bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of an emergency department electronic sepsis surveillance system on patient mortality and length of stay
Authors: Austrian Jonathan S , Jamin Catherine T , Doty Glenn R , Blecker Saul
Published: August 2017

Objective

The purpose of this study was to determine whether an electronic health record–based sepsis alert system could improve quality of care and clinical outcomes for patients with sepsis.

Materials and Methods

We performed a patient-level interrupted time series study of emergency department patients with severe sepsis or septic shock between January 2013 and April 2015. The intervention, introduced in February 2014, was a system of interruptive sepsis alerts triggered by abnormal vital signs or laboratory results. Primary outcomes were length of stay (LOS) and in-hospital mortality; other outcomes included time to first lactate and blood cultures prior to antibiotics. We also assessed sensitivity, positive predictive value (PPV), and clinician response to the alerts.

Results

Mean LOS for patients with sepsis decreased from 10.1 to 8.6 days (P < .001) following alert introduction. In adjusted time series analysis, the intervention was associated with a decreased LOS of 16% (95% CI, 5%-25%; P = .007, with significance of α = 0.006) and no change thereafter (0%; 95% CI, −2%, 2%). The sepsis alert system had no effect on mortality or other clinical or process measures. The intervention had a sensitivity of 80.4% and a PPV of 14.6%.

Discussion

Alerting based on simple laboratory and vital sign criteria was insufficient to improve sepsis outcomes. Alert fatigue due to the low PPV is likely the primary contributor to these results.

Conclusion

A more sophisticated algorithm for sepsis identification is needed to improve outcomes.
A Prospective Analysis of Neuromonitoring for Confirmation of Lead Placement in Dorsal Root Ganglion Stimulation
Authors: Falowski Steven M , Dianna Andreas
Published: August 2017

BACKGROUND

Dorsal root ganglion stimulation is a neuromodulation therapy used for chronic neuropathic pain. Typically, patients are awakened intraoperatively to confirm adequate placement.

OBJECTIVE

To determine whether neuromonitoring can confirm placement in an asleep patient.

METHODS

This is a prospective analysis of 12 leads placed in 6 patients. Lead confirmation was confirmed by awake intraoperative testing, as well as asleep testing utilizing neuromonitoring. Patients were used as their own control. Sensory and motor thresholds for each patient with awake and asleep neuromonitoring testing were recorded. Intraoperative impedance and postoperative programming were also recorded.

RESULTS

In each patient, paresthesias were generated prior to motor contractions in the awake patient. For each patient, somatosensory evoked potential responses were present after lowering below the dropout threshold of electromyogram responses with neuromonitoring. There were varying degrees of separation in the thresholds that did not appear to be consistent across level or diagnosis. Smaller degrees of separation between thresholds during awake testing also held true in the asleep patient. This was further confirmed with postoperative programming. Impedances did not alter the separation in thresholds or amount of stimulation required for responses. One patient was combative during awake testing, and therefore motor thresholds were not obtained. This same patient was determined to have a ventral placement, confirmed with awake and asleep neuromonitoring testing.

CONCLUSION

This series demonstrates that the proposed neuromonitoring protocol can be used in an asleep patient to assure proper positioning of the dorsal root ganglion electrode in the dorsal foramen by generating somatosensory evoked potential responses in the absence of electromyogram responses.
Medical Student Perceptions of Global Surgery at an Academic Institution: Identifying Gaps in Global Health Education
Authors: Mehta Ambar , Xu Tim , Murray Matthew , Casey Kathleen M.
Published: August 2017

Purpose

Robust global health demands access to safe, affordable, timely surgical care for all. The long-term success of global surgery requires medical students to understand and engage with this emerging field. The authors characterized medical students’ perceptions of surgical care relative to other fields within global health.

Method

An optional, anonymous survey was given to all Johns Hopkins medical students from February to March 2016 to assess perceptions of surgical care and its role in global health.

Results

Of 480 students, 365 (76%) completed the survey, with 150 (41%) reporting global health interests. One-third (34%) of responding students felt that surgical care is one of two fields with the greatest potential global health impact in the future, second to infectious disease (49%). A minority (28%) correctly identified that trauma results in more deaths worldwide than obstetric complications or HIV/AIDS, tuberculosis, and malaria combined. Relative to other examined fields, students perceived surgical care as the least preventive and cost-effective, and few students (3%) considered adequate surgical care the best indicator of a robust health care system. Students believed that practicing in a surgical field was least amenable to pursuing a global health career, citing several barriers.

Conclusions

Medical students have several perceptions of global surgery that contradict current evidence and literature, which may have implications for their career choices. Opportunities to improve students’ global health knowledge and awareness of global surgery career paths include updating curricula, fostering meaningful international academic opportunities, and creating centers of global surgery and global health consortia.
Clinician–Investigator Training and the Need to Pilot New Approaches to Recruiting and Retaining This Workforce
Authors: Hall Alison K. , Mills Sherry L. , Lund P. Kay
Published: August 2017

Clinician–investigators, also called physician–scientists, offer critical knowledge and perspectives that benefit research on basic science mechanisms, improved diagnostic and therapeutic approaches, population and outcomes medicine, health policy, and health services, yet few clinically trained health professionals pursue a research career. Sustaining this workforce requires attention to the unique challenges faced by investigators who must achieve clinical and research competence during training and their careers. These challenges include the duration of required clinical training, limited or discontinuous research opportunities, high levels of educational debt, balancing the dual obligations and rewards of clinical care and research, competition for research funding, and the need for leadership development after training. Women and individuals from underrepresented racial and ethnic groups comprise a small percentage of this workforce.

