobusinge Sarah , Kacker Seema , Kigozi Godfrey , Gray Ronald
Published: August 2016

Introduction:

Male circumcision (MC) is an effective intervention to reduce HIV acquisition in men in Africa. We conducted a cost analysis using longitudinal data on expenditures on services and community mobilization to estimate the marginal cost of MC over time and understand cost drivers during scale-up.

Methods:

We used a time series with monthly records from 2008 to 2013, for a total of 72 monthly observations, from the Rakai MC Program in Uganda. Generalized linear models were used to estimate the marginal cost of an MC procedure.

Results:

The marginal cost per MC in a mobile camp was $23 (P < 0.01) and in static facilities was $35 (P < 0.1). Major cost drivers included supplies in mobile camps with increasing numbers of surgeries, savings due to task shifting from physicians to clinical officers, and increased efficiency as personnel became more experienced.

Conclusions:

As scale-up continues, marginal costs may increase because of mobilization needed for less motivated late adopters, but improved efficiency could contain costs.