The authors summarize the recent literature on training for clinician–investigators, emphasizing approaches with encouraging outcomes that warrant broader implementation. Using this overview as background, they convened three workshops at the National Institutes of Health in 2016 to identify and refine key priorities for potential new pilot programs to recruit and retain the clinician–investigator workforce. From these workshops emerged three priorities for future pilot programs: (1) support for research in residency, (2) new research on-ramps for health professionals at multiple career stages, and (3) national networks to diversify and sustain clinician–investigator faculty. Implementation of any pilot program will require coordinated commitment from academic health centers, medical licensing/certification boards, professional societies, and clinician–investigators themselves, in addition to support from the National Institutes of Health.
Risk Factors Associated With Skin and Soft Tissue Infections Among Hospitalized People Who Inject Drugs
Authors: Phillips Kristina T. , Anderson Bradley J. , Herman Debra S. , Liebschutz Jane M. , Stein Michael D.
Published: August 2017

Objectives:

Skin and soft tissue infections (SSTIs) are common among people who inject drugs (PWID), and can lead to serious morbidity and costly emergency room and hospital utilization. A range of high-risk injection practices may contribute to these infections. The goal of the current study was to examine risk practices that were associated with SSTIs in a sample of hospitalized PWID.

Methods:

PWID (N = 143; 40.6% female) were recruited from inpatient medical units at a large urban hospital and completed a baseline interview that focused on infection risk. Measures included demographics, substances used/injected, and self-report of SSTIs (ie, abscesses, ulcers, or cellulitis) within the past year. The Bacterial Infections Risk Scale for Injectors—a 7-item index—assessed specific behaviors expected to increase the risk of acquiring SSTIs (eg, injection without skin cleaning, intramuscular injection).

Results:

The sample was 58% Caucasian and averaged 38.7 (SD = 10.7) years of age. Ninety-three participants (65%) reported at least 1 SSTI within the past year. Using a logistic regression model, the Bacterial Infections Risk Scale for Injectors (odds ratio 1.87, P = 0.004) and total number of injections over the past 3 months (odds ratio 2.21, P = 0.002) were associated with past year SSTIs.

Conclusions:

In conclusion, rates of past-year SSTIs were high in this sample of hospitalized PWID. Results suggest that interventions should target specific injection practices to reduce infection risk.
Nitrite Inhalant Use and HIV Infection Among Chinese Men Who Have Sex With Men in 2 Large Cities in China
Authors: Wang Xiaofang , Li Yanqi , Wu Zunyou , Tang Zhenzhu , Reilly Kathleen H. , Nong Quanxing
Published: August 2017

Objective:

This study aims to examine the role that nitrite inhalants play in HIV infection and risky sex behaviors among Chinese men who have sex with men (MSM).

Methods:

The study consisted of a baseline and a follow-up survey conducted in Beijing and Nanning, China. The baseline study recruited participants through online advertisements and peer referral to complete a questionnaire interview, oral rapid HIV test, and blood HIV and syphilis tests. The follow-up included a questionnaire interview, and optional oral and/or blood HIV testing. Questionnaires collected information about sociodemographic and behavioral characteristics. Univariable and multivariable logistic regression analyses were performed to evaluate associations between characteristics and nitrite inhalant use.

Results:

One-third (29.8%) of 510 participants at baseline reported nitrite inhalant use during male-male sex in the past 6 months. Nitrite inhalant use was associated with higher odds of HIV infection (odds ratio 2.0, 95% confidence interval 1.1–3.7). Factors associated with nitrite inhalant use were as follows: never married, currently living in Beijing, not willing to test for HIV with oral self-test kit, and seeking male sex partners via the internet. In follow-up, 270 of 317 responded MSM reported having male-male sex after baseline and 17% of them used nitrite inhalants during sex.

Conclusions:

MSM who use nitrite inhalants are more likely to engage in risky HIV behaviors and have higher HIV infection risk than those who do not. Identifying MSM who use nitrite inhalants for targeted HIV interventions, such as HIV testing, might make HIV-prevention efforts more efficient among this population.
A Review of Alprazolam Use, Misuse, and Withdrawal
Authors: Ait-Daoud Nassima , Hamby Allan Scott , Sharma Sana , Blevins Derek
Published: August 2017

Alprazolam is one of the most widely prescribed benzodiazepines for the treatment of generalized anxiety disorder and panic disorder. Its clinical use has been a point of contention as most addiction specialists consider it to be highly addictive, given its unique psychodynamic properties which limit its clinical usefulness, whereas many primary care physicians continue to prescribe it for longer periods than recommended. Clinical research data has not fully shed light on its “abuse liability,” yet it is one of the most frequently prescribed benzodiazepines. “Abuse liability” is the degree to which a psychoactive drug has properties that facilitate people misusing it, or becoming addicted to it, and is commonly used in the literature. We have replaced it in our manuscript with “misuse liability” as it reflects a more updated terminology consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In this paper, we have reviewed alprazolam's indications for use, its effect on pregnant women, misuse liability, withdrawal syndrome, pharmacodynamic properties, and suggest better clinical prescription practice of alprazolam by presenting an indepth theory of its clinical effects with use and withdrawal.
Genetics in inclusion body myositis
Authors: Rothwell Simon , Lilleker James B. , Lamb Janine A.
Published: August 2017

Purpose of review

To review the advances in our understanding of the genetics of inclusion body myositis (IBM) in the past year.

Recent findings

One large genetic association study focusing on immune-related genes in IBM has refined the association within the human leukocyte antigen (HLA) region to HLA-DRB1 alleles, and identified certain amino acid positions in HLA-DRB1 that may explain this risk. A suggestive association with CCR5 may indicate genetic overlap with other autoimmune diseases. Sequencing studies of candidate genes involved in related neuromuscular or neurodegenerative diseases have identified rare variants in VCP and SQSTM1. Proteomic studies of rimmed vacuoles in IBM and subsequent genetic analyses of candidate genes identified rare missense variants in FYCO1. Complex, large-scale mitochondrial deletions in cytochrome c oxidase-deficient muscle fibres expand our understanding of mitochondrial abnormalities in IBM.

The pathogenesis of IBM is likely multifactorial, including inflammatory and degenerative changes, and mitochondrial abnormalities. There has been considerable progress in our understanding of the genetic architecture of IBM, using complementary genetic approaches to investigate these different pathways.
Lack of joint hypermobility increases the risk of surgery in adolescent idiopathic scoliosis
Authors: Haller Gabe , Zabriskie Hannah , Spehar Shelby , Kuensting Timothy , Bledsoe Xavier , Syed Ali , Gurnett Christina A. , Dobbs Matthew B.
Published: August 2017

Generalized joint hypermobility (GJH) is a risk factor for developing adolescent idiopathic scoliosis (AIS); however, it is not known whether joint hypermobility influences the risk of progression to surgery. Beighton joint hypermobility scores were assessed in 570 female AIS patients. Multivariate analysis was carried out to determine whether Beighton hypermobility scores were predictors of surgical intervention. In this female AIS cohort, 24.7% (141/570) had GJH (Beighton score ≥4). Multivariate analysis showed that GJH did not influence the risk of surgery, although having no joint hypermobility (Beighton score=0) increased risk (odds ratio: 1.89; P=0.003). Females who had no hypermobility (score=0) had significantly larger curves than individuals who scored at least one point on the Beighton scale [50° (interquartile range: 26) vs. 42° (interquartile range: 24), P=0.001]. Evaluation of specific measures of joint hypermobility indicated that females who could not touch their palms to the floor were 2.1-fold more likely to have surgery than patients who could perform this task (P=0.001). None of the other features measured on the Beighton score correlated with surgical risk. The lack of joint hypermobility increases the odds of surgery in females with AIS. Specifically, inability to touch the palms to the floor is an indicator of progression to surgery.
Comparison of Clinical Findings of Congenital Muscular Torticollis Between Patients With and Without Sternocleidomastoid Lesions as Determined by Ultrasonography
Authors: Han Mi-Hyang , Kang Jin Young , Do Hyun Jung , Park Hyun Suk , Noh Hyun Jin , Cho Yun-Hwa , Jang Dae-Hyun
Published: August 2017

Aim:

To compare clinical findings for patients with congenital muscular torticollis (CMT) between those with and without a sternocleidomastoid (SCM) lesion.

Methods:

Medical records of 182 patients with CMT were retrospectively reviewed and the patients were divided into SCM lesion and nonlesion groups by ultrasonographic results. Intrauterine position, age, duration of therapy, rotation/tilting side, and the passive range of motion and angle of the neck were compared.

Results:

There were 74 SCM lesion and 108 nonlesion cases. The mean age at the first visit was 55.3 days in the SCM lesion group and 146.6 days in the nonlesion group. The mean therapy time in the nonlesion group was 66.5 days, significantly shorter than for the SCM lesion group (117.5 d). Tilting and rotation of the head in the same direction was observed only in the nonlesion group (n=9, 8.3%). Rotational limitation of the affected muscle side was 22.6 degree in the SCM lesion and 3.6 degree in the nonlesion group, and the tilting limitation was 19.2 degree in the SCM lesion and 10.4 degree in the nonlesion group.

Conclusions:

The nonlesion group had a better prognosis with shorter treatment duration. This group was more limited in head tilting than in head rotation, and the pattern of head rotation/tilting in the same direction was observed only in this group. These findings suggest that pathophysiological mechanisms and clinical characteristics may differ between CMT patients with and without SCM lesions.

Level of Evidence:

Level II—prognostic studies, retrospective study.
Recovery of Motor Nerve Injuries Associated With Displaced, Extension-type Pediatric Supracondylar Humerus Fractures
Authors: Shore Benjamin J. , Gillespie Bryce T. , Miller Patricia E. , Bae Donald S. , Waters Peter M.
Published: August 2017

Background:

Nerve injuries occur in approximately 11% of pediatric extension supracondylar humerus fractures (SCHF), yet there is scarce literature to guide clinicians on management. The primary goal of this study was to report the presentation, treatment, and outcome of motor nerve injuries associated with extension SCHF. Our secondary goal was to determine which injury and treatment factors were associated with prolonged motor nerve recovery.

Methods:

Two hundred forty-four traumatic nerve injuries associated with extension SCHF treated at a single institution between 1996 and 2012 were reviewed. Patients with iatrogenic nerve injuries or subjective paresthesias without motor deficit were excluded. Univariable and multivariable general linear modeling were used to compare recovery times across nerve injury types and to determine the effect of injury and treatment characteristics on recovery time.

Results:

Patients were a mean age of 6.7 years, with 89% presenting with a single nerve injury and 29% of the cohort experiencing a concurrent vascular injury. The majority of injuries (62%) were to the median nerve. Forty-three (18%) cases had acute nerve decompression at the time of fracture fixation. Five cases required subsequent surgery for poor nerve recovery; none of which underwent initial nerve decompression. Thirty-one patients were lost to follow-up after injury. Median time to nerve recovery was 2.3 months (IQR 1.4 to 3.7 mo); 60% of injuries had nerve recovery by 3 months and 196 (92%) patients had complete nerve recovery at final follow-up. A greater percentage of isolated median nerve (70%) injuries recovered within 3 months compared with radial nerve (42%) injuries (P=0.01). Multivariable analysis demonstrated that multiple nerve injuries took 54% longer to recover than single median nerve injuries (P=0.01), and single radial nerve injuries took 30% longer to recover than single median nerve injuries (P=0.04).

Conclusions:

The majority of nerve injuries associated with pediatric extension SCHF recover within 6 months without acute nerve decompression. The presence of either an isolated radial nerve injury or multiple nerve injuries is associated with prolonged motor recovery.

Level of Evidence:

Level IV.
Neuroprotective Effects of C-terminal Domain of Tetanus Toxin on Rat Brain Against Motorneuron Damages After Experimental Spinal Cord Injury
Authors: Sozbilen Murat Celal , Ozturk Murat , Kaftan Gizem , Dagci Taner , Ozyalcin Halit , Armagan Guliz
Published: August 2017

Study Design.

Experimental animal study investigating the efficacy of C-terminal domain of tetanus toxin application as neuroprotective effects on rat brain in a model of spinal cord injury (SCI).

Objective.

The aim of the present study was to investigate the possible role of C-terminal domain of tetanus toxin (Hc-TeTx) on cell death mechanisms including apoptosis and autophagy following SCI.

Summary of Background Data.

Traumatic SCI can lead to posttraumatic inflammation, oxidative stress, motor neuron apoptosis, necrosis, and autophagy of tissue. To promote and enhance recovery after SCI, recent development of devices and therapeutic interventions are needed.

Methods.

Twenty-eight adult rats were divided into four groups (n = 7 each) as follows: sham, trauma (SCI), SCI + Hc-TeTx, and SCI + methylprednisolone groups. The functional neurological deficits due to the SCI were assessed by behavioral analysis using the Basso, Beattie and Bresnahan (BBB) open-field locomotor test. The alterations in pro-/anti-apoptotic and autophagy related-protein levels were measured by Western blotting technique.

Results.

In this study, Hc-TeTx promotes locomotor recovery and motor neuron survival of SCI rats. Hc-TeTx also decreased expression of bax, bad, bak, cleaved caspase-3, Ask1, and autophagy-related proteins including Atg5 and LC3II in brain. Our study provides an evidence that cell death mechanisms play critical roles in SCI and that the nontoxic peptides including Hc-TeTx may exert protective effect and decrease cell death following SCI.

Conclusion.

Our preliminary findings suggest a possible therapeutic agent to improve survival after spinal cord trauma, but further analysis are still needed to evaluate the difference between acute and chronic injuries.

Level of Evidence: N/A
Rod Lengthening With the Magnetically Controlled Growing Rod
Authors: Cheung Jason P.Y. , Yiu Karen K.L. , Samartzis Dino , Kwan Kenny , Tan Boon-Beng , Cheung Kenneth M.C.
Published: August 2017

Study Design.

Prospective study.

Objective.

To identify the factors that are associated with rod slippage and to study the pattern of achieved length gain with a standard distraction methodology.

Summary of Background Data.

Ability to achieve successful magnetically controlled growing rod (MCGR) distraction is crucial for gradual spine lengthening. Rod slippage has been described as a failure of internal magnet rotation leading to a slippage and an inability to distract the rod. However, its onset, significance, and risk factors are currently unknown. In addition, how this phenomenon pertains to actual distracted lengths is also unknown.

Methods.

A total of 22 patients with MCGR and at least six distraction episodes were prospectively studied. Patients with rod slippage occurring less than six distraction episodes were considered early rod slippage whereas those with more than six episodes or have yet to slip were grouped as late rod slippage. The association of parameters including body habitus, maturity status, age of implantation, total number of distractions, months of distraction from initial implantation, initial and postoperative Cobb angle, T1-T12, T1-S1, T5-T12 kyphosis, curve flexibility, instrumented length, and distance between magnets in dual rods and between the magnets and apex of the curve with early or late onset of rod slippage were studied. Differences between expected and achieved distraction lengths were assessed with reference to rod slippage episodes and rod exchanges to determine any patterns of diminishing returns.

Results.

Patients had mean age of 7.1 years at diagnosis with mean follow-up of 49.8 months. A mean 32.4 distractions were performed per patient. Early rod slippage occurred in 14 patients and late rod slippage occurred in eight patients. Increased height, weight, body mass index, older age, increased T1–12 and T1-S1 lengths, and less distance between magnets were significantly associated with early rod slippage. Expected distraction lengths did not translate to achieve distraction lengths and reduced gains were only observed after achieving one-third of the allowable distracted length in the MCGR. Length gains return to baseline after rod exchange.

Conclusion.

This is the first study to specifically analyze the impact of rod slippage on distraction lengths and the risk factors associated with its onset and frequency. Increased body habitus and reduced distance between internal magnets significantly influenced rod slippage events. Diminishing returns in distracted length gains were only observed after a period of usage.

Level of Evidence: 3
Modic Changes and Disc Degeneration of Nonfused Segments 27 to 45 Years After Harrington Instrumentation for Adolescent Idiopathic Scoliosis
Authors: Akazawa Tsutomu , Kotani Toshiaki , Sakuma Tsuyoshi , Minami Shohei , Orita Sumihisa , Inage Kazuhide , Fujimoto Kazuki , Shiga Yasuhiro , Torii Yoshiaki , Umehara Tasuku , Iinuma Masahiro , Kuroya Shingo , Niki Hisateru , Ohtori Seiji , Takahashi Kazuhisa
Published: August 2017

Study Design.

A case-control study.

Objective.

The aim of this study was to investigate the long-term prevalence of the Modic changes and disc degeneration in the nonfused segments of the surgically treated adolescent idiopathic scoliosis (AIS) patients and compare with age- and sex-matched healthy controls.

Summary of Background Data.

No studies have looked at the association between Modic changes and low back pain in patients who underwent AIS surgery many years ago.

Methods.

Study subjects consisted of 194 patients with AIS who underwent spinal fusion with Harrington instrumentation between 1968 and 1987. Twenty-six patients (AIS group) underwent lumbar magnetic resonance imaging (MRI), whole spine X-ray, and patient-reported outcomes evaluations [Scoliosis Research Society-22 Patient Questionnaire (SRS-22), Oswestry Disability Index (ODI)]. The mean duration of follow-up observation was 36.1 years. The lowest fusion vertebra was used as follows: T12: 2 patients, L1: 4, L2: 11, L3: 6, L4: 2, L5: 1. Twenty-nine healthy age- and sex-matched individuals were selected as a control (CTR) group.

Results.

On the basis of MRI findings, a significantly higher percentage of subjects showed Modic changes in the AIS group (AIS group: 57.7%, CTR group: 13.8%). There were no significant differences in the percentage of subjects with disc degeneration rated Pfirrmann grade 4 or higher (AIS group: 61.5%, CTR group: 65.5%). SRS-22 scores for function and self-image were significantly lower in the AIS group. ODI was significantly worse in the AIS group. Modic changes in AIS group were found in the concave side of the curve in 61.9%. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes.

Conclusion.

Modic changes were observed in 57.7% of AIS patients 27 years or more after spinal fusion with Harrington instrumentation. The magnitude of lumbar coronal curve was found to be a significant risk factor of Modic changes. Modic change occurred at a higher frequency in AIS patients than CTR individuals, with lower function and worse ODI scores.

Level of Evidence: 4
Prevalence and Prognostic Association of Circulating Troponin in the Acute Respiratory Distress Syndrome
Authors: Metkus Thomas S. , Guallar Eliseo , Sokoll Lori , Morrow David , Tomaselli Gordon , Brower Roy , Schulman Steven , Korley Frederick K.
Published: August 2017

Objective:

Circulating cardiac troponin has been associated with adverse prognosis in the acute respiratory distress syndrome in small and single-center studies; however, comprehensive studies of myocardial injury in acute respiratory distress syndrome using modern high-sensitivity troponin assays, which can detect troponin at much lower circulating concentrations, have not been performed.

Design:

We performed a prospective cohort study.

Setting:

We included patients enrolled in previously completed trials of acute respiratory distress syndrome.

Patients:

One thousand fifty-seven acute respiratory distress syndrome patients were included.

Interventions:

To determine the association of circulating high-sensitivity troponin I (Abbott ARCHITECT), with acute respiratory distress syndrome outcomes, we measured high-sensitivity troponin I within 24 hours of intubation. The primary outcome was 60-day mortality.

Measurements and Main Results:

Detectable high-sensitivity troponin I was present in 94% of patients; 38% of patients had detectable levels below the 99th percentile of a healthy reference population (26 ng/L), whereas 56% of patients had levels above the 99th percentile cut point. After multivariable adjustment, age, cause of acute respiratory distress syndrome, temperature, heart rate, vasopressor use, Sequential Organ Failure Assessment score, creatinine, and Pco
2 were associated with higher high-sensitivity troponin I concentration. After adjustment for age, sex, and randomized trial assignment, the hazard ratio for 60-day mortality comparing the fifth to the first quintiles of high-sensitivity troponin I was 1.61 (95% CI, 1.11–2.32; p trend = 0.003). Adjusting for Sequential Organ Failure Assessment score suggested that this association was not independent of disease severity (hazard ratio, 0.95; 95% CI, 0.64–1.39; p = 0.93).

Conclusions:

Circulating troponin is detectable in over 90% of patients with acute respiratory distress syndrome and is associated with degree of critical illness. The magnitude of myocardial injury correlated with mortality.
Emergency Airway Response Team Simulation Training: A Nursing Perspective
Authors: Crimlisk Janet T. , Krisciunas Gintas P. , Grillone Gregory A. , Gonzalez R. Mauricio , Winter Michael R. , Griever Susan C. , Fernandes Eduarda , Medzon Ron , Blansfield Joseph S. , Blumenthal Adam
Published: August 2017

Background:

Simulation-based education is an important tool in the training of professionals in the medical field, especially for low-frequency, high-risk events. An interprofessional simulation-based training program was developed to enhance Emergency Airway Response Team (EART) knowledge, team dynamics, and personnel confidence. This quality improvement study evaluated the EART simulation training results of nurse participants.

Method:

Twenty-four simulation-based classes of 4-hour sessions were conducted during a 12-week period. Sixty-three nurses from the emergency department (ED) and the intensive care units (ICUs) completed the simulation. Participants were evaluated before and after the simulation program with a knowledge-based test and a team dynamics and confidence questionnaire. Additional comparisons were made between ED and ICU nurses and between nurses with previous EART experience and those without previous EART experience.

Results:

Comparison of presimulation (presim) and postsimulation (postsim) results indicated a statistically significant gain in both team dynamics and confidence and Knowledge Test scores (P < .01). There were no differences in scores between ED and ICU groups in presim or postsim scores; nurses with previous EART experience demonstrated significantly higher presim scores than nurses without EART experience, but there were no differences between these nurse groups at postsim.

Conclusions:

This project supports the use of simulation training to increase nurses' knowledge, confidence, and team dynamics in an EART response. Importantly, nurses with no previous experience achieved outcome scores similar to nurses who had experience, suggesting that emergency airway simulation is an effective way to train both new and experienced nurses.
Family Satisfaction With End-of-Life Care in the Intensive Care Unit
Authors: DeSanto-Madeya Susan , Safizadeh Parissa
Published: August 2017

Background:

Assessment of family satisfaction after the death of a loved one in the intensive care unit (ICU) provides a way to determine whether quality end-of-life care was received by the patient and family. The purpose of this systematic review was to explore the factors associated with family satisfaction with end-of-life care in the ICU.

Methods:

A systematic literature review was conducted using electronic databases CINAHL, MEDLINE, EMBASE, and PsychINFO. Databases were searched using a combination of search terms: “family satisfaction,” “end of life,” “intensive care unit,” and “family.” Results were limited to English-language reports of empirical studies published from January 2000 to January 2016. Studies describing adult family members’ satisfaction with end-of-life care of patients admitted or transferred to an ICU were included in the review.

Results:

The search yielded 466 articles. Review of the titles and abstracts resulted in 122 articles that underwent full review; 30 articles met study inclusion and were included in the final analysis. Major themes identified from the literature reviewed included communication, decision making, nursing care, ICU environment, and spiritual care.

Conclusions:

Families can provide valuable insight and information on the quality of care provided in the ICU at end of life. Their perceptions of communication, decision making, nursing care, the ICU environment, and spiritual support strongly influence their satisfaction or dissatisfaction with end-of-life care in the ICU. Personalized and frequent communication; assistance in the decision-making process; compassionate nursing care; a warm, family-friendly environment; and spiritual support can help alleviate the sequelae and enhance family satisfaction with end-of-life care in the ICU.
MiR-30e Attenuates Isoproterenol-induced Cardiac Fibrosis Through Suppressing Snai1/TGF-β Signaling
Authors: Zhang Wenqi , Chang Hong , Zhang Hexun , Zhang Lei
Published: August 2017

Background:

MicroRNAs are a class of small RNA molecules that inhibit protein expression through either degradation of messenger RNA or interference with protein translation. Our previous work suggested an involvement of miR-30e in myocardial fibrosis; however, the exact role of miR-30e in the pathogenesis of cardiac fibrosis and the underlying mechanisms are not known.

Methods:

Male Sprague Dawley rats were treated with isoproterenol (ISO) to induce cardiac remodeling and fibrosis and treated with either miR-30e agomir (AG) or antagomir and respective controls. The expression of miR-30e was evaluated by reverse transcription and quantitative polymerase chain reaction. Myocardial fibrosis was assessed by Masson's trichrome staining, and the level of oxidative stress and the expression of Snai1 and transforming growth factor-beta (TGF-β) were detected using Western blots.

Results:

A significant downregulation of miR-30e was found in the hearts of ISO-treated rats with cardiac fibrosis compared with nontreated controls. In vivo administration of miR-30e AG increased the survival of ISO-treated rats compared with AG-negative control administration, which was associated with reduced oxidative stress. We further identified Snai1 as a novel miR-30e target. Snai1 expression was significantly increased in hearts from ISO-treated rats, which coincided with decreased miR-30e expression and increased TGF-β expression. An miR-30e putative target sequence was identified in the 3′-untranslated region (UTR) Snai1. In a reporter assay, miR-30e greatly suppressed the activity of wild-type 3′-UTR–fused luciferase reporter, but showed no significant effect with the mutated 3′-UTR–fused reporter.

Conclusion:

MiR-30e attenuated ISO-induced cardiac dysfunction and cardiac fibrosis in a rat cardiac remodeling model. Mechanistically, miR-30e suppressed Snai1/TGF-β pathway which was involved in ISO-induced cardiac remodeling.
Intraoperative Evaluation of Body Surface Improvement by an Augmented Reality System That a Clinician Can Modify
Authors: Mitsuno Daisuke , Ueda Koichi , Itamiya Tomoki , Nuri Takashi , Otsuki Yuki
Published: August 2017

Background:

Augmented reality (AR) technology that can combine computer-generated images with a real scene has been reported in the medical field recently. We devised the AR system for evaluation of improvements of the body surface, which is important for plastic surgery.

Methods:

We constructed an AR system that is easy to modify by combining existing devices and free software. We superimposed the 3-dimensional images of the body surface and the bone (obtained from VECTRA H1 and CT) onto the actual surgical field by Moverio BT-200 smart glasses and evaluated improvements of the body surface in 8 cases.

Results:

In all cases, the 3D image was successfully projected on the surgical field. Improvement of the display method of the 3D image made it easier to distinguish the different shapes in the 3D image and surgical field, making comparison easier. In a patient with fibrous dysplasia, the symmetrized body surface image was useful for confirming improvement of the real body surface. In a patient with complex facial fracture, the simulated bone image was useful as a reference for reduction. In a patient with an osteoma of the forehead, simultaneously displayed images of the body surface and the bone made it easier to understand these positional relationships.

Conclusions:

This study confirmed that AR technology is helpful for evaluation of the body surface in several clinical applications. Our findings are not only useful for body surface evaluation but also for effective utilization of AR technology in the field of plastic surgery.
COMPARISON OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHIC CHANGES AFTER ANTI–VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY ALONE OR IN COMBINATION WITH PHOTODYNAMIC THERAPY IN POLYPOIDAL CHOROIDAL VASCULOPATHY
Authors: Teo Kelvin Yi Chong , Yanagi Yasuo , Lee Shu Yen , Yeo Ian Yew San , Tan Gavin Siew Wei , Mathur Ranjana , Chan Choi Mun , Wong Tien Yin , Cheung Chui Ming Gemmy
Published: August 2017

Purpose:

To compare changes in optical coherence tomography angiography in eyes with polypoidal choroidal vasculopathy after treatment with anti–vascular endothelial growth factor monotherapy or combined with photodynamic therapy.

Methods:

This is a longitudinal case-controlled study. The authors performed optical coherence tomography angiography at baseline and Month 3 in patients with treatment-naive polypoidal choroidal vasculopathy undergoing monotherapy (n = 10) or combination therapy (n = 13). We analyzed flow signal within the outer retina and choriocapillaris using automated segmentation. The authors analyzed the presence of pachyvessels using a 10.4-μm segment through Haller layer. The changes in each layer were compared between treatments.

Results:

At Month 3, both groups showed similar improvement in best-corrected visual acuity and central retinal thickness. However, flow signal within the polypoidal choroidal vasculopathy complex was decreased in more eyes after combination therapy than after monotherapy (84.6% vs. 40.0%, P = 0.04). Patchy reduction in flow signal within the choriocapillaris layer was noted in 15.4% and 10.0% after combination therapy and monotherapy, respectively (P = 0.61). Significant reduction in pachyvessel caliber was seen only after combination therapy but not after monotherapy (75.0% vs. 0.0%, P = 0.01).

Conclusion:

Longitudinal optical coherence tomography angiography demonstrates more significant reduction in lesion flow and pachyvessels in the short term after combination therapy than after monotherapy, although visual and structural OCT showed similar improvement.
FOVEAL AVASCULAR ZONE AREA AFTER INTERNAL LIMITING MEMBRANE PEELING FOR EPIRETINAL MEMBRANE AND MACULAR HOLE COMPARED WITH THAT OF FELLOW EYES AND HEALTHY CONTROLS
Authors: Kumagai Kazuyuki , Furukawa Mariko , Suetsugu Tetsuyuki , Ogino Nobuchika
Published: August 2017

Purpose:

To measure the foveal avascular zone (FAZ) area after internal limiting membrane (ILM) peeling and to determine the factors significantly correlated with the FAZ area.

Methods:

This was a retrospective, observational, and cross-sectional study. The affected and normal fellow eyes of 102 patients with unilateral macular diseases and 169 healthy subjects were studied. The patients underwent successful vitrectomy with internal limiting membrane peeling for an epiretinal membrane (n = 56) or a macular hole (n = 46). The superficial FAZ area and average foveal (within 1 mm) thickness were measured. The main outcome measures were the en face FAZ area measured in the optical coherence tomography angiographic images.

Results:

The FAZ area in the epiretinal membrane group (0.148 ± 0.094 mm2) and in the macular hole group (0.255 ± 0.111 mm2) were significantly smaller than that in the healthy control group (0.358 ± 0.118 mm2; all, P < 0.0001). Multiple regression analysis showed that a thicker fovea was significantly correlated with a smaller FAZ area in the epiretinal membrane group (r = −0.799, P < 0.0001), macular hole group (r = −0.473, P = 0.0042), and control group (r = −0.612, P < 0.0001).

Conclusion:

The FAZ area after internal limiting membrane peeling was smaller than that of the controls. A smaller FAZ area was correlated with a thicker fovea both in internal limiting membrane–peeled eyes and normal eyes.
EFFICACY AND FREQUENCY OF INTRAVITREAL AFLIBERCEPT VERSUS BEVACIZUMAB FOR MACULAR EDEMA SECONDARY TO CENTRAL RETINAL VEIN OCCLUSION
Authors: Lotfy Ayman , Solaiman Kamal A. M. , Abdelrahman Ayman , Samir Ahmed
Published: August 2017

Purpose:

To compare the safety, efficacy, and frequency of intravitreal injection of aflibercept and bevacizumab for treatment of macular edema secondary to central retinal vein occlusion.

Design:

Prospective, comparative, randomized, interventional study.

Patients and Methods:

Eyes with macular edema secondary to central retinal vein occlusion were randomized between two groups according to the intravitreal injection used. Group A included eyes treated with intravitreal aflibercept, and Group B included eyes treated with intravitreal bevacizumab injections. The inclusion criteria were macular edema secondary to central retinal vein occlusion and follow-up duration of at least 12 months after the first injection. Exclusion criteria were macular ischemia, associated diabetes, hypertensive or renal retinopathy, other retinal disease, and previous anti–vascular endothelial growth factor injection. The main outcome measures are central foveal thickness, best-corrected visual acuity, time intervals between injections, improved retinal nonperfusion, and any reported complication.

Results:

Group A included 39 patients with a mean age of 57.4 ± 8.2 years. Group B included 40 eyes with a mean age of 56.5 ± 9.1 years. Twelve months after the first injection, central foveal thickness significantly improved from 475.45 ± 71.05 m to 259.11 ± 20.67 m in Group A and from 460.22 ± 89.38 m to 264.29 ± 32.05 m in Group B; best-corrected visual acuity significantly improved from 0.81 ± 0.16 logarithm of the minimum angle of resolution (20/125) to 0.34 ± 0.14 logarithm of the minimum angle of resolution (20/40) in Group A and from 0.73 ± 0.15 logarithm of the minimum angle of resolution (20/100) to 0.33 ± 0.17 logarithm of the minimum angle of resolution (20/40) in Group B; the mean number of injections was 3.72 ± 2.93 in Group A and was 5.44 ± 2.85 in Group B (P < 0.05); and the mean interval between injections was 54.23 ± 8.47 days in Group A and was 35.12 ± 7.76 days in Group B (P < 0.05). Retinal nonperfusion improved in 9/12 eyes in Group A and in 3/8 eyes in Group B (P < 0.05).

Conclusion:

Both aflibercept and bevacizumab are comparably effective for treatment of macular edema secondary to central retinal vein occlusion without significant complications. However, the burden of frequent intravitreal injections could be significantly reduced when using aflibercept.
TEMPORAL VASCULAR ARCADE WIDTH AND ANGLE IN HIGH AXIAL MYOPIA
Authors: Jonas Jost B. , Weber Pascal , Nagaoka Natsuko , Ohno-Matsui Kyoko
Published: August 2017

Purpose:

Axial myopia is associated with elongation of the posterior ocular segment. The authors measured posterior fundus landmarks and assessed their associations with axial length.

Methods:

Using fundus photographs, the authors measured the vertical distance between the temporal superior and temporal inferior arterial arcade (VDA) and the angle kappa between the temporal arterial arcades among other morphometric variables.

Results:

The study included 456 eyes with a mean age of 61.2 ± 14.2 years (range: 13–88 years) and mean axial length of 29.4 ± 2.1 mm (range: 23.2–35.3 mm). Mean angle kappa was 91.3 ± 17.2° (range: 39–161°), and mean VDA was 7.93 ± 1.71 mm (range: 2.72–12.85 mm). In multivariate regression analysis, wider angle kappa was associated (regression coefficient r: 0.47) with shorter axial length (P = 0.002; beta: −0.17; B: −1.37; 95% confidence interval [CI]:−2.23 to −0.51), longer VDA (P < 0.001; beta: 0.27; B: 2.70; 95% CI: 1.85–3.54), shorter disk–foveola distance (P < 0.001; beta: −0.22; B: −4.76; 95% CI: −7.05 to −2.46), shorter vertical optic disk diameter (P = 0.002; beta: −0.14; B: −6.83; 95% CI: −11.1 to −2.56), lower number of any chorioretinal lesions (P = 0.007; beta: −0.13; B: −2.11; 95% CI: −3.63 to −0.58), and longer maximal vertical chorioretinal lesion diameter (P = 0.05; beta: 0.09; B: 0.92; 95% CI: −0.02 to 1.86). A longer VDA was associated (r: 0.31) with longer axial length (P < 0.001; beta: 0.22; B: 0.18; 95% CI: 0.10–0.25), wider angle kappa (P < 0.001; beta: 0.28; B: 0.03; 95% CI: 0.02–0.04) and higher number of chorioretinal lesions (P = 0.03; beta: 0.10; B: 0.16; 95% CI: 0.02–0.31). If eyes with chorioretinal lesions were excluded, the association between longer VDA and longer axial length was no longer statistically significant (P > 0.10).

Conclusion:

Axial elongation was correlated with decreasing angle kappa, caused by an elongation of the disk–foveola distance because of an enlargement of the gamma zone, whereas VDA remained constant. By contrast, horizontal length of macular Bruch membrane and vertical length of macular Bruch membrane were independent of axial elongation. Axial elongation did not lead to lengthening of Bruch membrane in the macular region in eyes without macular chorioretinal lesions.